Update surgery codes, avoid hospital lapses
It was supposed to have been a relatively simple procedure that would help a young footballer pursuing a degree in physical education to return to the playing field. Instead, medical negligence by a series of government medical staff first cost 17-year-old Priya her leg and eventually her life. Priya underwent surgery to repair a ligament tear. As part of the procedure, a tourniquet band was placed to restrict blood flow to the area being operated upon. After the procedure, the tourniquet should have been removed. Yet, the surgical team failed to do so. Even when Priya complained of pain after the surgery, it was dismissed as related to the procedure. It appears no one checked her leg and noticed the tourniquet. By the time the mistake was realised, it was too late: 24 hours had passed. Without blood flow, gangrene had set in. Another medical team amputated the leg, but even that could not save her.
An inquiry found five medical staff, including the surgeons, at fault for medical negligence. Police have booked all five. While accountability may have been fixed in the immediate case, clearly, there are systemic issues plaguing government medical facilities in Tamil Nadu that need to be studied. As proud as the state may be of its healthcare achievements, not all is well.
First, why was such a procedure performed at a peripheral hospital? Doctors have said the facility had been upgraded to handle surgeries, but this was the first time this particular procedure was performed there, and no protocol had yet been put in place. Second, even if a protocol specific to this procedure was not in place, the government facilities are supposed to follow a WHO checklist for surgeries. Is adherence to the checklist so poor? Third, while staffing may not have been an issue at play in this case, there are poorly staffed facilities where such oversights could occur. The Health Department has since conducted a workshop with surgeons at government hospitals and released a ‘reappraisal’ on protocols and checklists in the form of a booklet. Significantly, it has ordered the setting up of regional death audit panels in four districts to study deaths following surgeries at government facilities. These are welcome steps that may contribute to better compliance. If only a young life had not been the price to pay.