Understanding Heath Care Differently

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Dr KK Aggarwal

Recipient of Padma Shri

“A six year old boy is admitted to the Children’s Assessment Unit (CAU) at Leicester Royal Infirmary following a referral from his GP. Jack Adcock, who had Downs syndrome and a known heart condition, had been suffering from diarrhea, vomiting and had difficulty breathing.

Dr Hadiza Bawa-Garba was a specialist registrar in year six of her postgraduate training (ST6) with an impeccable record. She had recently returned from maternity leave and this was her first shift in an acute setting. She was the most senior doctor covering the CAU, the emergency department and the ward CAU that day. She saw Jack at about 10.30am. Jack was receiving supplementary oxygen and Dr Bawa-Garba prescribed a fluid bolus and arranged for blood tests and a chest x-ray. At 10.44am the first blood gas test was available and showed a worryingly high lactate reading. The x-ray became available from around 12.30pm and showed evidence of a chest infection.

Dr Bawa-Garba was heavily involved in treating other children between 12-3pm, including a baby that needed a lumbar puncture. At 3pm Dr Bawa-Garba reviewed Jacks X-ray (she was not informed before then that it was available) and prescribed a dose of antibiotics immediately, which Jack received an hour later from the nurses.

A failure in the hospitals electronic computer system that day meant that although she had ordered blood tests at about 10.45am, Dr Bawa-Garba did not receive them until about 4.15pm. It also meant her senior house officer was unavailable.

During a handover meeting with a consultant, which took place about 4.30pm, Dr Bawa-Garba raised the high level of CRP in Jacks blood test results and a diagnosis of pneumonia, but she did not ask the consultant to review the patient. She said Jack had been much improved and was bouncing about. At 6.30 pm, she spoke to the consultant a second time, but again did not raise any concerns.

When she wrote up the initial notes, she did not specify that Jack’s enalapril (for his heart condition) should be discontinued. Jack was subsequently given his evening dose of enalapril by his mother after he was transferred to the ward around 7pm.

At 8pm a ‘crash call’ went out and Dr Bawa-Garba was one of the doctors who responded to it. On entering the room she mistakenly confused Jack with another patient and called off the resuscitation. Her mistake was identified within 30 seconds to two minutes and resuscitation continued. This hiatus did not contribute to Jack’s death, as his condition was already too far advanced. At 9.20pm, Jack died.

November 2, 2015: Portuguese agency nurse, 47-year-old Isabel Amaro, of Manchester is given a two-year suspended jail sentence for manslaughter on the grounds of gross negligence.

November 4, 2015: At Nottingham Crown Court, Dr Bawa-Garba is convicted of manslaughter on the grounds of gross negligence.

December 14, 2015: Dr Bawa-Garba is given a 24 month suspended sentence.

December 8, 2016: Dr Bawa-Garbas appeal against her sentence is quashed at the Court of Appeal.

June 13, 2017: The Medical Practitioners Tribunal service says Dr Bawa-Garba should be suspended for 12 months and rejects an application from the GMC to strike her off the register. It says: ‘In the circumstances of this case, balancing the mitigating and aggravating factors, the tribunal concluded that erasure would be disproportionate.’

December 8, 2017: GMC takes the MPTS to the High Court and argues its own tribunal was wrong to allow Dr Bawa-Garba to continue to practice.

January 25, 2018: The GMC successfully appeals at the High Court bid to have the MPTS decision overruled, leading to Dr Bawa-Garba being struck off the medical register. Lord Justice Ouseley says: The Tribunal did not respect the verdict of the jury as it should have. In fact, it reached its own and less severe view of the degree of Dr Bawa-Garba’s personal culpability.’ Health secretary Jeremy Hunt says that he is deeply concerned about its implications.

January 26, 2018: Prominent GPs tell Pulse that the ruling raises serious questions about how doctors reflections are used and recorded, and that new guidance is now needed urgently.

