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The Day My Patient Died

Dr. Quresh Maskati

This patient had come from 1200 km away. He was a 35 year old male with rheumatoid arthritis with bilateral corneal opacities with bilateral peripheral corneal melts. In addition, the left eye had facial palsy with corneal exposure on attempted lid closure. Vision was only perception of light with accurate projection both eyes.  He had multiple medical problems besides his rheumatoid arthritis. He gave history of stroke with left sided hemiparesis 6 months prior. There was still residual weakness of motor function left upper extremity as well as left facial palsy as mentioned earlier. He had aortic stenosis with aortic regurgitation. However, he had been investigated extensively by a local cardiologist, including 2D echo studies and pronounced “fit for surgery”.

After discussion with my anaesthetist, it was decided to do bilateral amniotic membrane transplant with left eye lateral one-third tarsorapphy under general anaesthesia. She felt that the ejection fraction of the heart was good, the aortic condition was stable, and recent ECG showed no changes. It was also economically advantageous for the patient as he could go back to his home after 4 days. The risks of surgery and anaesthesia including death, were clearly explained to the patient and accompanying relatives.

 

The surgery went smoothly, lasting approximately 2 hours.  The patient was hooked up to a cardiac monitor as well as a pulse oximeter. All vital signs remained perfectly normal during the surgery and the cardiac monitor showed continuous sinus rhythm with no extra systoles or any other abnormalities during the entire duration of surgery. On table the patient recovered full consciousness, asked for me, complained to me of mild pain in the eyes (11.25am). I reassured him that this was due to the bilateral eye patches and that he would be all right soon. The anaesthetist then accompanied the patient as he was being wheeled to the ward.  She suddenly noticed that he had stopped talking and his breathing was irregular, while they were barely 10 feet outside the Operation room (11.30pm). The patient was immediately wheeled back to the OR and hooked up to the monitoring machines. 100% oxygen was started and he was once more intubated. He went into intermittent ventricular tachycardia and later into ventricular fibrillation. He was administered shocks using a defibrillator several times with no improvement. All emergency resuscitative measures including atropine, soda bicarb, decadron and even intracardiac adrenaline failed to revive the patient (12.30pm). I called in a cardiac ambulance to shift the patient to Cumballa Hill Hospital, which was diagonally across the street on the advice of the anaesthetist so that a pacemaker could be inserted. However the doctor accompanying the ambulance refused to transport the patient as she felt the patient was already clinically dead and she did not want the hassles of the patient being declared as having died during transport! We then called in the cardiologist from |Cumballa hospital who declared the patient dead.  However he was unable to give a death certificate as he said he was an employee of Cumballa. He could not give a death certificate to any patient not admitted to Cumballa. He agreed to write on our hospital case sheet that he examined the patient and found him dead (1.30pm). The patient’s relatives had been told the patient was serious when he was taken into the OT a second time. They were explained what had happened. They were told that sudden death in patients of aortic stenosis is known especially following stress, including surgical stress. As they had also talked to the patient post-operatively, they were understanding and realized it was not a surgical or anaesthetic complication. I then called up the nearest police station and asked the police team to come immediately.

 

The police team (2 sub-inspectors from Gamdevi police station) arrived an hour later (2.45pm). They asked me why I bothered to call them as all I needed was a friendly family physician who would sign a death certificate stating the patient died of a ‘heart attack’ and let the body go to the patient’s hometown. I said I did not want problems of a medico-legal nature later. They then explained the procedure to be followed. They would conduct a “panchnama” i.e. in the presence of witnesses, record the statements of the relatives. The body would then be sent to the JJ coroner’s court for a postmortem. After this the JJ authorities would issue a death certificate. This death certificate would have to be taken to an office in Kasturba hospital for permission to take the body out of the state. After this the relatives could take the body away. The cops were deliberately very slow with the recording of the statements.  However, because I had a clear conscience and the relatives were co-operative, we waited patiently for them to finish. It took them 2 hours to write about 2 pages of notes. In the meantime, from the yellow pages telephone directory, we had located a nearby undertaker. He assured that once we had the death certificate, he would take charge of the body, transport it to his office, embalm it, pack it in a casket and send it to the patient’s hometown along with one relative, by air, the next morning for Rs.13, 000/- for which full receipt would be given. The patient’s relative agreed to this rate. After the cops finished with the statements, they themselves called a govt. hearse, which took the corpse to the JJ hospital for PM. By this time the relative was losing patience. The morgue employees sensed this and told the relative that there were several bodies preceding their patient and it could take several hours. I had sent my hospital manager with the body and the relatives, precisely to prevent the relatives from getting taken for a ride. However, before he could open his mouth, the tired relative asked the attendant if he could speed up the process- he even told him how much money he was carrying!

The attendants took all the money. The forensic doctor issued the death certificate within an hour, after a very quick post mortem examination. The morgue attendants then rushed the body in the hearse to the railway station, where they made the train halt for 10minutes till they finished all the paperwork required. The relatives were bundled into the second class compartment and the corpse was put into the luggage compartment. At 7.30 pm the train left the station with the body and the 2 relatives (minus their money) for an 18-hour journey to their hometown.

 

The purpose of writing this article is to inform colleagues what is the official procedure to be followed in such circumstances and also the obstacles they may encounter so that they do not panic. The important thing is to explain as fully as possible to the relatives exactly what is happening and continuously communicate with them. If the relatives have understood that you have done your best, there is no need to resort to any shortcuts. Allow the law to take its course, even though the guardians of the law may want you to do otherwise!

QBM

 

Dr. Q.B. Maskati is a reknowned corneal surgeon from Mumbai and pastpresident of All India Ophthalmological Society (AIOS)