Distractions! I am getting behind my timetable for the on-going story. So let me press on. I shall only comment at the outset that with regard to the Junior Doctors Contract issue in the UK, I do think the government has acted with little integrity. What to do? I would vote no because I see no remorse in the government side for all the lies, the disruption, the manipulation. The details of the contract are almost immaterial. It is the intent I look for. Compare and contrast HK. The medical profession is out of control. But so is the legal profession. A legal expert indicated that they would not trust at least 70% of solicitors and barristers in Hong Kong. I have heard the same said about the doctors. Pretty shocking when you think about it. But a strong local government could do something about it; major law reform to change the adversarial medico-legal practice to an inquisitorial one. More of that later.
Okay, back to Zoey. She is convulsing. One expert has opined that this is most probably due to the inadvertent vascular injection of a small amount of local anaesthetic agent. I can accept that. They then went onto say that the total dose was within recommended limits. It clearly wasn’t and I find that conclusion unacceptable. Now, Francis Ho, the other expert on whose report the ‘defence’ was based, is very competent plastic surgeon but I do wonder how much pressure he was put under to submit his final report. He had access to my report where I indicated that I had sought independent corroboration for the patient’s weight. That must have been awkward for the defence solicitors so I wonder if Francis or the lawyers crafted point 8 in his conclusion, I quote, “320mg Xylocaine and 50mg of Pethidine are reasonable and safe dosages for a patient weight 50kg”. Yes, but that was not the weight of the patient was it? This was another report delivered on the Friday with the case beginning the following Monday. I do not think that is what an inquest should be about.
In point 11 Francis lists the equipment in the clinic including some drugs and says the list is fine for performing simple office surgery including simple breast augmentation.
In point 12 he states that Dr Wong’s clinic did not have a laryngeal mask, any endotracheal tubes and no equipment for intubation. He said that these are not required for procedures such as simple breast augmentation performed under ‘conscious local anaesthetic’ (sic).
Francis mentioned the default mode in too many clinics in Hong Kong; in exceptional circumstances a doctor should be able to access life saving equipment from the nearby clinics or the ambulance services.
I do not want to labour the point but this girl died because the operating surgeon had not provided life saving emergency equipment in his clinic. It defies logic to state that the clinic was appropriately equipped. She died. But I am getting a little ahead of the sequence of events. Lignocaine toxicity is rare, but because of the potentially fatal outcome of the complication should this be mentioned in the consent form? Also I wonder what mention was made with regard to fasting? This is a tricky one as if you tell the patient to fast it means that you are aware of the rare but identified risk of aspiration in a sedated patient who vomits. In other words, should be able to deal with it. If on the other hand no mention is made about fasting it means the surgeon is out of date and out of touch. And that is not safe.
So time line: it is 15:28 on 30 of April and Zoey has had 60mg of IV pethidine and a total of 320mg of lignocaine and adrenaline. She becomes sluggish and starts to convulse. Dr Wong inserts an oral airway and begins to give oxygen via a mask and sends one of his nursing staff to call for help. That does not mean call an ambulance (by telephone) it means going out into the shopping arcade and physically identifying people to help. At this stage the SaO2 was recorded to be around 90% but did fall to 80% and so Dr Wong used an Ambubag to increase the oxygen supply. At 15:40 Dr James Hwang arrived. He is a specialist in general surgery and has a clinic in the same building. What do you think he did? We shall continue in the next blog, which I shall post more quickly this time. In the meantime for office-based practitioners perhaps you could reflect upon the question in the box.