She dies when doctors pierce her heart
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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.Originally posted by oxford mushroom: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.
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. -
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).Originally posted by oxford mushroom: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.
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.
Any mechanical engineering undergraduate knows about it.
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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. -
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. -
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. -
SB:Originally posted by ShutterBug:NO CHARGES.
Tell me, how would you feel, if that old lady was your Mother, or Grandmother??
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. -
Very well worded.Originally posted by BillyBong: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.
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? -
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)?? -
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.Originally posted by ShutterBug: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.
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. -
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.Originally posted by oxford mushroom: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. -
y nt say if that person is frm e lee...Originally posted by ShutterBug:NO CHARGES.
Tell me, how would you feel, if that old lady was your Mother, or Grandmother?? -
"Medical Hub" guidelinesOriginally posted by Darkness_hacker99:Irresponsible, Incompetent and Inexperience fellow
and backed-up wif full support by the gabramen and "justice" legal system.
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I'm unfamiliar with the facts of the case since it was not disclosed, so i think it's fair to to assume the 'careless' implication was suggested by the press.Originally posted by ShutterBug: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?
Let's not be doubly quick to jump the proverbial gun.
As for pilots crashing planes, it has been proven that over 80% of all aircraft accidents have been attributed to mechanical and electronic failure of the plane. The remainding 20% has been shared between air traffic controllers, airport conditions and pilots.
Don't forget, passengers must also be aware of the dangers of air travel, which is why FAA, EASA, CAAS and other aviation agencies etc maintain such a tight grip on aircraft safety. While it is perceived as the most high-risk form of travel, it is also the 'safest', considering the laundry list of impeccable requirements for engine repair and fusalage integrity.
In the case of pilot error, i think the seriousness is compounded by the huge loss of life, rather than fact that it was caused by human error. -
In this regard, you are saying that NEGLIGENCE cannot be proven just because an "expert witness" testified that it wasn't a requirement to view the CT scan ? Then what is/was the CT scan for? And who was the CT scan for? A souvenir for patient?Originally posted by oxford mushroom: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.
So by this example, in any other mishap or tragedy, caused directly or indirectly by any professional in any specialized field of work, an "expert witness" can come into the picture and futifully absolve any liabilities on the part of the specialist?
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The issue on cost was raised in that for procedures to be performed safely and well-supervised requires more manpower than is currently recognized.Originally posted by sgheartland: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)??
If you have been through NS digging fox-holes overnight till completed ---> that is but one exercise.
House officers and medical officers work like that every 6 days.
I remember on Medicine rotations as a house officer, I had basically no sleep or rest save 1/2 hr or 1 hr to wash up before the day begins anew.
You work to the point of being short of breath. Physically and mentally demanding. AND the job was not complete -- ie., still many patients needed stuff done for them -- there was just too much chores and stuff loaded.
I swear if I were ever in a position to change the way things are done - if these are indeed training positions as the GMC intended originally, then in many ways the supervisors and system failed the trainees.
The main reason ----> inadequate resources in terms of manpower, time. Becos' cost of procedure is not adequately reimbursed - so hospitals will only want the cheapest and free manpower to do them. -
I do not agree with Oxford mushroom states that "If Junior doc doesnot get enough of such experiance,we will hve increasing senior doc who lack the expertise"
According to my son who is the doctor, there are so many similiar cases have occured in their field of work in other countries, they do not need to make this type of mistake to gain their experiance.
Moreover,they are treating with human being not other live stock,one life loss will affect the whole family members' living.
The issue here is however why such a case happened,is it cause of low grade class of hospitalization or something wrong with the quality of the docs involved??? -
Hi Dogtor, to all that, you have the hospital management to blame. Right?Originally posted by Dogtor:The issue on cost was raised in that for procedures to be performed safely and well-supervised requires more manpower than is currently recognized.
If you have been through NS digging fox-holes overnight till completed ---> that is but one exercise.
