Wednesday, June 19, 2024


Dhaka Tribune

Where is the accountability in Bangladesh’s healthcare?

Lessons and guidelines for best medical practices drawn from the tragic loss of Raahib Reza

Update : 17 Apr 2024, 10:56 AM

Raahib Reza, a young and talented IT professional and entrepreneur, and a loving father to a young daughter, tragically passed away on February 19, 2024, following a routine endoscopy at a prominent private hospital in Dhanmondi, Dhaka. This incident has deeply shaken public confidence and rightfully raised serious concerns about the standards of care and accountability within Bangladesh’s healthcare system. I feel compelled to draw lessons from this tragedy so that more lives are not cut short due to what can only be concluded to be the result of a series of medical oversights and negligence. As physicians, it is our collective ethical responsibility to reflect on mistakes to prevent similar occurrences in the future. 

Liability: Gaps in the initial analysis

Every patient has the expectation and the right for physicians to listen to their complaints and conduct relevant examinations. Doctors world over, have basic obligations to fulfil and the responsibility to identify possible diagnosis by analyzing patient history, correlating it with examination findings, and drawing up a management plan. They draw out missing information through leading questions. Raahib consulted with a Senior Liver Specialist of the country’s premier postgraduate medical institution due to symptoms of indigestion, reflux, and hiccough, yet there was an absence of documented history, examination findings, or provisional diagnosis in his medical consultation file. This is contrary to standard practice. 

Prior to prescribing any medication, doctors need to understand the conditions being treated. For Raahib, a young man with obesity and sleep issues, the first step should have been to conduct a detailed inquiry into why he was experiencing sleep issues. Patients with obesity, in particular, should immediately raise suspicions about the possibility of obstructive sleep apnea, characterized by interrupted breathing for 10 seconds or more during sleep, and prompt questions regarding their history of snoring. In such instances, prescribing medication such as Clonazepam (a benzodiazepine drug) can further exacerbate the condition. Not considering the implications of a patient’s condition, especially when proposing a medical procedure, would be considered a glaring failure on the part of the physician.

Patients are not expected to recognize the significance of their medical history or conditions. Physicians cannot deflect blame onto patients for not mentioning particular conditions, especially if such contentions cannot be independently verified. Thus, the criticality of proper documentation in the medical consultation file. It is crucial to emphasize that this is not the patient’s liability.

Medical students are presented with cases to explore without having all the history and information. A skilled examinee will piece together the necessary information to arrive at a diagnosis. This critical thinking and deductive reasoning are essential aspects of becoming a doctor. When physicians ignore their medical training and fail to consider obvious possible medical conditions, it raises serious questions. Were they too preoccupied to assess the patient? Did they neglect to do so? Worse yet, did they lack the necessary knowledge?

Physicians cannot deflect blame onto patients for not mentioning particular conditions

Understanding treatments and risks

Patients have the right to be fully informed about treatment options. It is the ethical duty of doctors to explain risks and potential complications and to involve patients in the decision-making process. Healthcare providers must ensure that patients comprehend the information so that they can make informed decisions and opt for safer choices. Regrettably, as indicated by different reports and statements, the doctor appears to have failed to do so with Raahib. More shockingly, there was no formal consent signed by him. If there is no emergency and the patient possesses full capacity, any signature other than that of the patient is legally unacceptable.

It is imperative for the medical profession to stay abreast of global best practices. Assertions of there being no worldwide guideline mandating the explanation or obtaining of consent for deep sedation during endoscopies are categorically false. According to the British Society of Gastroenterology, “patients should receive comprehensive information about what to expect from the sedation and patients are involved in shared decision-making, where possible, when choosing which sedative medication (if any) to proceed with during an endoscopic procedure.”

Raahib`s Father Md Rezaul Haque

The choice of sedative or anaesthetic medication is critical depending on the patient’s medical history and condition. Differences between sedation and general anaesthesia lies in the patient’s level of consciousness, the need for equipment to support breathing, and possible side effects. The Royal College of Anaesthetics (RCOA) explains deep sedation as a state where the patient will be asleep, unlikely to communicate during the procedure, and unable to recollect what happened. Breathing may also slow down. In the UK, deep sedation must be administered by a sedationist with the expertise equivalent to an anaesthetic doctor. RCOA recommends adjusting the level of sedation based on the patient’s biometrics and comorbidities and for continuous monitoring and assistance to be provided as needed.  