January 30, 2018: An influential international doctors group accuses the GMC of treating black and minority ethnic doctors ‘differently and harshly’, following the High Court case.

January 31, 2018: Dr Bawa-Garba’s defence body releases a statement saying e-portfolio reflections were not used against her in court, despite ‘wide misreporting’ that they were. But Pulse uncovers that her reflections were used in court, from a document submitted as evidence by the on-call consultant on the day.

February 7, 2018: Following a crowd funding campaign, which raised over £335,000, Dr Bawa-Garba decides to appeal the ruling, and considers appealing the manslaughter conviction from 2015.

February 12, 2018: The GMC refutes claims that there was discrimination in its decision to launch a High Court bid. In response to an open letter from the British Association of Physicians of Indian Origin (BAPIO), the GMC said the accusations were ‘troubling and without merit’.” [From media reports]

Dr KK: This is a historic case and will be remembered in the history of medical profession. We also must react, or this will lead to unnecessary antibiotics. In history, no case has been filed for giving an antibiotic, but all cases filed are due to delay in instituting an antibiotic, as also happened in this case. One of the experts in this case said in the court if antibiotics were given at admission the child would not have died.

Dr KK Aggarwal

Padma Shri Awardee Vice President CMAAO Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Night shifts increase breast cancer risk, especially for nurses

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Ectopia cordisis a rare birth defect and affects five per million births globally

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Women must take precautions and make certain lifestyle changes to prevent birth defects in babies

New Delhi, 20 December 2017: As per statistics, Ectopia cordis is a rare birth defect and is reported to happen in 5 per one million births globally. About 250 such cases have been reported globally and another 23 cases have been recorded in India. This condition is more common in male infants. Among the various types, abdominal ectopic cordis has a better prognosis while cervical and thoracic ectopia cordis are quite fatal within days.

Ectopia cordis is an extremely rare birth defect in which the heart is abnormally located either partially or totally outside the chest cavity. Normally, the heart is located in the chest cavity in between the lungs. However, in this rare condition, the heart forms either partly or totally outside the chest cavity. The ectopic heart may protrude through the neck, chest, or abdomen. In most cases, the heart protrudes outside the chest through a split breast bone [sternum].

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, “This birth disorder is usually fatal and a new born with this condition rarely survives for more than a few hours or days. During a baby’s development in the mother’s womb, the chest wall does not fuse together as it normally should. This prevents the heart from developing in normally, leaving it exposed outside the chest wall. Ectopia cordis is also classified in two different ways according to its location: with reference to chest cavity and with reference to the vertebral column. As the heart may be positioned completely outside their body, itis unprotected and extremely vulnerable to injury and infection. This condition almost always involves additional problems with the structure of a child’s heart and can lead to difficulty in breathing, low blood pressure, poor circulation, low blood pH, and electrolyte imbalance (dyselectrolytemia).”

Most of the infants born with ectopia cordis have other medical problems as well. This includes other abnormally developed organs.

Adding further, Dr Aggarwal, said, “Infants who survive birth with this condition require intensive care including incubation and use of a respirator. Experts may also use sterile dressings to cover the heart. Other supportive care, such as antibiotics to prevent infection, is also needed. There are cases in which it may be attempted to relocate the child’s heart inside their chest and close their thoracic cavity. However, this has many challenges, particularly if the child has severe defects.”

Although this is a condition that cannot be prevented, there are certain tips a woman can follow to prevent other birth defects in newborns.

  • Consume a healthy diet rich in fruits, vegetables, and whole grains. Limit the intake of processed or junk food.
  • Quit smoking or drinking as both these habits can harm the fetus. Avoid any form of drugs as well.
  • Some infections that a woman can get during pregnancy can be harmful to the developing baby and can even cause birth defects. Follow a healthy lifestyle to avoid these.
  • Get all your pregnancy vaccinations on time and take any medications prescribed as per schedule.

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