JDWNRH asks for early pa­tient re­fer­ral

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Jigme Dorji Wangchuck Na­tional Re­fer­ral Hos­pi­tal ( JDWNRH) asked the early re­fer­ral of the pa­tients from pe­riph­eral hos­pi­tal to pre­vent death and as­sures peo­ple to trust in avail­ing the ser­vices from JDWNRH .

This state­ment was made in ac­cor­dance to the Bhutan Med­i­cal and Health Coun­cil's ( BMHC) de­ci­sion to rep­ri­mand three doc­tors and three nurses for two years on Novem­ber 8 .

The six health pro­fes­sion­als were charged with neg­li­gence of duty re­sult­ing in death of a pa­tient, Bali Man Rana, post surgery at JDWNRH and breached the sec­tion 6.2.3 ( duty of care) of the Med­i­cal and Health Coun­cil Reg­u­la­tions, 2005.

The de­ci­sions from the BMHC was car­ried out af­ter thor­ough in­ves­ti­ga­tion and stud­ied the facts and var­i­ous ev­i­dences on state­ments of the wit­nesses, pa­tient his­tory sheet, ex­pert opin­ions and pro­fes­sion­als in­volved in pro­vid­ing care to the pa­tient.

Ac­crod­ing to BHMC, it was found out that dur­ing the op­er­a­tion, the con­sul­tant sur­geon, who was on call did not in­structed the res­i­dent doc­tor on call to closely mon­i­tor the pa­tient af­ter surgery.

The res­i­dent doc­tor had not in­formed the sur­geon waho was on call duty dur­ing the in­ci­dent. And the in­tern doc­tor had not in­formed the res­i­dent doc­tor on call. The three nurses were found mon­i­tor­ing till 2 am and nurses were not found at the nurses' duty sta­tion

Ac­cord­ing to the JDWNRH press re­lease, the de­ceased was re­ferred from Paro Hos­pi­tal af­ter in­jury to the ab­domen by a log on the morn­ing of April 12 and ar­rived JDWNRH at 1pm on April 13, past 24 hours.

It states that se­ri­ous sit­u­a­tion was quickly di­ag­nosed and emer­gency surgery was per­formed fol­lowed by trans­fu­sion of two units of blood to treat his blood loss.

It fur­ther stated that the surgery found out hole in the in­tes­tine, necro­sis( the death of most or all of the cells in an or­gan or tis­sue due to dis­ease, in­jury, or fail­ure of the blood sup­ply) of small bowel and three liters of blood in the ab­domen. And the pa­tient post sur­gi­cal care was pro­vided.

“In the case of hole in in­tes­tine with spillage of bowel con­tents into the peri­toneal ( mem­brane which forms the lin­ing of the ab­dom­i­nal) pre­sent­ing late to the hos­pi­tal, the death is sig­nif­i­cant even in the best of cen­ters,” it stated.

There­fore op­er­a­tion time in­ter­val, which has ap­peared to be the sin­gle most im­por­tant mor­tal­ity and mor­bid­ity is an in­di­ca­tor pre­dict­ing sur­vival.

JWDNRH made their stand that there is enough ev­i­dence on early treat­ment could have saved the life.

In sur­gi­cal ab­dom­i­nal emer­gen­cies, it states not to let the pa­tient with in­fla­ma­tion of the tis­sue that lines the in­ner wall of ab­domen to see both sun­rise and sun­set.

BMHC stated that the res­i­dent on call was found in­volved in the surgery till 10 pm as­sist­ing the sur­geon on call in­stead of mon­i­tor­ing the pa­tients in the ward. Ac­cord­ing to res­i­dency pro­gram, res­i­dents are re­quired to as­sist the sur­geon dur­ing the emer­gen­cies and not ex­pected to be in the ward all the time since there are in­tern doc­tor and nurses to mon­i­tor the pa­tient. Nurses car­ried out mon­i­tor­ing till 2 am as per the doc­tors or­der, it stated.

“The last recorded vi­tal signs at 2 am were all in nor­mal range and did not show wor­ri­some de­te­ri­o­ra­tion that re­quired fur­ther mon­i­tor­ing. In­terns and res­i­dents work un­der su­per­vi­sion and guid­ance of spe­cial­ist and they are an­swer­able to their se­niors and the univer­sity,” it fur­ther states.

JWDNRH press re­lease men­tions that the pa­tient was re­ferred af­ter 24 hours, there­fore gravely af­fect­ing the pa­tients health.

JWDNRH rea­sons that BMHC's state­ment on late re­fer­ral was not the fac­tor caus­ing the death but lack of mon­i­tor­ing for few hours was the cause of death has no sci­en­tific ev­i­dence.

JWDNRH also states that the cas­cade of in­fec­tion called sep­ticemia would have set in due to late re­fer­ral which could in turn cause fa­tal events like pul­monary block­age or car­diac ar­rest in spite of the timely sur­gi­cal in­ter­ven­tion which had been ren­dered by the sur­gi­cal team at the JDWNRH.

“This is in no way to de­fend the ab­sence of mon­i­tor­ing for the stated time in­ter­val but the lack of mon­i­tor­ing can­not be equated with neg­li­gence on the part of lim­ited staff who are work­ing for a straight 12 hour shift with many pa­tients to be mon­i­tored, hence the blame of neg­li­gence by the sur­gi­cal team caus­ing death has no med­i­cal and sci­en­tific ba­sis,” it states.

JDWNRH is con­cerned that shar­ing of in­di­vid­ual names on a na­tional me­dia de­fames and de­mo­ti­vates the health pro­fes­sion­als who work hard to pro­vide the stan­dard care that pa­tient needs.

JWDNRH shares that sad demise and loss of Late Bal­i­man will be able to pre­vent such mishaps in the fu­ture and re­gain peo­ple's trust to avail our reded­i­cated ser­vice.

JWDNRH made their stand that there is enough ev­i­dence on early treat­ment could have saved the life.

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