Shapol Mohamed YE AR 13
WHAT
healthcare
CAN LEARN FROM
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ne of the most and wife to Martin, has had a BBC significant causes documentary produced about her. One of death in the morning she was due at the hospital to world is also have her sinus problem treated. The one of the most doctor had told her the chances of overlooked. It is complications were tiny and they had not malaria, HIV, done the same procedure countless times. or COVID-19, but medical errors. At 8:35 Elaine was in the operating According to the World Health theatre and for the anaesthesia to be Organisation, four in ten patients are delivered had a cannula, a straw-shaped harmed in primary care, such as at GPs, tube, inserted into the back of her hand. and 80% of those cases are preventable. Anaesthetics are strong drugs that disable Meanwhile, in hospitals, one in ten patients many of the patient’s vital functions, and are harmed. Globally, this breathing is usually assisted causes 2.6 million deaths. by an inflatable pouch that For comparison, annually THE RELUCTANCE is inserted into the mouth malaria and HIV cause and sits just above the OF THE 405,000 and 770,000 deaths, airways. The oxygen is HEALTHCARE respectively. Coronavirus SECTOR TO MAKE then pumped in artificially. has caused 350,000 deaths In Elaine’s case, there ERRORS MORE at the time of writing this. was a problem; her jaws TRANSPARENT Medical errors do not had tightened whilst she HAS SLOWED discriminate between rich was, essentially, in a deep PROGRESS. and poor countries - both sleep and the mask was are affected equally. Clearly, unable to be inserted into this is a significant problem that needs her mouth. Of course, that had happened to be tackled and I think we can reduce plenty of times before and the surgeons that number by introducing a few simple were ready to try with smaller masks. At measures. 8:37, she was beginning to turn blue and Now, you might be giving me the look her oxygen levels were 75%. that a parent gives a toddler searching Meanwhile, Martin and the kids were the dog’s mouth for the thing that makes buying the cookies that Mum always the barking noise. It’s a cute idea but liked, so they could give them to her in idiotic. You might be saying: how can the afternoon. you do that? Doctors don’t kill patients Back in the operating theatre, the on purpose. Of course, they don’t medics tried another type of mask to sit healthcare professionals have the purest over the mouth and nose; it still didn’t intentions to help. work. This wasn’t anything too unusual. Elaine, mother to Victoria and Adam Following standard protocol, at 8:41 a
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paralysing agent was injected to disable her jaw completely so that her mouth was now fully open. A light was shone in the back of her mouth so the tube could be inserted directly into her airway; this was normally visible, a hole with the vocal cords on either side, but in this case they were hidden by the mouth’s soft palate. The situation was becoming critical. The surgeon kept jabbing the tube, hoping that he would find the airways. At 8:43, at 40%, the oxygen levels were so low that they were troublesome to measure; Elaine’s heart rate fell to 69 then to 50, meaning there was little oxygen getting to the heart. The problem with low oxygen levels is that your brain starts to swell; that can prove fatal. Thankfully, in this situation, there is one last option that surgeons can turn to: tracheostomy, whereby an incision is made directly into the throat and the tube is inserted directly into the windpipe, completely bypassing the mouth. As you can imagine, this is risky but it is the last resort. Twelve minutes in, the nurse prepared the tracheostomy kit and notified the surgeons. The surgeons, under pressure, ignored the nurse. Time was passing and the nurse thought perhaps the surgeons had already thought about that option but ruled it out for a reason that she was unaware of. Elaine was now deep blue and her heart rate was a meagre 40 beats per minute. Every second wasted narrowed her chances of survival. The surgeons continued their increasingly frantic attempts to force in the tube while the nurse continued to agonise over whether to speak up. It took 20 minutes for the surgeons to bring Elaine’s oxygen levels back up to 90% and by then it was already too late. Later, an MRI scan was taken of her brain and it showed irreparable brain damage at best. At 11 am, Martin got a call telling him to get to the hospital as soon as possible. Knowing something was wrong, he left the kids at home, with the cookies they had baked for their Mum. The surgeons had said it was a routine operation with very low chances of complication. Elaine was young and healthy. Martin couldn’t figure
