LAHORE, July 16: The management of a Karachi-based private hospital, Orthopaedic and Medical Institution (OMI), has described “cardio respiratory arrest due to septicaemia and multi-organ failure” as the prime cause of death of senior PPP leader Fauzia Wahab during her treatment at the health facility.
The OMI has submitted its detailed version titled ‘medical summary’ to the PMDC, defending its position amid allegations of medical negligence in Ms Wahab’s case.
This is the first complete clinical assessment and treatment process to surface after the death of 55-year-old Ms Wahab that incited a countrywide debate on the alleged medical negligence of top OMI surgeons, physicians and consultants.
The Disciplinary Committee of the Pakistan Medical and Dental Council (PMDC) is looking into this case of alleged medical negligence, which led to death of a prominent political leader on June 17. The summary was presented at the meeting of the Disciplinary Committee of the PMDC in Islamabad on July 9.
Chaired by senior lawyer Barrister Aitzaz Ahsan, the committee has directed the officials to issue notices to all medics besides other staff who provided treatment to Ms Wahab at OMI.
Dawn obtained a copy of the medical summary carrying details of multiple surgeries performed on Ms Wahab during her 23-day treatment, pre-and-post-operative aggressive care and follow-up treatment provided by leading surgeons, physicians besides diagnosis.
Submitted by OMI Director (Medical Services), the summary said Ms Wahab was admitted under care of Dr Badar Siddiqui on May 24 for Laparoscopic Cholecystectomy, which was scheduled next day. Ultrasound of abdomen that was already done showed gall stones.
Pre-anaesthesia assessment was done by Dr Wajahat Malik (anaesthetist) who declared her fit for general anaesthesia.
Laparoscopy revealed an inflamed gall bladder, which had dense adhesions with duodenum and omentum. On separation of the omentum a fistula was found between the gall bladder and pylorus. At this point the consultant decided to convert to open procedure to securely close the fistula. Cholecystectomy was done and the fistula in the pyloric region was closed in layers with omental patch. A drain was placed in the sub-hepatic region and the surgical wound was closed. A complete surgical procedure was performed under general anaesthesia administered by Dr Wajahat.
Ms Wahab had an uneventful recovery from anaesthesia and was shifted to her room. She was mobilised in her room. She had problem in passing urine for which she was catheterised as advised by the consultant.
Ms Wahab was haemodyhnamically stable, but complained of epigastric pain on the evening of May 26 that was managed with analgestic injection according to the advice of the consultant. She was mobilised in her room during the last 24 hours.
At around 9pm on May 26 she collapsed and developed hypovolaemic shock. The consultant was informed immediately who ordered to shift her to ICU and to resuscitate her initially with plasma expanders and later with blood transfusion. Her blood pressure got stabilised and she was fully conscious and oriented.
Ultrasound of abdomen was done urgently that showed pockets of free fluid. At 1:30am on May 7 her abdomen became tense and her blood pressure began to fall. Diagnosis of intra-abdominal bleeding was done and emergency laparotomy was decided by the consultant.
Pre-anaesthesia assessment was again done by Dr Wajahat. Her family members were explained by the consultants about high risk of surgery due to her unstable condition. They agreed and gave their consent for emergency surgery.
Laparotomy was jointly performed by Dr Badar Siddiqui and Prof Shafiq-ur-Rehman under general anaesthesia. Free blood was found in the abdomen, which was cleared and the source of bleeding was searched. The operated areas namely Cystic Duct and Cystic Artery clips were found to be in position and secure. The suture line of the repair of the fistula was found to be satisfactory. The liver bed was examined and no evidence of gross bleeding was found. The bed was stitched.
Fresh blood was still found coming in the operative filed. Search was made on the left side and the blood was seen coming from Porta Hepatis from the left side from inside the liver. The consultants decided to pack the area and wait. After observing the area for 15 minutes the consultants decided to place two abdominal drains and the surgical wound was closed.