It is also paramount that healthcare providers are clear as to which medication is administered, as any discrepancy poses a direct threat to patient safety. R Bezel et al (1987) published a case report that documented life-threatening temporary cessation of breathing in a patient with obstructive sleep apnoea following administration of Midazolam. Thus, to reduce this risk, the British Society of Gastroenterology recommends exclusively using low-strength Midazolam (1 mg/mL) instead of high-strength formulations.  

Conversely, if Propofol or general anaesthesia is used for sedation, ECG, automated non-invasive blood pressure, capnography (a device measuring blood carbon dioxide levels), and core body temperature needs to be monitored and recorded so that healthcare providers can swiftly identify and intervene when patients deteriorate. Moreover, the dosage needs to be meticulously measured and administered rather than applying through a venous line until the patient falls asleep, which is fraught with potential lethality. Any deviation from these established safety measures can only lead to one conclusion: adequate safety procedures are not being observed.

There is no room for inadequacy

Inadequate healthcare systems, lacking proper equipment and skilled persons, can quickly lead to fatal outcomes. Consider the importance of blood pH (refers to how acidic blood is) that normally ranges between 7.35-7.45. However, a drop to 7.01, as was the case with Raahib, signals a grave prognosis, indicating that the drug administered during the procedure caused fatal respiratory depression. Consequently, his breathing became abnormal, leading to carbon dioxide retention and oxygen deprivation. When a patient is retaining carbon-dioxide inside blood, only low flow oxygen should be given, as administering high flow oxygen is potentially lethal. In the absence of proper monitoring and a skilled person to recognize the deterioration, and react accordingly, the patient will reach a state of no return.

Incorrect selection and dosage of sedative drugs, coupled with lack of skilled personnel and inadequate facilities, can lead to other complications. The lamentable state of ICU services in many Bangladeshi hospitals can easily lead to sepsis followed by multi-organ failure. Moreover, involving other specialists when a patient is beyond recovery, and wilfully ignoring the principal cause of a patient’s fatal outcome is unequivocally unacceptable. This raises the question: Why would doctors and hospitals engage in such an apparent charade? 

It is crucial to ensure that patients awaiting procedures are adequately prepared and not subjected to long waiting times. Waiting extended periods of over 12 hours without food or water, as was the case with Raahib, can cause undue exhaustion, stress, and exacerbate risk. If doctors are four to five hours late, then they should reschedule the procedure.

Inadequate healthcare systems, lacking proper equipment and skilled persons, can quickly lead to fatal outcomes

Furthermore, it is imperative that doctors meticulously review all pre-assessment reports to determine the safety and potential risks of patients. The British Society of Gastroenterology recommends pre-assessment and enhanced periprocedural monitoring for patients with obstructive sleep apnoea and/or a high body mass index, as they face an increased risk. Suffering from both conditions, Raahib’s tests also revealed diastolic dysfunction and a heart pumping capacity (42%) significantly below the normal threshold. As there was no urgent or life threatening situation, the procedure should have been postponed until his cardiac suitability was confirmed by a cardiologist.

It sets a dangerous precedent when a doctor neglects to review pre-assessment reports and subsequently downplays the importance of doing so by questioning the feasibility of reviewing every patient’s reports and whether it is practical to accommodate all necessary tests within the country context. Such statements are not only alarming but also threaten patient safety. No healthcare system permits a doctor to compromise safety under any circumstance. If a doctor lacks the time to review reports, it begs the question: why request them in the first place, and why proceed with the procedure? 

Human Chain Image from Facebook cut

Own up to the truth

It is of great shame to the medical profession when doctors or hospitals fail to exhibit genuine remorse or accountability in the face of mistakes or negligence, indicating a dereliction of responsibility. Even more distressing is the tendency to try and shift blame onto patients. Attempts to divert attention from the true cause of death, and even resorting to threats against patients’ families, are not unheard of. This lack of accountability, empathy, compassion and honesty within the medical community is startling. 

While doctors and hospitals may see patients as just a number, their unnatural passing wreaks havoc on families, leaving a permanent and irreparable void in their lives.

Dr Rifat Hasan Mazumder is a Consultant Rheumatologist & Acute Physician, Clinical Governance Lead and Educational Supervisor for Medicine Trainees, The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, UK.

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