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Sunday, July 22, 2018

Code Blue

In December 2012, four critically ill patients at Sushruta Trauma Centre died when the oxygen supply snapped. Five years on, few lessons appear to have been learnt. The Indian Express looks at the state of affairs

Written by Kaunain Sheriff M | New Delhi | Published: October 2, 2017 5:37:30 am
Sushruta Trauma Centre, medical negligence, trauma centre, delhi's trauma centre, oxygen supply, delhi healthcare Outside Sushruta Trauma Centre. (Source: Oinam Anand)

Fix responsibility and initiate corrective action. These were directions given by the Delhi Medical Council (DMC), which looks into cases of medical negligence, to the Delhi government on August 30. The directions came after the Council conducted an inquiry into a December 5, 2012, incident, when four critically ill patients on ventilator at Sushruta Trauma Centre’s ICU unit died after oxygen supply from the gas plant stopped. The DMC’s recommendations, delayed by almost five years, comes weeks after 60 children died, reportedly for want of oxygen, in Gorakhpur’s BRD Medical College Hospital.

“In this (Sushruta’s) case, there was no medical negligence on part of doctors… but unfortunately lives were lost due to administrative lapses. Hence, the Delhi government is requested to fix accountability and initiate corrective measures to prevent such incidents,” the DMC told the government.

After the 2012 incident, Sushruta Trauma Centre — the only trauma care centre run by the Delhi government — had come under immense scrutiny. The government sacked two doctors, and Delhi Police arrested the technician and supervisor of the private firm given the contract for supplying oxygen gas cylinders and maintaining the centralised gas plant.

The DMC has now asked the government to appoint a full-time medical superintendent (MS) here. “The trauma centre is running with an additional superintendent. He works under the MS of LNJP Hospital. Every file, whether on finance or procurement, has to be routed through the MS at LNJP. He (the additional superintendent) cannot take decisions on his own. In government machinery, it takes so much time for a file to move from one department to another. Without a full-time MS, this leads to further delay,” Dr Girish Tyagi, DMC secretary, said.

Sushruta Trauma Centre, medical negligence, trauma centre, delhi's trauma centre, oxygen supply, delhi healthcare It was started by the Delhi government in 1998 to provide critical care management to acute polytrauma victims, including those with head injuries, with round-the-clock emergency services. (Source: Oinam Anand)

Despite the deaths, few lessons appear to have been learnt. “The ventilators are functional. But they can be fully functional only when there is reliable back-up. When the electricity goes off, there is a delay in back-up, which means a delay in oxygen supply. The centre requires a reliable back-up without interruption — as we only deal with emergency cases and critical care. This has to be rectified if you want to avoid a repeat of 2012,” a doctor said.

When contacted, Additional Superintendent Dr Ajay Bahal said, “We have an emergency panel installed now, these issues can be resolved immediately.”

A senior official of the health department also said that Sushruta “has to be attached to a tertiary care unit as we have to refer complex cases. So, there is actually no requirement for a separate superintendent”.

However, he admitted, “The centre requires more manpower in terms of security. Also, CCTV cameras need to be installed.”

Reliable back-up and CCTVs are just some of the many challenges that the trauma centre — which attends to over 19,000 patients per year — is facing. Consider these:

Only two operation theatres (OTs), one shut and one operational: The trauma centre was started by the Delhi government in 1998 to provide critical care management to all acute polytrauma victims, including those with head injuries — with round-the-clock emergency services.

On paper, the centre has three emergency OTs and one minor OT. While the administration claimed the centre has “two functional OTs”, a doctor explained, “Only one OT has been functional for the past year. The other one was functional for some time, but is not used anymore. It was experiencing short circuits; instead of getting it fixed, they shut it. A trauma centre cannot run with a single OT.”

Detailing the possible repercussions, another doctor added, “A majority of cases we deal with are neurosurgery-related. These require a minimum four hours of surgery. So if another trauma case is admitted during this period, the patient is made to wait. We can only conduct investigations on him, and the delay can be fatal.”

Sources told The Indian Express that earlier this year, a trauma patient with a head injury — which led to localised bleeding inside the brain — was made to wait for about two hours as the OT was occupied. The patient later died, sources said.

“The OT was being used for an elective surgery scheduled in advance, as it does not involve medical emergency. As a result, an actual emergency case was delayed. Elective surgeries can be referred to tertiary care units, ” a doctor said.

