Navigating Covid-19 measures to treat this patient was a challenge. But it turned out to be a blessing
Here, I would like to share how a team of doctors and administrators at two hospitals had to work around various Covid-19 restrictions to get her transferred to my hospital where I could treat her and how those precautionary measures actually became a blessing in disguise for me.
This happened in the first week of June, during the Phase One re-opening after the Covid-19 circuit breaker.
At about 8pm on a Friday night, I received a call from Dr G, a good friend and a general surgeon, asking for my opinion on a patient he just saw.
The patient, Ms A, was 36 weeks pregnant. This was her first pregnancy, which was smooth till four weeks ago when she experienced intermittent post-prandial upper abdominal pain.
She had consulted her family doctors a few times, and the Accident and Emergency department once. She was given some gastric medicine and discharged.
But on that fateful day, her pain was so severe that it became unbearable; she also had fever and had been vomiting the whole day.
She went to the maternity hospital her obstetrician was based in. On further questioning, she had not eaten nor passed urine that day.
As it looked like a surgical problem, her obstetrician called Dr G, who found Ms A’s left abdomen tender.
A liver function test showed elevated liver enzymes. Full blood count showed leukocytosis, which meant the number of white blood cells was higher than normal.
He asked for an urgent ultrasound scan of her abdomen, which showed gallstones and stones in the common bile duct.
Dr G called me to seek my opinion on doing an endoscopic retrograde cholangiopancreatography (ERCP) on her.
ERCP is a procedure combining X-ray and endoscopy to diagnose and treat problems in the liver, gallbladder, bile ducts and pancreas.
ENCOUNTERING THE FIRST ROADBLOCK
I agreed with Dr G that the stones in her bile duct could be the cause of her severe pain. Her left abdominal pain and tenderness could mean concurrent pancreatitis. ERCP was indicated.
But there were some outstanding issues, both medical and logistic.
Medically, doing ERCP on a pregnant patient is a challenging job, especially in a 36-week-pregnant lady. Firstly, the patient cannot lie in the usual prone position.
Secondly, X-ray exposure, no matter how minute, may have longstanding harmful effects on the foetus. Thirdly, doctors have to double check all medications used to ensure that they do not cause any adverse effects on the foetus or the pregnancy.
Lastly, special techniques, such as fluoroscopy-free or minimum fluoroscopy ERCP, are needed for pregnant patients to reduce risk of radiation exposure to the foetus.
The logistic challenge was that the maternity hospital that Ms A had visited did not have the facility for ERCP, and although I was accredited at the maternity hospital, I was stationed at hospital N, a general hospital 750m away.
To attend to Ms A at her maternity hospital would require a formal application to the Ministry of Health (MOH). It would thus be easier to transfer Ms A to hospital N.
Ms A’s obstetrician, who could not cross into hospital N, then got his colleague, Dr E, to take over management of the case.
Both of them called up hospital N’s labour ward and arranged for an ambulance transfer for Ms A. But just before Ms A was to be moved, we faced another logistical issue.
CROSSING A RAGING RIVER
Under MOH guidelines, patients were discouraged to cross hospitals. Hospital N required a negative Covid-19 swab result, which took at least one working day to process, before it could take in a patient from another hospital.
Yet Ms A was in great pain and needed immediate medical care, and preferably an urgent ERCP.
Undeterred, Dr G contacted the chief executive officer of hospital N at about 10pm that Friday, who agreed to allow Ms A to be transferred over.
But she had to be isolated at the “fever ward” and have a Covid-19 swab done as soon as possible.
I finally saw her at around midnight.
After examining her, I suspected acute pancreatitis as well as cholelithiasis, commonly known as gallstones.
We started her on standard medical treatment and by 7am the following morning, tests had confirmed that she indeed had acute biliary pancreatitis and choledocholithiasis, or gallstones in the bile duct.
Since Ms A had some uterine contractions the night before, Dr E also started her on a drip to slow down her contractions. Concurrently, she was given medication to help the foetus mature, in case there was preterm labour.
I asked for an urgent magnetic resonance cholangiopancreatography (MRCP) — a non-contrast scan safe for pregnant women.
I needed to know the number, sizes and locations of the stones. Then, another logistic hurdle came.
CLIMBING A TOWERING MOUNTAIN
As hospital N was not a designated Covid-19 hospital, the whole scanning room and patient holding area would need thorough disinfection after a potential Covid-19 patient visits.
Thus, the hospital’s rules required Ms A to have a negative Covid-19 swab result before she is allowed to undergo the MRCP.
Well, rules were rules and we tried not to break any of them during a pandemic.
I did a Covid-19 swab on Ms A on admission. Hospital N would expedite the process, so her test results would be ready by 5pm that day, and the laboratory manager would call me about the results so I could arrange for the MRCP.
The radiologist on call was notified and prepared for an MRCP by 6pm, subject to her negative Covid-19 swab.
At about 5pm, Dr E called and asked if we could delay Ms A’s MRCP, as there was evidence of foetal distress and he was planning for an emergency caesarean section.
I did not mind. Since Ms A’s condition had improved after medical treatment, delaying the MRCP and ERCP for a few days would not be a big problem.
At that juncture, the foetus’ survival and well-being took the top priority.
A SMOOTH SAILING DESCENT
Ms A had an uneventful Caesarean delivery on Saturday night. The baby was born healthy, but was kept overnight at the neonatal unit for observation as he was a preterm newborn.
Ms A’s MRCP took place on Monday morning; it showed lots of stones in a dilated common bile duct and gallbladder.
I did an ERCP by Monday afternoon. Several cholesterol stones were removed in a standard procedure.
Ms A and her husband were very thankful for the care by the whole team, including Drs E and G, the nursing staff, the CEO, and myself.
I joked with them that if the hospital had allowed me to break rules and do the MRCP on Saturday morning, she might not be thankful to us. I would have proceeded to do an ERCP on Saturday afternoon.
Assuming the foetal distress had still occurred at the same time as it did, this would have been after the MRCP and ERCP.
Any events occurring after a procedure or treatment would be deemed a potential complication.
Hence, if I had done an ERCP as planned, I could be faulted for potentially causing the foetal distress.
If there were any further complication to the newborn, like development delay or hypoxic damage, Ms A would have a case to take legal action against me for compensation, as well as over the next 21 years, as the premature birth and its associated complications would be deemed an obstetrician event.
Yes, it would be difficult to decide if the fetal distress was caused by an MRI scan, an ERCP procedure, or totally unrelated. But the temporal relationship, that is, fetal distress occurring after the scan and procedure, would make causation a possibility.
And whenever patients sue their doctors, even if doctors did nothing wrong, they will have to use a considerable amount of time, energy and financial resources to defend themselves.
Ms A, her husband and I had a good laugh. But to me, it actually wasn’t funny.
MORE THAN JUST SKILLS
As doctors, we aim to solve patients’ problems in an effective and timely manner. But adverse effects can occur after treatments, procedures, or operations, which may or may not be related to the medical treatment.
Ironically, while we are held responsible when an adverse event occurs after an active intervention, we are usually not blamed for procrastination or inaction.
Sometimes if we try too hard to help our patients, we can become a victim if things don’t go smoothly afterwards. In this instance, I was saved by the strict rules of Covid-19 precautions.
I was lucky. As a doctor, we certainly need good knowledge, clinical skills and bedside manner to be competent.
But I guess we also need a good daily prayer for safe doctoring.
ABOUT THE AUTHOR:
Dr Desmond Wai is a gastroenterologist and hepatologist in private practice. This is adapted from a piece which first appeared in the September issue of SMA News published by the Singapore Medical Association