Shit that happens, and some that really, really shouldn’t

Two incidents germane to this blog are currently keeping our local press busy this past week. I would put the first in the “shit happens” category – a cluster of tragedies that look connected and cause hysteria, but probably aren’t; the latter, however, is a clear sign something was clearly not working, and policy needs changing.

The first concerns the inexplicable deaths of 4 toddlers aged 1-3 and severe neurological damage sustained by 2 others in the past weeks. No common factor has been found, though one infant had the widespread, though rarely deadly, Coxsackie B virus in her stool.
According to the Health Ministry communique I received at my work email, recent environmental, nutritional and vaccine exposure have been ruled out.

However, the public hysteria over these deaths was easily exploited by an opportunist, who spread an internet rumor claiming the children’s deaths were caused by the ever-popular corn/peanut snack Bamba…which sent Osem’s (Bamba’s manufacturer) stock plummeting.

The second event happened about a week and a half ago:

Dr. Galit Sa’ada-Ophir (Ph.D in sociology~estherar), 37, died Thursday in the obstetrics ward from massive abdominal bleeding caused by the surgical incision. Her family said the medical and nursing staff did not listen when she said she was feeling progressively worse following the birth.

The source at Hadassah said yesterday that he believed the internal bleeding went unnoticed at the end of the surgery, and she received no treatment for it, despite her complaints.

The story as was told by her brother on Israel Radio is mentioned here:

The deceased’s brother, Rom, explained that when Galit told the staff she felt as if she was going to pass out she was told this was common following such a delivery and was given two non prescription pain killers and told to rest. When her husband Moshe arrived to visit in the morning she was already connected to a mechanical breathing device and he saw the bed was “full of blood”.

What is known for certain is that Rom asked how she felt when she was brought to the unit from the recovery room at 18:00. She told him she was feeling fine. Rom reports that his brother Oded spoke with Galit later on, but she said “I cannot speak. I feel like I am going to pass out.” At 22:00 she received medication as cited above. No doctor was sent to check on her but her chart indicated that a shift physician entered a note [at some point] that her signs and symptoms were in line with her condition. Later on, Moshe telephoned her but she did not answer. He became concerned and telephoned the nurse’s station but they told him “don’t worry. She is just too tired to pick up”, but that was not so explained Rom, since Galit always always answers the phone.

The C-section was a repeat elective one, and given the multiple birth, quite probably medically indicated. But if events transpired as Galit’s brother claimed…dismissing a post-surgical patient’s complaints in this way is inexcusable. And given the rarity of the situation and the hint of a scandal , this was on the front page of all the papers last week. Because this is most definitely shit that shouldn’t happen.

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2 Responses

  1. Stories are changing about the death of Dr. Saada-Ophir. I have my sources, which I cannot reveal. But the nursing staff DID attempt to get a doctor to look at the patient, more than once, and the reply they got was that the doctor was too busy elsewhere, and to give her additional pain medication. This, in spite of clearly charted evidence [although not overwhelming evidence] of blood loss and shock [increasing pulse, decreasing blood pressure, Cheyne-Stokes respirations] The nurse recorded that she called the doctor repeatedly. There is some reason to believe that the surgeon thought that because the nurse was a new graduate, she didn’t know what she was seeing, but she did.

    It most emphatically should not have happened. This is clear malpractice. But while the family is now attempting to blame everyone, the fact is that the nursing staff did what it was able to do, in the absence of a doctor. And there is reason to believe that some of the charting was done ex post facto and made to look as if done at the time.

  2. In the United States the nurse would be held liable if she did not execute the chain of command. That means if the Doctor is not coming to see the patient, she would call her nurse manager. If no luck there, she would call the chief of OB or the Doc on call. And she would keep calling up the chain of command until a resolution was found.

    I don’t know the whole story and feel very badly for all involved especially the nurse who was trying to get help for the woman only to be blown off.

    You are absolutely correct, in this day and age this should not happen and sounds like criminal neglect on the Doctors part. However, I don’t have all the evidence so I really cannot say.

    Also I just cannot fathom a Doc not coming to see a patient they just did surgery on when a nurse tells them the bleeding is excessive. I just can’t imagine that at all. Unless the Doc was in the OR, but in that case he/she could send a midwife or L&D nurse to concur that yes, the patient is bleeding like a stuck pig!

    ANother question I would have, was a code called? Call a code and you are going to get attention.

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