She dies when doctors pierce her heart

last SG · 2006-07-22T12:10:47+00:00

dead person not big shot right? then no problem liao. great to be docs in SG . make mistake during training? no prob... more guinea pigs there...

oxford mushroom SG

Originally posted by Dogtor:
Some observations:

1. [b]Inexperienced doctors need to get experience - so how? Of course, some patient will always end up being the first case of some trainee doc. Doctor choice applies only to private full fee-paying docs. BUT please note that many consultants have not done procedures in years, so sometimes the best people are usually senior registrars or registrars in their 2 or third year!!

2. More importantly is the need to ensure adequate supervision.

3. Puncture of the heart is a known complication of thoracentesis and pleural biopsy - even in the best of hands, and even under radiological guidance.

4. In our restructured hospitals - they are also our training institutions. The aforementioned procedure takes approximately 1 hour to perform. It takes about 1 hour to organize all the pre-procedure blood tests and radiographs and to review the results. Post-procedure it takes half an hour to write the procedure note, get a post-procedure radiography and review the result. A trainee doc and a supervising doc if paid at locum rates (at least $60/hr) will put in about 2.5 hours getting this thing done (so labour cost - just doctors only not including ancillary staff) will be $300. The procedure equipment and peri-procedural tests etc would cost something. The last I was told way back in 1998 when I was helping out with these procedures was the private docs were charging about $1200 procedure fee.

So ..... I wonder how much this procedure would have been billed and what was actually paid by patient/medishield/medisave.

If you have truly instructor/clinical faculty supervision, who set aside time (ie, consultants, experienced registrar = time = >$200/hr), clearly medical training/education and procedure costs will be very high.

WHO WANTS TO PAY?

I did my graduate medical training in the USA for 6 years, estimated to cost the US government $100 000/year - all free. + Great lifestyle and freedoms in the USA. SINGAPORE CANNOT COMPETE!!!!

Now I am FT in USA ?!?!!?[/b]

Years ago, we first trained to insert chest tubes by practising on cadavers...there were lots of unclaimed bodies in the mortuary in those days. By the time we first performed the procedure under supervision on a live patient, we had already done at least 5 insertions on dead bodies. Obviously, you have to practise on simple cases before going on to the complex ones.

Nowdays, young doctors do not have any dead bodies to practise on. What's worse is that many patients refuse to allow a junior doctor to do the procedure, which means we have medical officers who haven't even done a single chest tube insertion. In the past, housemen used to do 2-3 chest tube insertions every day!

With more patients refusing to allow our juniors to do procedures, we are just pushing the problem back. Our housemen do not perform any procedures and now we have more senior medical officers who are completely inexperienced with some procedures.

As for billing for this procedure, if the patient is a C class patient, they probably won't have to pay for the procedure anyway...their expenses are capped.

oxford mushroom SG

That's not true. The ward consultant knew about the enlarged heart and it did not prevent him from asking a completely inexperienced MO to perform the procedure. So what if the other doctor knew about the enlarged heart, the MO still had to do the procedure.

If there is any fault, it lies with the consultant for improper delegation of the job, although it must be said that chest tube insertion should be within the competence of an MO. I do not know if the MO is a foreign talent (I suspect he is) but in any case, there are problems with training of junior doctors as I mentioned in an earlier post. Part of that fault lies with patients.

All medical diagnoses are an exercise of judgment. Based on your knowledge and experience, you make a judgment as to the most likely diagnosis. You hope to be right most of the time but NO DOCTOR IN THE WORLD IS EVER ALWAYS RIGHT.

One way to reduce errors is to involve other doctors to arrive at a consensus opinion. It is already a requirement in the UK for multi-disciplinary teams of experts to decide on treatment of various cancers, so it is no longer the knowledge and experience of a single doctor but a whole team of them.

Of course that is 'inefficient', takes a longer time and costs more. That is the price of quality. Unfortunately, Singaporeans are not prepared to pay more for quality healthcare..there are forumners who think that we do not need highly trained doctors and high-tech diagnostics. In this case, as suggested by the expert witness from Singapore Heart Centre, radiology guided chest tube insertion might have prevented the tragedy.

But Singaporeans will kpkb about the high cost of healthcare. As I said, you pay peanuts, you get monkeys.

Dogtor SG

As always, Oxford Mushroom - you are quite right and wise - rendering you as one of the docs who is almost always right.

The dogmatic approach in Singapore with high and mighty consultants and a unchallenging junior doc class can sometimes result in poorer care.

Complex medical care requires a multi-disciplinary approach and the physician-in-chief of today should be trained to assimilate care options/opinions, which at times is quite lacking. The medical fraternity thinks it is a sign of weakness to ask for help or to use a team-approach?!?!?

