Part III. The Case of Dr. Hadiza Bawa-Garba
On the ward, Jack received enalapril/Vasotec [an ACE inhibitor drug which is used to treat high blood pressure]. Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problems. It is also used to treat heart failure and to help prevent people with a certain heart problem (left ventricular dysfunction) from developing heart failure, none of which Jack Adcock had. The principle adverse effects are very low blood pressure, an electrolyte imbalance, and/or kidney failure]
Dr. Bawa-Garba had not prescribed enalapril, and she clearly stated in her plan that enalapril must be stopped—the drug lowers blood pressure and is absolutely contraindicated in shock. Nor was enalapril given by the nursing staff—they stuck to the doctors’ orders. The source of the order remains a mystery, and despite its danger, the drug was given.
An hour after receiving enalapril, Jack had a cardiac arrest. After vigorous attempts at resuscitation, interrupted for a minute by Dr Bawa-Garba mistaking Jack for another child who was not for resuscitation, Jack was pronounced dead.
Jack died from streptococcal sepsis which had not been diagnosed during his life. His circulatory system initially seemed to be functioning well. The boy maintained his blood pressure so well on his own that he deceived everyone about the true nature of his critical condition. In hindsight, his body had been fighting the streptococci for some time, but by the time he was assessed in the CAU he was so deteriorated that his body could not even mount an elevated temperature. The fatal dose of enalapril took out all the effectiveness of his resistance and precipitated circulatory collapse.
I can attest from personal experience; when a patient dies, a part of the doctor dies, at least for a physician who is not a sociopath. That level of grief, disappointment, fear, and guilt, are especially intense when the doctor realizes that he or she made fatal error. Underscore error. Away from the hubbub of the ward, the OR, or ER, many doctors like Dr. Bawa-Garba, and me express their grief by excessive introspection, reliving the events to ask what they could have done differently—the more conscientious a doctor, the more self-critical. Every physician and surgeon makes a mistake sometime; anyone who has never done so has not been in practice long enough, done enough procedures, made enough decisions, or had enough responsibility; or he or she is a liar.
The nature of a medical error—whether you are at fault or not—has to become a learning experience, a very sharp one. The doctor has to concede that he/she was wrong; but you must go on nevertheless if you expect to be a useful doctor thereafter–you achieve closure. Clinical medicine—in the long term–is arguably shaped less by science and more by experience–including the many errors and the near-misses doctors face personally. One can learn from others’ experience—like the Texas kindergarten child who learns when the child sitting next to him gets a spanking. Clinical medicine is in large part heuristic [mental shortcuts] writ large.
After Jack’s death, Dr. Bawa-Garba was distraught, and her consultant encouraged her to record her failings in her electronic portfolio. She could have–if she wanted–written about the system failures of that day. But that would have been like making excuses. A physician or surgeon does not prosper or even keep working in a serious medical field like pediatrics or surgery if you try to shift blame to others, to things, or to the system.
So, when the buckled girder
Lets down the grinding span,
‘The blame of loss, or murder,
Is laid upon the man.
Not on the Stuff—the Man!
… The Gods have no such feeling
Of justice toward mankind.
To no set gauge they make us-
For no laid course prepare-
And presently o’ertake us
With loads we cannot bear:
Too merciless to bear.
-Rudyard Kipling, Hymn of the Breaking Strain
