There's an article in today's Star (Mum upset at award for death of son)regarding the death of Nui Jia Yuan in 2003, which concerns me because the level of aftercare provided by this particular doctor seemed wanting.
I'd like to first make clear that my opinion is based solely on this particular article. I have no access to the medical or autopsy records or the original press report regarding this boy's death in 2003. If today's article was reported accurately, then there are a few things concerning this case that I felt the need to comment on.
I have never done a circumcision before but it is usually done with a local anaesthetic, which numbs only the relevant parts of the body, and a sedative, to keep the patient calm and relaxed during the procedure. The injections in the buttocks and private parts in the article refer to the anaesthetic and the injection in the arm, is I presume a cannula to provide venous access to the patient. The doctor can inject the sedative through the line and any other drug or treatment required in case of anything untoward occuring i.e. like an allergic reaction to the sedative administered.
It was this part of the report that boggled me because:
a) if the boy was unconscious due to the sedative, the doctor should keep him in the clinic under supervision until he wakes up
b) how much sedative that he gave the poor kid that he would only wake up in four to five hours time?
It's standard procedure to monitor your patient, no matter how minor the surgery is, until he regains consciousness. You don't just pack them off home and say don't worry, they'll be up and about soon enough. It is unsafe to do so. I think doctors make the mistake of thinking that because a sedative is 'milder' and does not require the services of an anaesthetist, that you don't need to be as concerned about them as say a person who has had a general anaesthetic. I know at least two anaesthetists who grumble about the wide
In the two hospitals I've worked in, day case patients for endoscopies are usually administered a class of drug called benzodiazepines, usually a drug called midazolam which has a short half-life. (Day cases are patients who come in for a procedure then after a period of recovery in hospital, go home the same day, barring any complications.) Even then, I know at least two anaesthetists who grumble over the widespread use of midazolam in day case surgeries without what they deem to be inadequate support.
(By the way, I know some people get confused and think an anaesthetist [or anesthesiologist in the US] is a technician but they are actually doctors. Masters-of-the-Universe aka Surgeons tend to think of anaesthetists as their bitches but anaesthetists are highly skilled autonomous doctors. They are very clever too - they bloody well have to be because their professional exams are damn hard.)
Benzodiazepines reduce anxiety and agression, sedates and induces sleep and also reduces muscle tone and co-ordination. They are not a painkiller, and does not stop you producing a reflex to pain stimuli, even if you are asleep. They also cause a degree of respiratory depression i.e. like when you have too much alcohol, but patients should generally be able to maintain their own airway.
The problem comes when a patient is so heavily sedated that the body does not respond when it finds itself cut off from oxygen. Imagine somebody who is heavily asleep and they are snoring. Snoring is a sign of a partially blocked airway, reasons including obesity, bad sinus problems, or just a bad sleeping position. Eventually a snoring person will turn over on to their side and the snoring stops. They manage to do this while 'being unconscious.'
By the conclusion of autopsy report reported here, you could infer that the boy asphyxiated either because he was so heavily sedated that his breathing stopped or that he was placed in an incorrect position while he was sleeping and blocked off his airway. Either which could have been prevented if he was monitored in the clinic and proper advice given to the parents.
Again, I don't have the full facts on the case and for all I know Dr. Kubendran could have done everything right and this was an unfortunate accident. I'm going by what was reported in the papers but it seems such a tragedy that something like this could have been prevented by simple measures.
I'd like to first make clear that my opinion is based solely on this particular article. I have no access to the medical or autopsy records or the original press report regarding this boy's death in 2003. If today's article was reported accurately, then there are a few things concerning this case that I felt the need to comment on.
According to the facts of the case, Jia Yuan, who was four then, was taken to Klinik dan Surgeri Kuben on March 26, 2003 after the boy complained of pain during urination.
Dr Kubendran examined the boy and asked Nui and Lim to bring him in again on March 28 for circumcision.
The boy and his parents arrived at the clinic at about 1pm and Dr Kubendran
administered injections to the boy’s arm, buttocks and private parts before
performing the procedure.
I have never done a circumcision before but it is usually done with a local anaesthetic, which numbs only the relevant parts of the body, and a sedative, to keep the patient calm and relaxed during the procedure. The injections in the buttocks and private parts in the article refer to the anaesthetic and the injection in the arm, is I presume a cannula to provide venous access to the patient. The doctor can inject the sedative through the line and any other drug or treatment required in case of anything untoward occuring i.e. like an allergic reaction to the sedative administered.
The parents then took the boy home and the doctor informed them that he would
regain consciousness within the next four to five hours.
It was this part of the report that boggled me because:
a) if the boy was unconscious due to the sedative, the doctor should keep him in the clinic under supervision until he wakes up
b) how much sedative that he gave the poor kid that he would only wake up in four to five hours time?
It's standard procedure to monitor your patient, no matter how minor the surgery is, until he regains consciousness. You don't just pack them off home and say don't worry, they'll be up and about soon enough. It is unsafe to do so. I think doctors make the mistake of thinking that because a sedative is 'milder' and does not require the services of an anaesthetist, that you don't need to be as concerned about them as say a person who has had a general anaesthetic. I know at least two anaesthetists who grumble about the wide
In the two hospitals I've worked in, day case patients for endoscopies are usually administered a class of drug called benzodiazepines, usually a drug called midazolam which has a short half-life. (Day cases are patients who come in for a procedure then after a period of recovery in hospital, go home the same day, barring any complications.) Even then, I know at least two anaesthetists who grumble over the widespread use of midazolam in day case surgeries without what they deem to be inadequate support.
(By the way, I know some people get confused and think an anaesthetist [or anesthesiologist in the US] is a technician but they are actually doctors. Masters-of-the-Universe aka Surgeons tend to think of anaesthetists as their bitches but anaesthetists are highly skilled autonomous doctors. They are very clever too - they bloody well have to be because their professional exams are damn hard.)
Benzodiazepines reduce anxiety and agression, sedates and induces sleep and also reduces muscle tone and co-ordination. They are not a painkiller, and does not stop you producing a reflex to pain stimuli, even if you are asleep. They also cause a degree of respiratory depression i.e. like when you have too much alcohol, but patients should generally be able to maintain their own airway.
The problem comes when a patient is so heavily sedated that the body does not respond when it finds itself cut off from oxygen. Imagine somebody who is heavily asleep and they are snoring. Snoring is a sign of a partially blocked airway, reasons including obesity, bad sinus problems, or just a bad sleeping position. Eventually a snoring person will turn over on to their side and the snoring stops. They manage to do this while 'being unconscious.'
When the boy failed to wake up, Jia Yuan’s parents took him to the clinic
at about 4pm. After examining him, Dr Kubendran told them to rush him to Banting
Hospital.
However, Jia Yuan had died on arrival.
The autopsy report issued by KL Hospital’s forensic department cited
asphyxia as the cause of Jia Yuan’s death.
By the conclusion of autopsy report reported here, you could infer that the boy asphyxiated either because he was so heavily sedated that his breathing stopped or that he was placed in an incorrect position while he was sleeping and blocked off his airway. Either which could have been prevented if he was monitored in the clinic and proper advice given to the parents.
Again, I don't have the full facts on the case and for all I know Dr. Kubendran could have done everything right and this was an unfortunate accident. I'm going by what was reported in the papers but it seems such a tragedy that something like this could have been prevented by simple measures.
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