Dogtor SG

Ummmmmmm..... the last time I used a steroscope was examining a fungus during biology class in RJC in 1988 to 89 ......

ShutterBug SG

Yes, you do have a point. However, I do not see the logic why ANY person in ill or good health, would want to or readily submit themselves to a YOUNG and or INEXPERIENCED doctor for any kind of invasive procedures?

How doctors are trained in the medical industry either with a cadaver or a live patient, is an onerous issue for medical schools/universities. Otherwise, how could NASA train astraunauts to operate and undertake procedures in space on earth? Yes they have huge olympic sized pools, and hence I believe means of practice should be creatively developed for medical training as well.

On the issue of costs in healthcare here, all I can say is - our gov has made enough money, it's high time it starts making a little less and give public SAFE & decent healthcare that matches costs and not hide behind a slew of stats abd economic jargonic summary.

oxford mushroom SG

Nobody wants an inexperienced doctor to perform a procedure on them, but you cannot gain that experience unless you practise it on your patients (albeit under supervision). Would you prefer that your surgeon operates on you having years of experience practising on pigs and rabbits alone?

The next best thing to live patients would be cadavers but hardly any Singaporeans would donate their bodies to science nowadays. If patients do not allow our junior doctors to gain experience with performing procedures, we will have more disasters like this one.

Creative means? Sure, we train junior doctors using simulators but the technology is very expensive but far from realistic. It's like learning to fly using a simulator only without real flying experience. Would you accept a pilot who passed the flying test on the simulator and allow him to fly a 747 passenger plane next? But that's what we are asking our doctors to do if they are not allowed to learn such procedures on live patients under supervison.

In the UK, patients generally do not object to young doctors practising such procedures as long as there is adequate supervision. One big reason is because they do not pay upfront anyway.

An experienced doctor is the result of learning from his many mistakes. As Edison said when he was asked about his success after failing 1000 times to invent the electric bulb, "I have not failed. I've just found 10000 ways that won't work."

If patients refuse to participate in the training of junior doctors, we will not have experienced doctors in future. Ultimately, it is the patient who suffers.

ShutterBug SG

In this case, as you have pointed out in much details, it would suffice to say that all trainee (or otherwise young and or new) doctors should/must be supervised when carrying out such procedures.

sourketchup SG

[quote]Originally posted by oxford mushroom:
[b]
That's not true. The ward consultant knew about the enlarged heart and it did not prevent him from asking a completely inexperienced MO to perform the procedure. So what if the other doctor knew about the enlarged heart, the MO still had to do the procedure.[quote]

Beg to differ. If the medical officers are not competent enough to do the job, they should say so. "First, do no harm", isn't that right? Second, it is not a matter about them being inexperienced doing the procedure, it is about an X-ray that is available, that would give information about a part of the body that they are going to insert a tube into, and one did not pass on the information, and the second one did not bother to check. This is not just inability to perform a procedure, my friend, this is simple carelessness which have resulted in a family losing a loved one.

iceFatboy SG

it is a tragedy for the victim & family.

I am quite appalled that nothing was done for the victim, but just someone who probably have read more medical books have come out with a statement that covers everythng up.

I believe further investigation should be carried out.

yes, the aim is not to penalise but how to assure the public that a next victim won't be swept under th blanket again.

Given the current state of our medical, I question the flu exercise as more of a confidence blooster for the public than more functional exercises.

oxford mushroom SG

Originally posted by sourketchup:
Beg to differ. If the medical officers are not competent enough to do the job, they should say so. "First, do no harm", isn't that right? Second, it is not a matter about them being inexperienced doing the procedure, it is about an X-ray that is available, that would give information about a part of the body that they are going to insert a tube into, and one did not pass on the information, and the second one did not bother to check. This is not just inability to perform a procedure, my friend, this is simple carelessness which have resulted in a family losing a loved one.

You missed the point. As the expert witness pointed out, it was not a requirement to view the CT scan before performing the procedure. Further, even if the second doctor knew of the enlarged heart, it would have made no difference. The ward consultant, who would have known about the enlarged heart, nevertheless ordered the MO to perform the procedure. The consultant was not sufficiently worried to order the procedure to be performed under radiological guidance.

MOs should be competent to perform chest tube insertions, a procedure that used to be done routinely by more junior housemen. The problem is that junior doctors now have little opportunities to gain experience because the larger numbers of private patients refuse to allow junior doctors to do the procedure.

Ultimately, young doctors have to learn and pick up experience. If they do not learn from patients with simpler conditions, their first case might well be a difficult case like this one.

