Sunday, April 20, 2008

Times I Screwed Up (2)


Like a frozen scene captured on film, the ambience of the moment remains as vivid today as it was then. A crumpled photo of a golden-haired, bearded Jesus lay on the floor, his hands clasped in prayer with loving eyes towards heaven. Tan’s wife had been holding the photo just a while earlier. From the corner of my eye, Tan’s wife stood a metre or two away watching us anxiously in our futile efforts of bringing a dead man back to life. To the medical personnel, he was just another patient. To her, that was her companion in health and sickness, love and war, life and beyond. Tears streamed down her flushed face, each droplet refracted into an array of mini-lucent colors by the golden Sabbath sun rays. Her weeping was tangible but inaudible, silenced within the helter skelter of chaos. Even as Tan laid there in



I Remember


“Can you please come now? I’m really sorry. But I really don’t know what to do. Tan is desaturating with low GCS.”

Like a horror dream, the phone call jolted me from sleep. I rummaged and stared at my clock. It was 5.00 am on a Sunday morning. It took me a while to absorb the reality of the situation. Did my colleague Yati really call to ask for help?My handphone confirmed the phone call. If Yati had indeed called me, then Tan was indeed in distress.

He shouldn’t be, though. There was no reason for him to be in distress, not at all.

Fifty-something year-old Tan was admitted two weeks before that. A Sino-Kadazan from Keningau, his name was fully Chinese yet he spoke no Mandarin or any Chinese dialect. Like most Sino-Kadazans, he was Chinese only by name but not by culture or language. Like most Sabah folks too, he was especially trusting and simple-minded.

Tan was a survivor. He was first admitted three years prior to this for a massive heart attack. From the medical records, his heart stopped beating for almost ten minutes. Most patients do not survive asystole and usually even if they do, it is not without severe significant brain damage. Miraculously, Tan survived that life-threatening episode and his heart started beating at a normal rate and rhythm again. He did not escape unscathed. He suffered a stroke during the resuscitative process which left him paralysed on the left side of his body.

Even so, Tan made a gradual and almost complete recovery to regain function of his body. Within a year of the heart attack and stroke, he was back in his estate, tapping rubber nonchalantly in the company of his wife. He was a little sluggish in his movements but he got by nonetheless. Where help was needed, his loyal lady saw to his needs. Life went on for the ageing couple. They had children who were working in the city but were contented in the humble nest they had built back in Keningau.

Everything was fine and quiet and blissful until Tan fell while working in his estate one rainy dawn.

He was admitted for surgical management of a broken left hip bone. We traced his records and were amazed that he pulled through a massive cardiac event with minimal functional impairment. The medical and anaesthetic teams reviewed him and cleared him for surgery.

Yati and I were both house officers back then. She was a graduate from Universiti Islam Antarabangsa (UIA) with wealthy parents well-connected to both UMNO and Anwar’s PKR. We had worked well in our previous postings and had cooperated effectively in the management of most of our patients. She was the first to attend to Tan when he was admitted.

Tan came to my attention when he first complained of difficulty in passing urine. I asked a few questions and looked at his charts. He was also constipated and nauseous. He was on morphine for pain relief. The culprit was immediately obvious. I struck off the morphine from his charts, put him on laxatives and assured him that the urinary retention and constipation will soon come to pass. I was reluctant to insert a urinary catheter despite the insistence of the staff nurses. As far as the staff nurses were concerned, all they want is one less complaining patient. From a doctor’s point of view, everything is about the possible risks against benefits to the patients. In Tan’s case, the underlying reason for his problems was obvious and there was no reason to put him on a urinary catheter.

I left for the clinics. I returned two hours later.

Unknown to me, in my absence, the staff nurses had persuaded another house officer to put Tan on a urinary catheter. I was less than amused but did not pursue the matter further.

Tan was scheduled for surgery soon. An outbreak of a fungal infection over the planned surgical site however prevented us from performing surgery until the infection has cleared.

One week later, the skin infection showed little signs of imminent recovery. Unsurprisingly, Tan developed a urinary infection due to the indwelling catheter. I started antibiotics and tried to remove the catheter but it was stuck, simply stuck. The balloon that held the catheter in place would not deflate. It was adamant and unrelenting despite all our measures. We referred to the urology team for assistance. The urology medical officer, a UKM graduate took three days to come to attend to Tan. Under ultrasound guidance, he punctured the balloon of the urinary catheter and successfully removed it. It only took fifteen minutes.

Tan was fine again, or so I thought.

