Monday, June 2, 2008

Times I Screwed Up (3)

It was already two days after the traumatic episode on the day I first saw him. From a young bull working with concrete cement and heavy tools, Kumar was reduced to a pathetic soul fighting for a brief breath of fresh air. Kumar was heavily sedated and connected to a portable bedside ventilator providing much needed breathing assistance.

Times I Screwed Up (3)

He was already in a very ill condition on the first day I saw him. Kumar hailed from India, a migrant worker who traveled across the ocean to do hard labor in a construction site in Sabah Borneo. Twenty-three years old with abundant energy and presumably lots of hopes and dreams, he was on the building’s second floor when it collapsed under him one humid Sabah afternoon.

Three of his co-workers were killed instantly in the concrete rubble. According to eyewitnesses, they were on the ground floor when ferrying bricks with a wheelbarrow the roof came tumbling upon them. Kumar was one of the seven survivors. He also had the worst injuries. Upon arrival at the casualty unit, he gsping for breath and was already drifting in and out of consciousness. He was instantly intubated to protect his airways from blood, secretions and any recently ingested food. His injuries included a broken jaw and a fractured tibia. There were no notable brain injuries on the CT scans.

It was already two days after the traumatic episode on the day I first saw him. From a young bull working with concrete cement and heavy tools, Kumar was reduced to a pathetic soul fighting for a brief breath of fresh air. Kumar was heavily sedated and connected to a portable bedside ventilator providing much needed breathing assistance.

Tousled lines and meandering tubes protruded out of his bodily orifices. Figures in red were blinking in a frenzy on the monitor screen next to him, pleading for attention from any passer by. He emitted a terrible stench comprising a blend of dried, stale blood with fresh, loose stools, spilled concentrated urine with thick, greenish retained phlegm. His left leg was wrapped in a cast, with scattered areas stained by blood and pus seeping through the bandage. His other limbs were restrained to the bed, indicating a recent attempt by the patient to remove the many irritating apparatuses invading his now frail body.

It was a daunting task to review an ill patient for the first time. A ventilated patient can’t talk. One has to read through the thick medical notes from page one to get a faint idea of who the patient is. It didn’t help that most doctors’ writing is as decipherable as the Dead Sea Scrolls.

Kumar’s observation charts were not very reassuring either. He was running a high grade fever despite being on multiple antibiotics. He was not passing much urine despite the voluminous fluids. His heart rate ran between 120-140 beats per minute, with an increasingly low blood pressure. Blood investigations revealed a deteriorating kidney.

We changed antibiotics and searched for any hidden foci of infection. Blood cultures, urine sampling, tracheal aspiration and wound swabs yielded nothing, yet his fever and symptoms of worsening sepsis did not relent. Despite aggressive hydration and eventual inotropic support, Kumar remained critically ill on the brink of death. He was taken off sedation and morphine two days later.

He did not wake up, however.

In fact, Kumar never woke up ever again.

He merely deteriorated into a deep comatose state and passed on uneventfully.

His employers came to collect his remains. The agent who brought him to Borneo made a brief mention of a wife and two young kids and duly moved on.

I moved on too. It was hard trying to feel sad and sympathetic over a patient whom I’ve not spoken to directly or gotten acquainted to personally. A mortality meeting was held to discuss his death but these audits are usually done as a routine practice rather than a genuine inquiry. We came out of the meeting with no conclusion on Kumar’s death.

Cause of death: Indeterminate.

I may sound callous but to be honest, Kumar was quickly erased from my mind.

He was gone and very much forgotten, until one day – one typical, lackluster working day.

An elderly man was not passing urine after his hip operation. He was fasted the whole night before and was still kept fasted after the surgery. I checked on him and discovered that his left arm was entirely swollen and effusive. It felt doughy. It happened overnight according to him.

It was at that moment that I experienced both a dumbstruck and a eureka moment. Suddenly, everything about Kumar came rushing back to haunt me demanding accountability and a verdict.

Kumar did not die of a overwhelming infection. Kumar did not pass away from a severe brain injury. Kumar did not succumb to a fractured tibia or a broken jaw.

Kumar died from dehydration.

His intravenous (i.v) drip was not running. The i.v line was out of place. His right arm was swollen, just like the old man I was attending to.

All the fluids we were giving. All the costly antibiotics and supportive medications. They never reached the man. He was basically drying up inside out while remaining sedated and restrained. No wonder he never responded to any treatment. That was why his kidneys were failing and he passed little urine. We did everything but did not check his iv line. As a result of our carelessness and oversight, a wife will walk life without her husband and two kids will grow up not knowing their father.

A team of skilful surgeons, a band of enthusiastic interns, an armamentarium of sophisticated medical contraptions, a cocktail of potent medications – they were all defeated and put to shame by a non-functioning intravenous line.

What a needless death.

Such an unredeemable mistake.

Guilt and remorse show no mercy when they punish the convicted. In Kumar’s case, I plead guilty as charged.

Will he be one of the five people I meet in heaven?

If I ever reach heaven, that is.


darren said...

everything happens for a reason. he's now free from worldly problems.

sojourner said...

thanks for sharing this story. i guess we all have had our fair share of 'times we screwed up'. i would like to believe that if you met Kumar in heaven, he would not blame you for his death

Product of the System said...

Friend, why are you reading blogs when you're Down Under on a much needed break?

cute little angel said...

I'm just blog-hopping and I must say that what u've wrote about really touched me. Sometimes we fail to look at the small things which we find irrelevant, we take these things for granted and in the end it is these little things that matter the most, that makes all the difference. Nevertheless, you did your best. U did all u cld do within ur capabilities. You made the best dicisions you clould make at that point in time aand that is all that matters. More importantly, you now know your mistake and you will be much more careful next time and prevent many more deaths. It's far better than not knowing and letting it happen over and over again.
p/s I'm just giving my two-cents worth kay? DOn't mean to offend anyone >.<

Alan said...

if he's in heaven, you'll certainly meet him...

jj said...

again another story about the importance of an IV line.
i'm working in HDOK sandakan, (surgery department), where my bos (the well known mr ng) is very particular about an IV line.
he will say the F*** and the S*** word if he notice that the pt had problems with IV line ie infected, not securing properly, swollen arms.
he will check the pt's IV line every morning round and is our duty (not the SN) to make sure its all OK.

ccc said...

Err... Out of way IV line in a ventilated patient for 2 days? Are you sure? Sounds quite impossible to have only a single brannula in trauma patient, and without CVL with hypotension after ventilation...

pilocarpine said...

good point, ccc.

Product of the System said...

Dear CCC/Pilocarpine,

I didn't really want to add in too much medical details.

Unfortunately, it was the presence of a central line that made everything worse. The morphine and midazolam were being infused thru the central line (it was a single lumen long line inserted by a house officer as the orthopaedic MOs were not confident of inserting one). He had two other large bore cannulas, one grey another orange. The orange one was removed after he developed thrombophlebitis. The grey one was left in situ and was the culprit culminating in Kumar's death. The morphine and midazolam were unfortunately still being delivered to the patient, rendering him sedated and weak while dying of thirst and dehydration at the same time.

It didn't help that the nurses change IV drips every 6 hours without wondering why there was still so much left each time. I only found out about this much later.

Do you see why i don't wanna add too much details?

It becomes a blame game as well as one that is too technical for non-medical personnel to appreciate.

This blog is not meant for doctors alone, mind you.

Thanks for questioning though. It shows that you guys are thinking...