House officers and medical officers work like that every 6 days.
I remember on Medicine rotations as a house officer, I had basically no sleep or rest save 1/2 hr or 1 hr to wash up before the day begins anew.
You work to the point of being short of breath. Physically and mentally demanding. AND the job was not complete -- ie., still many patients needed stuff done for them -- there was just too much chores and stuff loaded.
I swear if I were ever in a position to change the way things are done - if these are indeed training positions as the GMC intended originally, then in many ways the supervisors and system failed the trainees.
The main reason ----> inadequate resources in terms of manpower, time. Becos' cost of procedure is not adequately reimbursed - so hospitals will only want the cheapest and free manpower to do them.
What's happened to the upper echelons of organizational management? Where have all the administrative managers, directors, etc been doing?
They are relaxing in one corner, kiao-kah and drinking coffee, chit-chatting with friends, etc while the real work doers like yourself and other doctors are being battered with workloads after workloads....
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I fully agree with this.Originally posted by foomwee88:I do not agree with Oxford mushroom states that "If Junior doc doesnot get enough of such experiance,we will hve increasing senior doc who lack the expertise"
According to my son who is the doctor, there are so many similiar cases have occured in their field of work in other countries, they do not need to make this type of mistake to gain their experiance.
Moreover,they are treating with human being not other live stock,one life loss will affect the whole family members' living.
The issue here is however why such a case happened,is it cause of low grade class of hospitalization or something wrong with the quality of the docs involved???
Firstly, there are tons and tons of pass cases to be revealed in class before the doctor graduates. I suspect that schools of medicine did NOT have a module highlighting on pass cases and what to look out for in certain operations, etc...this you have the school to blame for lack of foresight to conduct such modules!
Secondly, you do NOT need a cadaver for experience. In this highly modern society, you can have look-a-like body made of foam, etc and with realistic organs etc (foam-gel like synthetic human body), which can also come up with complications (depending on the teacher, like sudden blood flow, sudden heart beats, lost of oxygen intake, or enlarged organs, etc) to see if the students can cope with funny cases. -
Simulations are never quite the same. You can have all the theory lessions in the world but it is a very different experience when you have to do it on a live patient. All medical practitioners will tell you that. Why do you think UK students go on electives to Malaysia and Africa to gain experience with certain procedures and deliveries?Originally posted by nightzip:I fully agree with this.
Firstly, there are tons and tons of pass cases to be revealed in class before the doctor graduates. I suspect that schools of medicine did NOT have a module highlighting on pass cases and what to look out for in certain operations, etc...this you have the school to blame for lack of foresight to conduct such modules!
Secondly, you do NOT need a cadaver for experience. In this highly modern society, you can have look-a-like body made of foam, etc and with realistic organs etc (foam-gel like synthetic human body), which can also come up with complications (depending on the teacher, like sudden blood flow, sudden heart beats, lost of oxygen intake, or enlarged organs, etc) to see if the students can cope with funny cases. -
Originally posted by ShutterBug:
One important element of negligence is to prove dereliction of duty and the standard required is as stated in Bolam's test, ie. the standard of any ordinary workman who professes to have an ordinary level of skill'. It is the test of one's peers...what another doctor at a similar grade or level of experience would have done. He does not have to be the most skilled person, but just an ordinary MO having the skill of any other ordinary MO.
In this regard, you are saying that NEGLIGENCE cannot be proven just because an [b]"expert witness" testified that it wasn't a requirement to view the CT scan ? Then what is/was the CT scan for? And who was the CT scan for? A souvenir for patient?
So by this example, in any other mishap or tragedy, caused directly or indirectly by any professional in any specialized field of work, an "expert witness" can come into the picture and futifully absolve any liabilities on the part of the specialist?