The night before Yati’s call, I had checked on Tan, just six hours prior to her SOS call. Tan was well and cheerful and even bade me good night. His wife had just given him a new hair cut. The ward was too stuffy, warm and humid that Tan had opted for an army crew cut. He looked younger and definitely much neater in his new crop. He looked like a bald version of Phua Chu Kang, only a little greyer and wrinkled.

I will never forget the scene that greeted me that morning when I reached the ward. Tan was barely conscious. In fact, he was barely breathing. He was running a fever of 42 degrees. His oxygen saturation was only 86% on high flow oxygen. Apart from the oxygen supplement, little else was done for him since the time he deteriorated. In her panic of the sudden and unexpected downturn of Tan, Yati had somehow forgotten basic resuscitative measures. It didn’t help that the orthopaedic registrar on-call was incompetent and irresponsible.

Personally, I was outraged and furious but that was not the time for a blame game. Amidst the need to rush and the urge to yell, a list of probable diagnoses raced through my mind. Tan’s blood pressure was low - it could have been another heart attack. He was breathing but not responding – it could have been a stroke – an infarct or a bleed or something like that. It may be a deep vein thrombosis with migration to the lungs. It could be a fat embolism from his long bone fracture. It could have been respiratory failure from orthostatic pneumonia, if that was possible.

We inserted lines and tubes and a new urinary catheter. That was when the truth surfaced. No urine flowed into the catheter or rather, it was not urine. It was pus, frank pus – thick, foul-smelling, green-colored fluid.

It was not a heart attack or stroke or any embolism. It was a simple urinary tract infection that had set in from the catheter. Despite his apparent general wellness, Tan had been increasingly ill all these while with pus forming in his urine, his bladder and up to his kidneys converging finally as pyelonephritis and full blown sepsis. By now, all our efforts were in vain, like a chase after the wind.

We commenced CPR soon after. Like a frozen scene captured on film, the ambience of the moment remains as vivid today as it was then. A crumpled photo of a golden-haired, bearded Jesus lay on the floor, his hands clasped in prayer with loving eyes towards heaven. Tan’s wife had been holding the photo just a while earlier. From the corner of my eye, Tan’s wife stood a metre or two away watching us anxiously in our futile efforts of bringing a dead man back to life. To the medical personnel, he was just another patient. To her, that was her companion in health and sickness, love and war, life and beyond. Tears streamed down her flushed face, each droplet refracted into an array of mini-lucent colors by the golden Sabbath sun rays. Her weeping was tangible but inaudible, silenced within the helter skelter of chaos. Even as Tan laid there in lifeless bliss and heavenly awareness, my thoughts were tumultuous with troubling images of an elderly lady wandering alone in a wide and misty rubber estate. Beneath my apparent energy and vigor, I was in fact very numbed and sore within and without.

Lying there was a patient who once conquered a stroke and a massive heart attack. He was now losing a battle to a urinary tract infection. Such irony.

Tan died two hours later, after we exhausted our armamentarium of inotropes, atropine and cardiac defibrillator and maximum ventilator settings.

Throughout the whole episode, only the two of us then house officers were at the forefront. The specialists came, took a peek, shook their heads, gave a grin and left. The medical officers came and had no clue what was going on.


Tan didn’t die however because of incompetent medical officers and uncaring surgeons.

He died from neglect – and that would never happen if I as a house officer then were more vigilant.

5 comments:

jj said...

why the title "times i screwed up (2)? it is so obvious that he died because of sepsis with pyelonephritis. i think you did well in managing him, personally i agree with you urethral catheterization can be harmful.
stop blaming yourself, blame others.

Anonymous said...

jj jj.... i wonder whether you really understand this story.. ask POTS to play the blame game pulak. isk isk isk.... typical malaysian doctors.

Anonymous said...

THE WEAKEST LINK

This gentleman died a NEEDLESS death.

A chain is only as strong as its weakest link. In this instance the staff nurses are the weakest link.

Mr Tan was conscious. He could alert the nurses whenever he needed to relieve himself.

They did not want the trouble of having to bring the bed pan to him. Sticking the urinary catheter was a convenient way of dealing with something they considered a nuisance.

They were thinking only about themselves not the welfare/well being of their patients.

It is a COP OUT Period.

Q8-) Apoplectic kindred spirit

Anonymous said...

isn't this semi-confession or post death analysis, fodder for the old woman to seek legal recourse? negligence? malpractice?

writingangel said...

It wasn't your fault. You have done what you can to help him..