Part II. The Case of Dr Hadiza Bawa-Garba
British house officers [interns] have become supernumerary. Whereas, once the senior house officer was the busiest person in the hospital; it is now the registrar [~resident]. That day, Dr Bawa-Garba was taking referrals from general practitioners and emergency physicians, surgeons, and midwives, and responding to emergencies on the wards, along with the usual multiple inquiries that–in hindsight—may well turn out to be clinically irrelevant. Lacking help–even secretarial assistance–the young registrar had to telephone pathology for results because the hospital IT system was down. The results she needed–let alone the abnormal results that were crucial—were not automatically or in a timely fashion, being included in the electronic health record.
She was performing skilled procedures like lumbar punctures because no one else in her team–which should normally be comprised of an intern and an even more junior trainee–could. Dr Bawa-Garba was in effect, triple booked. She had to make critical decisions, do the routine scut work; and also supervise and teach her nonprofessional team.
At 10:30 am, she assessed Jack Adcock–a 6-year old boy with Down syndrome–who was referred by the general practitioner for nausea, vomiting, and diarrhea. Jack was normally a lively chap who had a past surgical history of a repaired atrioventricular canal defect and was on enalapril for high blood pressure. He was afebrile but looked dehydrated and sick. Dr Bawa-Garba made a presumptive diagnosis of fluid depletion from gastroenteritis and administered an intravenous fluid bolus immediately and started him on maintenance fluids. She requested a chest radiograph; sent off bloods for blood count, renal function, and inflammatory markers; and drew blood gases, which showed that Jack was acidotic with a pH of 7 and a lactate of 11.
The metabolic profile confirmed her working diagnosis of shock from gastroenteritis; but, judging from the tests she ordered, pneumonia was in her differential. After the initial fluid bolus, Jack seemed to be trending in the right direction, metabolically. The repeat blood gas showed he was less acidotic, with a pH of 7.24, heading towards a normal pH of 7.4.
At 3 pm, she viewed the chest radiograph herself, which had been done art 12:30 pm. It showed that Jack had pneumonia. She prescribed antibiotics, which were given at 4 pm. Another lack in the NHS is that x-rays are not routinely interpreted by radiologists;—there are not enough of them in the NHS to handle that load. Jack was moved from the CAU to the ward.
Earlier that day, Bawa-Garba had admitted a terminally-ill child with a DNR [Do Not Resuscitate] order to the side-room on the ward. This child was seen by another consultant during that long day and discharged home in the afternoon. At 7 pm–unknown to Dr. Bawa-Garba–Jack Adcock was transferred from CAU to the same side-room on the ward. At around 8 pm Jack began to deteriorate further, whereupon the on-call anesthesiology and pediatric registrars were quickly summoned. Despite urgent treatment, Jack suffered a cardiac arrest; CPR was commenced and endotracheal intubation was performed. Dr. Bawa-Garba attended the cardiac arrest call to the side-room believing it to be the terminally-ill child she admitted earlier with a DNR order. She requested the team to stop resuscitation. However, she came to realize that it was the wrong patient within 2 minutes, and therefore recommenced CPR.
At 4:30 pm, Dr. Bawa-Garba met Dr O’Riordan–the attending–in the hospital corridor. She showed him the boy’s blood gas results and explained her plan of action. Her boss did not see Jack.