At least four units of blood and fresh frozen plasma were transfused during surgery. The patient was shifted back to ICU at 7am on May 27 and kept electively on mechanical ventilators as advised by the treating consultant.
Fresh blood was coming from the abdominal drains (about 800ml during the first eight hours after laparotomy). The bleeding did not settle despite multiple transfusions of blood and platelets. Post-operative tests revealed low haemoglobin and low platelet count with some derangement in the clotting profile.
Due to suspicion of bleeding disorder Dr Tahir Shamsi (haematologist) was called in for consultation. In his opinion the patient was developing DIC (Disseminated Intra-vascular Coagulation). He recommended that Factor VII (Novoseven) be given intravenously to avert the possibility of progression to full blown DIC. Factor VII was administered immediately as advised by the consultants and within two hours the drainage of blood was reduced to significant amount.
The patient was relatively better on the morning on May 28. Antibiotic regime was reviewed and post-operative management was continued under the guidance of Prof Tipu Sultan (consultant anaesthesiologist) and Prof Tasnim Ahsan (consultant physician & endocrinologist). Ultrasound of abdomen was repeated on the same day which showed no collection in the peritoneal cavity. The consultants decided to continue mechanical ventilation for another day and then to plan for removal of abdominal packs.
Prof Jaffer Naqvi (nephrologist) was also consulted as patient’s blood urea and creatinine started to rise.
Pre-anaesthesia assessment was done by Prof Tipu Sultan who explained the high risk involvement in the proposed surgery.
The patient was taken to operation theatre on May 29 for removal of abdominal packs which was jointly done by Dr Badar Siddiqui and Prof Shafiq-ur-Rehman under general anaesthesia this time administered by Prof Tipu.
The sutures were opened from the original incision. Abdominal packs were gently removed, the area was dry and no fresh bleeding was seen. The liver was found to have purple areas spread over both lobes, these signified areas of infarct. Two abdominal drains and a T-Tube was placed as a safety valve after which the surgical incision was closed.
The patient was shifted to ICU and the consultants decided that mechanical ventilation will be continued for the rest of the day.
By the evening the same day she was haemodynamically stable and drainage was settled. The patient’s condition and lab reports were satisfactory on the morning next day therefore Prof Tipu decided to start weaning off from ventilator which continued gradually under his guidance. Ventilator was disconnected and the patient was taken on T-Piece with oxygen at 9am on May 31.
She was breathing spontaneously and was maintaining satisfactory blood gasses. Her fever was not settling and pan cultures were inconclusive therefore antibiotics were reviewed again. She remained on T-Piece for the whole day and remained comfortable however it was decided to put her back on the ventilator overnight to prevent exhaustion.
The patient was extubated by the constant anaesthesiologist at 8:45am on June 1 and culture was sent from the endotracheal tube. However, to prevent exhaustion he decided to re-intubate the patient at 12:30pm on the same day and to start mechanical ventilation. Chest X-Ray was repeated which showed bilateral basal haziness therefore ultrasound of chest was done which showed mild to moderate bilateral pleural effusion.
Dr Mosavir Ansari (pulmonologist) was consulted who advised to continue antibiotics and ventilation as he was suspecting pneumonia. Ultrasound of chest was repeated on June 2. Ultrasound of abdomen was also done which did not reveal any new collection in the peritoneal cavity.
The patient remained stable on mechanical ventilator and the drainage was settled. Closed observation and aggressive post-operative management was continued accordingly. Weaning off from ventilator was again started from June 3. Tracheal secretions revealed growth of pseudomonas species therefore antibiotic regime was readjusted by the consultants according to the sensitivity report.
Intermittent T-Piece trials were continued for short periods to help in weaning off ventilator however they proved to be unsuccessful. Chest X-ray was repeated on June 4 which showed increase in bilateral haziness. As multiple trials to wean off from ventilator had failed and the patient had pneumonia the consultants decided to plan Tracheostomy which would help in weaning off from ventilator.
