It is recorded that Dr James Hwang arrived at 15:40 and commenced cardiac massage. I wonder why? Of course, the ‘non-essential equipment’ included a cardiac monitor. So no help there. Palpating a pulse in a patient who is convulsing (still) and probably cyanosed at least.

At 15:45 Dr Wong’s wife arrived and she called an ambulance. Perhaps the only person not in denial. This was a catastrophe unfolding before their very eyes. A young girl was dying. At 15:55 Dr Yuen Hing-yiu, a specialist in ENT arrived and attempted to secure IV access (but failed).

At 16:05 an ambulance arrived.  This was not equipped with emergency life-saving equipment. At the same time, Dr Yuen managed to secure IV access into the right hand and infused Normal saline and ??? 100mg of hydrocortisone IV. It appeared that the working diagnosis of the lead surgeon was that this was an allergic reaction to lignocaine.

By 16:33 a second ambulance had arrived – it still had no intubation equipment but it did have a cardiac monitor. At this time Dr Yeun gave IV adrenaline and a fourth specialist emerges from the shopping arcade, Dr Ho Chung Ping. At last at 16:50 a third ambulance arrived with a laryngeal mask, which was inserted with good effect. Or not? Dr Wong states that the “ventilation via the laryngeal mask resulted in improved oxygen saturation above 85%”. 

The patient started to convulse at 15:28. The patient is still fitting at 15:55 (that is why Dr Yuen could not get IV access). By the time she had stopped fitting it is reported that without using the Ambubag her saturations ranged from 40-70%. She would have already sustained irreversible brain damage by the time Dr Wong’s wife made the first call to the emergency services. It would be interesting to hear a recording of that call. Was the life threatening nature of the medical catastrophe relayed to the dispatcher?

Pethidine: a powerful narcotic. If given IV it is recommended that it is given by ‘very slow’ IV infusion. The maximum dose should be no more than 50mg of IV pethidine every three to four hours. AND. Again from the data sheet: “Pethidine should not be administered by intravenous injection unless resuscitative equipment and narcotic antagonists are readily available.” Now, what do they mean by ‘resuscitative equipment’? This is Basic Life Support. Every medical student knows what is meant by the ABC of resuscitation.  Quite frankly if this parody of resuscitation was performed in the final year medical examinations and the students were being assessed by Professor Gavin Joynt and Professor Charles Gomersall, I absolutely guarantee, these four senior specialist, licenced to practice medicine on the people of Hong Kong, would have failed with historic low marks.

Let me be quite clear; I understand it must have been a nightmare for those doctors. And the point of retelling the story is not to ‘punish, but to illustrate how corrupt the medico-legal practice is in Hong Kong. We have two reports submitted at the eleventh hour and both are found to be wanting and indeed deceptive. But I wonder who is the architect of the deceit?

We shall continue to look at that in the next blog but let me be quite clear the objective is to present evidence to the family and to the people of Hong Kong that there has been a terrible miscarriage of Justice. But this is an indication of the complete breakdown in the process of Law when conducted in an adversarial manner. There has to be winner and a loser and Truth is of little importance.

The inquest must be re-opened and the key points made by the coroner in his summing up must be withdrawn as unsound. What were they?

1) Was the total dosage of lignocaine given more than the recommended amount? The coroner said the experts could not agree on this.

Let us call the experts to give evidence under oath in open court.

2) Was the clinic appropriately equipped for such a procedure? The point here is that it is not just the procedure that needs to be considered but potentially life threatening complications. Airway. Breathing. Circulation. Without oxygen, the brain starts to undergo irreversible anoxic damage in as little as four minutes.

If you are going to use powerful sedatives in addition to large volumes of local anaesthetic drugs you have to be prepared to deal with life threatening complications that require airway control and protection. And a convulsing patient? Diazepam. So simple, so quick. And if you have an unconscious patient and no intubation equipment? Every first aider knows: the recovery position.

Zoey did not die. She was unlawfully killed.

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Andrew Burd (Prof)

The Chinese University of Hong Kong.

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