As always with cases like these, I fear the hospital response will be to limit chest tube insertions to even more senior doctors. But that is only prolonging the inevitable. If housemen and junior MOs are not allowed to perform such procedures, in a few years, we will have senior MOs and registrars who will be doing the procedure for the first time.

This case has everything to do with error of judgment and experience. That is why the court did not find any negligence relating to the two MOs. Of course the Coroner's verdict does not prejudice any subsequent litigation the family might bring, but they will have a high hurdle to clear.

sourketchup SG

Have to disagree with you there, and with the expert witness as well. The CT scan is there to show the heart is enlarged, and hence, the danger of perforation during the insertion would be very much higher. If the more senior MO was aware of it, it would definitely have made a difference. Surely more care would have been taken during the procedure. Or, if the procedure is deemed too dangerous, not attempted at all. Pleural effusion may not kill, a perforated heart definitely will.

It just doesn't make sense. The CT scan is there, but the results were not kept in mind before the procedure. It is like a surgeon performing an operation refusing to look at the films of a CT scan, knowing full well that it has been done beforehand.

nightzip SG

Have to disagree with you too. We know that the procedure will be done with or without the CT, its not the point. The point is that if the doctors have seen the CT, they would have been MORE cautious in performing the operation. (Not not operating).

Further, thinking back, why he had poke through the heart? It would require a large force to pierce through it...apparently, if manually done, any experienced doctor/surgeon would have "felt" the unusually more force needed to pierce through than normal, i.e. the lungs. Mad

Any mechanical engineering undergraduate knows about it. Mr. Green

oxford mushroom SG

That's why I said that if there is any fault, it lies with the ward consultant for delegating it to a MO. The consultant did not think that the enlarged heart necessitates a radiology-guided procedure and in fact, all of us have performed left-sided chest tubes in patients with enlarged hearts before without problem. It all depends on the degree of heart enlargement and the skill of the operator. We do not know how big the heart is, the ward consultant knew, and decided that his MO could handle it. He was wrong.

Every doctor should take proper care when performing a procedure in all patients. I am not sure I undrestand how one can take 'more care' when doing a particular case and 'less care' with other cases. However, knowing the heart is enlarged may mean that the doctors might abort the procedure earlier and ask for radiological guidance. However, that is pure speculation and the court cannot predict what the doctors would have done differently had they known about the enlarged heart. The expert witness apparently did not think that it would make a material difference and the court has accepted his evidence.

As for the force required, chest tube insertion does require a fair amount of force, depending on the gauage of the trochar and the patient's musculature. There is a give when the trochar clears the chest wall and therefore it is important to prevent the trochar from going too far in when the resistance of the chest wall suddenly gives way. I suspect that was how the MO penetrated the heart. If the patient had been moving during the procedure, the position of the trochar might have changed and that might contribute to penetration of the heart as well.

That is why it is so important that junior doctors must gain experience from doing lots of procedures on live patients with simpler conditions. The way I see it: the problem in this case isn't that the MO didn't exercise enough care, I think it is a matter of competence and experience.

That said, even in the best of hands, penetration of the lung (more common), heart and even liver and spleen have been reported. It is a known complication of the procedure, although with experience, the complication rate obviously falls.

However, I do not understand why the ward consultant decided on a chest tube instead of a pleural tap. If there was a large effusion, it would be easy to tap it with a small needle from the back. You will not clear all the fluid, but it should relieve the breathlessness significantly. After all, if the effusion is due to her failing heart, it will re-collect unless the diuretics and digoxin work.

In a patient with an enlarged heart, that would be much safer and the worse that can happen is that you puncture the lung and cause a pneumothorax, which is far better than puncturing the heart.

sourketchup SG

Is the consultant aware of the findings of the CT-scan? We are assuming that he knows that the heart is very enlarged. It has to be. Puncturing the liver or the spleen are known complications, but these organs are just adjacent to the chest wall. In comparison, the heart, which is quite centrally located, has to be pretty enlarged to be anywhere close to the chest muscles.

As to how they can be "more careful" as compared to "less careful" or "always careful", the point is that if both are aware of how big the heart is, and still elected to go ahead with the procedure, at the very least they are very conscious of the fact that the heart is very close to the pleural muscles. And if they are not confident, don't do it. As doctors, they should "first do no harm".

The issue here is, the guiding doctor is not aware of the enlarged heart because first, the junior doctor did not say. Second, that guiding doctor did not bother to check. Isn't it a doctor's duty to review through every single radiological test, especially one so pertinent to this planned procedure, before proceeding with it?

Now assuming that the senior consultant knows the CT scan results, I still do not think the consultant should be implicated, simply because if these two doctors think they are not up to it, they should say so, and ask for senior assistance. The point is, it seems that the more senior of the two, who is supervising the procedure, is not even aware of the enlarged heart of the patient.

