An evolving essay and insight into Medicine and the Law in contemporary Hong Kong.

A girl’s brain was destroyed due to medical negligence. She had entrusted her life to a celebrity cosmetic surgeon who was going to make her breasts larger.  This was going to be her birthday present for her boyfriend. She spent her twenty-fifth birthday in the intensive care unit of the Queen Elizabeth Hospital (QEH) in Hong Kong. A decision had to be made. The operation started on the afternoon of the 30th of April 2010. There was a medical catastrophe. The patient wasn’t weighed. She was given a toxic dose of anaesthetic. She started to convulse. The surgeon did not know what to do. She underwent prolonged periods of starvation of oxygen to her brain. Essentially the celebrity cosmetic surgeon had killed the patient. The drug over dosage and the toxic response are survivable with appropriate treatment. But before considering cause or effect or specific treatments it is absolutely mandatory for a surgeon to address the essential life support of a patient in his care. This is the ABC of immediate life-support that every doctor needs to know. This means ensuring that the Airway is patent (an anatomical assessment). Then that the patient is Breathing (a physiological assessment). The ‘C’ is for Circulation to ensure there is blood flowing around the body critically between the lungs and the brain. The brain is the vital bit. The bit that gives us conscious awareness of our individuality. The brain and how it works is a mystery. But what is not a mystery is that the delicate cells within the brain will begin to die if they are deprived of oxygen for longer than four minutes.  The thermal cooling of the brain cells makes them less metabolically active, less demanding of oxygen and in therapeutic cooling or in accidents, for example falling into freezing water, the four-minute threshold can be extended.

The problem is that brains are plastic, they are dynamic structures and have a rich network of neural connections. The brain can relearn new things, can find different ways of doing things even though the primary control cells have been killed. To say that a brain has lost all capacity for function, has no hope of any repair; to say that a brain is dead, is not an easy thing to do. And that is why the certification of brain death requires very experienced doctors and a series of objective tests that repeatedly prove negative for brain function.

When this young girl was admitted to QEH it was noted she had fixed, dilated pupils. She had suffered prolonged anoxia and the history was indicative of brain death. But she must be given a chance and so she is admitted to the Intensive Care Unit where she is intubated and attached to a mechanical ventilator. This is a machine which forces air into the lungs and allows the blood to be oxygenated and if there was any surviving brain tissue, any functioning brain tissue, it could perhaps be detected.

The 4th of May 2010 was Zoey’s birthday. Her inconsolable boyfriend sat weeping at her side. She looked perfect. So peaceful. So beautiful. As if she was just sleeping. A machine controlled the rhythmic movements of her chest. Her boyfriend held her hand and begged, willed, wished, prayed, for any sign, any tiny movement that might indicate she was getting better. Her mother, sister, friends and doctors and nurses hoped and prayed that she had some life left in her. But her birthday passed. And the next day and the next. There was pressure. Immense pressure. From the press anxious to know what had happened and what was happening. The surgeon, his family and friends and professional colleagues were numb. Anger flared. The most unfortunate anger. The specialists employed by the Government had to speak with the relatives and prepare them for the worst. It is a moral duty, an ethical one. But the boyfriend was in shock. In horror at a loss he just could not comprehend. He was angry. He spoke to the press. He called the doctors ‘murderers’ not knowing that he was both right and wrong. Eventually the staff had no option. Medical futility; the brain dead are with us no more. Let us release their bodies, albeit that they contain all the perfections of reality. Even the warmth of the skin in this comforting cocoon brings comfort. 

Why did she die? That is what an inquest is about. Preliminary details are sorted, filtered, sifted. You do not want to hold up the system by going too slowly; you don’t want to bring the system into disrepute, by going too fast and getting things wrong.  A complaint is made to the police. An investigation is commenced and those being investigated are notified. There is panic, there is stress, there is anger, there is guilt and there is a complete closing of the ranks. This is the herd mentality of professionals but what holds them together is a complex mixture of self-survival and self-interest. And when letters arrived the phone calls began and the ears of the insiders was sought. And the response was unanimous. Get a good lawyer. Pay for yourself or claim the costs from your insurance. More phone calls, some on the record and some off. It was becoming obvious that mistakes had been made and things could become messy and hence expensive. The four doctors each sought legal representation, the cost of which was to be covered by a medical indemnity assurance scheme the Medical Protection Society (MPS). The point about this rather shadowy organization is that they stress they are NOT an insurance company and that financial support was granted on a discretionary basis. They sought what was in the best interests of the whole society even if that meant trying to destroy the professional reputation of one of its members. Highly unethical and all done at the expense of doctors and patients.

Andrew Burd (Prof)

The Chinese University of Hong Kong.

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