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If an expert witness testifies that he himself might not consider it a requirement to view the CT scan, it sets the bar much higher for the plaintiff. You have a reputable school of opinion which holds that the action of the MO in question is reasonable. What the plaintiff will have to do is to get more experts of his own to show that the first expert is not reasonable. It is not enough to show that some other experts disagree...as long as there is a minority expert opinion that is reasonable and reputable, it suffices to show that there is no dereliction of duty.
Of course the standard of one's peers may vary from locality to locality. It might be perfectly reasonable to expect a MO in a remote village of Africa to be competent enough to perform amputations (MOs in parts of Malaysia used to do that...they were the only doctors available and of course their medical training must keep that in mind). That would not be reasonable in Singapore, of course.
If junior doctors are not given sufficient exposure and experience during supervised training to perform a given procedure, the standard expected of them will drop for that procedure. -
... heheheee...Originally posted by oxford mushroom:One important element of negligence is to prove dereliction of duty and the standard required is as stated in Bolam's test, ie. the standard of any ordinary workman who professes to have an ordinary level of skill'. It is the test of one's peers...what another doctor at a similar grade or level of experience would have done. He does not have to be the most skilled person, but just an ordinary MO having the skill of any other ordinary MO.
If an expert witness testifies that he himself might not consider it a requirement to view the CT scan, it sets the bar much higher for the plaintiff. You have a reputable school of opinion which holds that the action of the MO in question is reasonable. What the plaintiff will have to do is to get more experts of his own to show that the first expert is not reasonable. It is not enough to show that some other experts disagree...as long as there is a minority expert opinion that is reasonable and reputable, it suffices to show that there is no dereliction of duty.
Of course the standard of one's peers may vary from locality to locality. It might be perfectly reasonable to expect a MO in a remote village of Africa to be competent enough to perform amputations (MOs in parts of Malaysia used to do that...they were the only doctors available and of course their medical training must keep that in mind). That would not be reasonable in Singapore, of course.
If junior doctors are not given sufficient exposure and experience during supervised training to perform a given procedure, the standard expected of them will drop for that procedure.
You know, I just realized, all the fancy terms legalities and technicalities that you mentioned, won't mean squat if the patient those two blokes killed was some minister's grandmother or mother.
They'll be in a way, 'strung up like dead ducks' by now.
It's all basically carelessness, regardless how sensible you make it all appear. And the more detailing you provide would only make it look prejudiced.
So then if such technicalities shields doctors from prosecution, this means any doctor can get away with murder. -
I find it really hard to understand. How can any reasonable doctor fail to look at a CT scan of a part of the body that he/she is about to perform a procedure on? It is like leaping without looking. Would a surgeon cut open an abdomen without looking at a CT abdomen if the films are available? Heck, he would put the films up and look at them as he is operating!
By this principle, the 2 doctors in this case has already failed the Bolam's test. Anyway, this is just my own opinion on this case. Bottomline is, doctors should thoroughly review every patient's casenotes before doing a procedure. -
No one really knows, only those two docs.Originally posted by sourketchup:I find it really hard to understand. How can any reasonable doctor fail to look at a CT scan of a part of the body that he/she is about to perform a procedure on? It is like leaping without looking. Would a surgeon cut open an abdomen without looking at a CT abdomen if the films are available? Heck, he would put the films up and look at them as he is operating!
By this principle, the 2 doctors in this case has already failed the Bolam's test. Anyway, this is just my own opinion on this case. Bottomline is, doctors should thoroughly review every patient's casenotes before doing a procedure.
But from what I see, as detailed by oxford_mushroom, it appears they can just lean on technicalities and absolve themselves from any liabilities as the surgeons who caused the puncture of the patient's heart. -
In my opinion,if the docs made any error or mistake,then they should be at fault.The litmus test is based on reason.
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A memeber said docs need to practice on this procedure. Of course,young docs should practice.But if the procedure is risky as this one, shouldn't experienced doc be on his side to ensure the 'practicing' doc does not make error?