Family members were consulted regarding the need of Tracheostomy for which they agreed and gave their consent for another high-risk procedure. Tracheostomy was performed at 7pm on June 5 by Prof Tariq Rafi (consultant ENT surgeon) under general anaesthesia administered by Prof Tipu. The patient was shifted to ICU where mechanical ventilation was continued.
The patient was fully awake the next morning but was electively kept on ventilator due to pneumonia. The patient was comfortable on ventilator but her blood pressure started to rise therefore opinion was also taken from Dr Tahir Saghir (cardiologist). He revised the anti hypertensive therapy.
T-Piece trials were again given over the next two days but failed therefore mechanical ventilation was continued. The patient passed large amount of malaena on June 9 and became unstable. Intravenous Transamine and blood transfusion was given and the patient recovered in two to three hours. There was no further episode of malaena over the rest of the day. She again passed malaena at 12:30am next day after which two units of blood were transfused. She remained unstable all night despite sedation and continued ventilation.
Dr Zaigham Abbas (gastroenterologist) was consulted who visited the same day and advised conservative treatment.
The June 10 chest X-ray did not show any improvement therefore pulmonology opinion was taken from Dr Javed Warind who advised changes in antibiotic regime and ventilator settings. No episode of malaena was observed during rest of the day. The patient was showing signs of fluid retention in third space and lungs therefore I/V fluids were reduced and diuretic therapy was started next day as advised by the consultants.
Ultrasound of chest was repeated the same day which showed possible collapse/collection at left lung base. Ultrasound of abdomen was done which did not show evidence of any intra-eritoneal collection. The patient was kept sedated and mechanical ventilation was continued under the guidance of Prof Tipu.
The patient continued to retain fluid in the third space despite limiting fluid intake and administering diuretics therefore it was decided by the nephrologist that excess body fluid needs to be removed via ultra-filtration during haemodialysis.
The family was explained regarding need of haemodialysis for which they agreed and gave their consent. Haemodialysis was performed on June 13 and ultra-filtrate was removed as advised by the nephrologist. She was referred to Dr Badar Dhanani (dermatologist) for the management of perineal rashes and cellulitis on right hand.
Echocardiogram was done the next day which showed moderate mitral regurgitation, pulmonary artery hypertension and normal left ventricular function.
Haemodialysis with ultra-filtration was repeated on June 14. Caloric intake and doses of antibiotics were reviewed according to the patient’s renal status. Sedation was reduced slowly to let the patient be more awake in order to assess the possibility of weaning off from ventilator.
Input of infectious disease specialist Dr Naseem Salahuddin was also obtained on June 15 and June 16 during which ultra filtration was done as recommended by nephrologist.
The management of the patient was being overseen by a team of consultants along with input from relevant specialists as required.
Fauzia’s condition did not improve despite the aggressive treatment and her level of responsiveness decreased gradually therefore Dr Aziz Sonawala (consultant neurologist) was consulted on June 16 for neuronal dysfunction. Dr Sonawala then suggested MRI of brain which was done the same day under supervision of Prof Tipu.
A detailed counselling regarding patient’s extremely critical condition was done by Dr Badar and Prof Tipu the same day.
MRI of brain revealed brainstem and thalamic infarcts along with oedema. Dr Sonawala visited again on June 17 and after detailed examination concluded that clinically the patient had no response. He performed the 1st set of brainstem criteria which showed absence of all major reflexes. He advised to repeat the 2nd set of brainstem criteria after six hours and not to resuscitate. He spoke to patient’s family members in detail after which they agreed and consented for DNR supportive care protocol to be followed.
The 2nd set of brainstem was also negative after which detailed family counselling was done by the treating consultants and they were informed about brainstem death of Ms Wahab. The family then decided for systematic withdrawal of life support. The mechanical ventilation was continued on air.
“Ms Wahab’s condition continued to deteriorate and she expired at 8:10pm on June 17. The cause of death awas ascertained to be cardio respiratory arrest due to septicaemia and multi-organ failure,” the OMI management concluded.