Sources said an order was then issued by authorities to undertake only emergency cases in the OT. “However, the OT continues to witness elective cases — mostly orthopaedic cases that aren’t emergencies. They get operated here because we cannot send everyone away,” a source said.

However, Dr Bahal said, “We have two OTs. We have kept one just for neurosurgery, in case of an emergency. We run only one OT at a time, considering the workload at the hospital. But both are functional.”

Key investigations and equipment lacking: A key facility lacking in the ICU, a doctor said, are external infusion sets — of the 18 sets, 16 are non-functional. The set helps deliver a drug into the patient’s body in a controlled manner, and is considered essential to rule out medication errors in the ICU, a doctor said.

The centre also carries out routine blood investigations and is equipped with a blood bank. However, an official at the centre said, “The blood bank operates with very limited resources. On many occasions, we are told there is no stock of a particular blood group. Patients are then asked get it from outside.”

Less then a fortnight ago, sources at the centre’s pathology laboratory said two tests — ABG (arterial blood gas) analysis and complete blood count (CBC) — were unavailable. “There was a problem with the machine. However, both tests are available now,” a hospital source said.

“The ABG test is crucial in diagnosing oxygenation levels of critically ill patients in the ICU, while CBC is a basic test done to understand a patient’s underlying medical condition. When the test was not available, we used to make do without it as it is expensive and poor patients couldn’t afford it,” a doctor said.

Dr Bahal, meanwhile, said, “There is no problem; all tests at the laboratory are available now.”

Equipment required for spine injuries not replaced: For the time being, the centre has stopped conducting surgeries related to spine injuries because of the damaged C-arm machine, required to safely operate on trauma injuries involving the spine and vertebra. The machine helps the orthopaedic surgeon visualise the complex structure, and to accurately place screws and other implants to fix spine injuries.

“We cannot open the entire spine to operate on injuries. We need a C-arm machine to accurately perform surgeries. We had a fully-functional machine earlier, but it got damaged. It hasn’t been fixed or replaced,” a doctor said. Sources said the centre had the machine until two years ago. It is yet to be replaced.

ICU at LNJP vs Sushruta: The Indian Express spoke to doctors from both hospitals, which function under the same Medical Director, and found that key facilities offered at the tertiary care unit are not available at the trauma centre. For instance, at LNJP Hospital, ICU patients who cannot consume food orally are given nutritional fluids directly through the veins. “Total parenteral nutrition (TPN) is used in such cases and it costs around Rs 3,500. TPN fulfils the nutritional requirement, which is key for recovery. This is available here,” a doctor at LNJP said.

However, this is lacking at the trauma centre. “We don’t have TPN, so we give patients milk and dal soup. Critically ill patients need TPN to recover fast,” a doctor at the centre said.

Doctors also said the centre should have key equipment such as a fibre optic tool for intubation during anaesthesia. “Most complications due to anaesthesia are from airway problems. This tool can help the specialist manage a difficult airway. But we don’t have it here,” the doctor said. LNJP Hospital, on the other hand, has this facility.

Infections-prone ICU, no pollution control inside OT: According to sources in the hospital administration, an inspection inside the ICU by a microbiologist last week found that the facility was prone to infections by microorganisms. The centre has now been directed to conduct fumigation inside the ICU, a member of the administration said.

Doctors who perform emergency surgeries round the clock also aired concerns about the absence of a scavenging system inside the OT, meant to collect and remove gases. Drugs administered by an anaesthetic contain gases such as nitrous oxide. In some cases, the levels exceed the necessary amount, polluting the OT. “A scavenging system is required to remove these excess gases. Without it, we continue to inhale them. If doctors are exposed to it for a long time, it compromises their health,” a doctor said.

Lack of training of nurses, junior residents: Code blue is an emergency situation in a hospital when a patient in cardiopulmonary arrest requires specialists to rush to a specific location and begin immediate resuscitative efforts. The training for code blue is key at a trauma centre, but doctors said that no such training is performed here.

“New junior residents join every four months. Technicians and nurses need to be trained in emergency situations as well. However, no code blue training has taken place in the recent past,” a doctor said.

Another doctor pointed out that lack of adequate training of junior residents can lead to delayed treatment. “Golden hour refers to a time period lasting an hour or less following a traumatic injury, during which there is the highest probability that prompt medical treatment can prevent death. Due to lack to training of junior residents, even ECG tests are not performed properly. There have been instances when senior residents have left surgeries midway to attend to an emergency,” a doctor said.

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