As the expert witness puts is, "it would have been wise for Dr Verma to have done so in this case because he was unfamiliar with the patient's case and the CT scan was already available."

The same witness also "noted that the inexperienced Dr Wijeweera should have prepared for the case thoroughly."

I really hope this case serves as a sad warning that all doctors should review their patients thoroughly before performing any procedures.

ShutterBug SG

After observing you people's knowledgeable discussion and debates, I still see GROSS NEGLIGENCE on the part of the two doctors involved.

Black is Black, white is white.

Unless someone here is suggesting there is gray - a mixture of both black and white.

BillyBong SG

SB:

At some point, we need to be mindful of how we address criminal charges against doctors in the course of mistakes that may or may not cost lives. Their job is to save lives and it would be extremely difficult to work for fear of retribution. After all, even great doctors make mistakes.

In my experience, there are several professions that, on a daily basis, tread precariously near danger. Doctors, Aerospace engineers, shipyard supervisors etc etc. While they are essentially licensed and certified for the job, there are also plenty of things that could go wrong, especially during the course of daily work.

Doctor's rank among the highest in such professions, simply becuase they lack sufficient sleep and are overworked in all areas. This increases the danger of clinical errors in the OR and diagnosing incorrect drug prescriptions to patients.

As much as we want to find closure by arrowing a scapegoat, sometimes, accidents do happen. The headlines (sensationalised for maximum effect) was seriously damaging and implied that negligence was probably the cause. Given the outcome of the investigation, it is therefore likely that the caption was wholely misleading in its innuendo.

Still, a life was unnecessaryily lost. Those two doctors will be mentally scarred for life; that is their eternal punishment. Putting them in the dock and reading charges against them would have been cooking an already boiled egg.

ShutterBug SG

Very well worded.

But still, it doesn't change the CARELESS nature of what transpired in the name of saving a life, as medical professionals.

Can the same then be said when a pilot crashes am airline resulting in hundreds of lives lost????

Scarred for life indeed it will be again?

sgheartland SG

I think right now we are really caught in a bind. Blaming the doctors cannot bring the dead back to life but the guilt will be there for those who are negligent and they jolly well remember it.

On the other hand, costing results in this situation. But the thing is can most of the people afford to pay. IF can stay in A ward, who dun want. It is not really that we want cheap things but how much do we have left to spend on medical fees for ordinary Singaporeans after all expenses.

So does it mean that whether we want cheap or cannot afford, that is life and we have to accept the kind of treatment from our health care system?

Justifying the deaths on cost is not right. The main thing now is to see that similar negligence do not take place, and don't do it for the people, do it to protect their own reputation (or is this type of review also too costly)??

oxford mushroom SG

There are strict criteria to establish negligence and the coroner has established that there is no negligence in his judgment. Although this will not influence the results of any subsequent civil litigation, it increases the likelihood that a second judge will come to the same decision.

The ward consultant will be liable if the junior doctors are found liable, by virtue of vicarious liability. As far as I understand, the ward consultant based his decision ask the the MO to insert the chest tube based on the chest X-rays, not the CT scan. In other words, even if the CT scan had not been done, it would not have influenced his decision.

In negligence, you have to establish duty of care, dereliction of duty, causation and damage. If you try to argue that failure to review the CT scan was the negligent act, you have to establish that the act directly led to damage. Since even the expert witness testified that it wasn't a requirement to view the CT scan before doing the chest tube insertion, you have a problem trying to establish dereliction of duty beyond the standard of Bolam's test. Further, if the ward consultant would have ordered the procedure anyway irregardless of the scan results, unless the MOs would refuse to proceed had they seen the CT scan (highly unlikely if the consultant told them to go ahead), you have a problem trying to establish causation.

We do not know exactly where the trochar was inserted. Normally the risk of cardiac trauma is very low even if the heart is very enlarged, as long as it is inserted correctly. It is more likely that the angle or the site of insertion was incorrect, perhaps because the patient moved during the procedure.

Yes, this patient is already dead. The more important issue is how to prevent such occurrences. One element of the solution is to get junior doctors to do more such procedures under adequate supervision. If junior doctors do not get enough of such experience, we will have increasing senior doctors who lack the expertise.

sourketchup SG

Yes. A doctor with a sense of responsibility would review all investigations before performing a procedure or operation. But it would not be easy to prove this technical detail in a court of law that if the 2 doctors had borne in mind what the CT thorax showed, then this tragic incident would DEFINITELY not have occured. I wonder how the family members are feeling now? Hope they find closure and get on with their lives.

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