Murder or malpractice?

Syed Mansoor HUSSAIN

We publish this article by a Pakistani doctor in the backdrop of the controversy surrounding the Blood Bank and blood transfusions in this country, to provide our readers an international perspective on the subject. We welcome your comments on this topic.

Physicians are up in arms after a fellow physician was accused and arrested for murder in a Lahore hospital.

This is how the story goes. A young man came to a hospital with a broken bone, underwent surgery for its repair, might or might not have had intra-operative problems, required blood after surgery and died from a mismatched (incorrect blood group) transfusion.

After the patient died, his family accused the physician, who had performed the operation and ordered the blood transfusion, of murder and the physician was arrested on that charge.

The first question, in a case where the patient has undergone surgery that has had an unfortunate outcome, would be whether the situation arose due to an accepted range of complications or was the result of plain incompetence or negligence.

If the surgeon was adequately trained and did the appropriate operation and encountered expected complications then he cannot be accused of any wrongdoing.

If on the other hand he was not qualified to perform that operation then those responsible for allowing him to operate in a government hospital are equally culpable and complicit in his actions.

The major point of contention however seems to be the transfusion of blood: the blood administered to the patient did not match his blood type and therefore caused a fatal reaction. Here I would like to add that blood transfusions are a common method of replenishing lost blood for a patient after surgery. Blood transfusions are safe but occasional reactions can occur even in well-tested and 'cross-matched' blood.

Having worked in the US for more than three decades, I found that blood transfusion is treated with great respect. Before the blood can be given to a patient at least two people, a physician and a nurse sign off thus assuring that the blood being given was of an appropriate group and had indeed been matched with the patient's blood to assure compatibility.

Basically all of us have blood that belongs to certain groups, and most of us can receive blood from other people that have a similar blood group or groups that are compatible with our blood. Before any major operation that might require blood transfusion during or after surgery, the patient's blood is matched with that of several donors and then collected prior to the operation.

Occasionally, due to intra-operative problems, more blood might be required than planned for and in an emergency situation, cross matching might not be possible. In such situations, blood from a compatible group might be transfused. Blood groups are based on the ABO system and a person with an AB group can receive a transfusion from any blood group. But a person, for instance with an A group, cannot receive blood from a B group without developing a life threatening reaction.

I do not want to talk about any particulars of this case since it is a legal matter and as such making any judgements based upon newspaper reports is not a good idea. But I can make some general observations about the problems with blood transfusions in most public hospitals.

The first is the concept of a privately owned and commercially run blood bank. Blood is an extremely valuable resource and can only be acquired from a human donor. Therefore, commercialising such an activity can clearly lend itself to considerable misuse.

Donors might be what are called professional donors, who get paid for their blood. The blood is often not checked properly for diseases transmitted through blood, especially the different incurable forms of hepatitis and AIDS. Testing properly for these diseases is expensive and cuts into the profit margins.

Also, most private blood banks do not have well trained staff and appropriate technical facilities since all these cost money and once again that cuts into the profit margins. So, in my opinion private commercial blood banks should be immediately closed down.

Only those blood banks that are attached to a hospital should be allowed to function. More importantly, all blood banks, whether they are attached to hospitals or are run by the government should be scrutinised and checked for equipment and testing at regular intervals to assure that they are doing the appropriate testing and labelling of the blood.

For me, the most important aspect of this case is whether the doctor or the nurse at the patient's bedside properly checked the blood. As I mentioned above, in the US a physician and a nurse check the blood to make sure that the accompanying paper slip from the blood bank has the right patient, the right blood group and the correct dates for when the blood was drawn and cross-matched and what tests were done on it. Blood cannot be transfused without these checks.

However when I first started working in a public hospital in Lahore, I found to my surprise and even horror that the person responsible for giving the blood was often the lowest person on the medical totem pole. The physician never checked the blood to make sure of all the things I mentioned above.

My beef in this matter is that most public hospitals that I know of have no established guidelines about blood transfusions: who is supposed to sign off on blood before it is given to a patient. The absence of established guidelines is clearly responsible for mistakes of the sort that have been alleged in this case.

If the doctor ordering the transfusion is to be held responsible for such an error then so must the hospital administration that either has no established guidelines for blood transfusions or does not enforce them.

Medical errors are well known to be a major cause of death or serious injury in a hospital setting even in medically advanced countries like the US. The way to fix this problem is through education, establishing protocols for most routine activities and then enforcing these protocols rigidly.

Moreover, medical malpractice laws in the US make such errors when discovered extremely costly for those found to have made them. Finally, I do not believe that any physician however incompetent actually and deliberately wants to harm his patients.

Syed Mansoor Hussain has practised and taught medicine in the US. He can be reached at smhmbbs [email protected].