4 March 2013

South Africa: Gauteng Patient - Five Weeks of Hell and Then Death

Patient CZ’s horror story represents a myriad of breakdowns within the Gauteng health system – ranging from stockouts of critical drugs, long delays in investigative and diagnostic procedures and stockouts of basics such as clean linen.

A young doctor, who shared Patient CZ’s case timeline, has left the public sector, and is now doing sessions in the private sector.

“It is soul destroying. One takes the death very personally,” says the doctor.

“I had to leave or it would have destroyed me and my family,” he adds.

Five weeks after being admitted with a suspect spinal lesion, Patient CZ, only in his twenties, died quietly in the early morning - in pain, confused, depressed and with his dignity destroyed. This is a timeline of his five weeks at Charlotte Maxeke Johannesburg Academic Hospital:

14 April – Patient CZ presents at a Community Health Centre in the Johannesburg CBD with chronic chest pain and is referred to Johannesburg Hospital.

14 April – Patient CZ is admitted to the Emergency Medicine Unit with chest pain, general body weakness and knee pain. His symptoms are thought to be consistent with symptomatic anaemia.

15 April – Malaria is excluded and macrocytic anaemia diagnosed.

16 April – Vitamin B12 deficiency is identified as the cause of the macrocytic anaemia and treatment was prescribed and started. Right leg was described as weak by the physiotherapist.

17 April – Patient CZ complains of severe weakness in the body and is found to no longer able to move his legs. It was thought to be suggestive of a spinal cord lesion and a new complication. The doctor identified it as a neurological emergency.

It was arranged for the patient to have an urgent neurology consult, thoracic and lumbar spine x-rays and an urgent MRI. Intravenous steroid Decadron prescribed and administered. Titrallac (an oral calcium supplement) is out of stock in the ward and cannot be administered.

Patient CZ is seen by a registrar who confirms the likely diagnosis of a spinal cord lesion.

Further recommendation for an urgent MRI.

18 April – Urgent MRI is postponed to the following week due to the waiting list. Titrallac remains out of stock in the ward.

19 April – Need for an urgent MRI remains and doctor tries to negotiate an earlier date with no success. Doctor is informed that the urgent and non-urgent MRI list has been combined making the waiting list even longer. The patient is promised an MRI later on the 19th or on the 20th.

20 April – There is no change in the patient’s condition with the MRI still pending. Patient later informs the doctors that an MRI had been done, but nobody contacted the doctors to review the scans. The MRI Unit is closed and the doctors informed that the unit is “locked” as it was Saturday.

21 April – The Decadron intravenous steroids, needed to reduce the swelling around the spinal cord in this case, is now out of stock in the ward and not administered. The MRI report finally became available late on the day after the head of department of medicine intervened.

The MRI report indicated an abnormal growth extending into the spinal cord, compressing is as well as a second abnormal lesion on the inside of his spinal cord. The out-of-stock intravenous steroids were critical to allow for the possible recovery of his leg, bladder and bowel functions.

A surgeon is contacted to urgently assess the patient. The oncologist indicates that he will take over management of the patient should it prove to be cancerous.

22 April – Surgeon reviews the patient and notes that he must be prepared for an excision biopsy, a surgical procedure that would remove the lesion compressing the spinal cord and offer a more accurate diagnosis of the lesion.

It is noted that the surgery is due on 23 April.

Patient complains of pain and Tramadol, an oral opioid analgesic is prescribed, but not administered as it is out of stock.

A pre-operative consult is done by an anaethetist.

23 April – Gastroscopy done as part of investigation for Vit B12 deficiency. No documentation is contained in the file indicating whether urgent surgery took place.

24 April – Still no indication of surgery.

25 April – A peripheral smear indicates that cancer is present and the need for an urgent specialized biopsy is noted. This procedure, a CT-guided FNA is a procedure whereby a needle is placed into a lesion to remove a sample of tissue, which is used for diagnosis. The needle is guided to the abnormal lesion using the CT scan.

26 April – A note indicates that this urgent biopsy procedure has been booked. for 17 May. A clerk indicates the doctor can return on 30 April to check if the patient can be “squeezed in” earlier. Patient is prepared to radiation therapy, which is indicated as urgent, however it is postponed. It is again indicated that urgent surgery is required to relieve the compression. A neurosurgeon notes that it is now too late for surgery as the spinal cord symptoms were now permanent.

27 April – Patient is reviewed by an oncologist and the urgent biopsy is again noted.

29 April – Biopsy is still not booked.

30 April – It is discovered that the radiologists only do the CT guided FNA biopsies on Thursday and the next Thursday is 3 May.

3 May – The biopsy is still not done.

7 May – It is noted that the patient has developed acute spastic paralysis of the lower limbs.

8 May – Chemotherapy is commenced despite the absence of a biopsy. A new intravenous steroid Solumedrol is prescribed, but not administered as it is out of stock.

11 May – The urgent CT-guided FNA biopsy is to be rebooked and the patient started on antidepressants. First notes that the spinal cord is now unsalvageable. The spinal cord biopsy is moved to 7 June.

14 May – It is noted that there was now additional risks for infection including paraparesis (could not move or feel his legs), urinary and faecal incontinence (inability to anticipate or control the flow of urine or faeces) and possible pressure sores (due to an inability to move the lower half of his body). The patient is prescribed Ciprofloxacin, an antibiotic to treat infections, but he does not receive it as the drug is out of stock.

17 May – Notes indicate that the patient presents as depressed.

18 May – A catheter is prescribed to prevent the patient from lying in his own urine. It is noted that clean bedding is out of stock. Patient questions why his procedures are postponed.

19 May – Patient has diarrhoea indicating sepsis.

22 May – Shortly after midnight a doctor notes the patient’s low blood pressure, “warm to the touch” as well as vomiting and diarrhoea.

Shortly before 6am the patient suffers a seizure and was booked for an urgent CT scan of his brain. At 8.50am, five weeks after presenting to the hospital, Patient CZ is declared dead. No post mortem is conducted.

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