Everything About The Kidney Failure Patient Who Died Of A ‘Medical Misadventure’ On The Operating Table

By
Shawn Ambrose
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When you see a doctor for an illness, you don’t, even for a second, entertain the thought that they don’t know what they’re doing.

This is why we so easily place our lives in their hands.

While they have rightfully earned this trust, all it takes is one tiny mistake for someone to lose their life.

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Everything About The Kidney Failure Patient Who Died Of A ‘Medical Misadventure’ On The Operating Table

And that’s what may have happened to Lee Kuen Ngian, a kidney patient at Tan Tock Seng.

The 74-year-old died in 2016 from acute haemorrhage after an artery and a vein was accidentally punctured during a catheter insertion procedure for his peritoneal dialysis, reported The Straits Times.

For the uninitiated, peritoneal dialysis is a way to remove waste products from your blood when your kidneys can’t adequately do the job any longer.

In the procedure, a sterile fluid is introduced into the body through a permanent tube placed in the peritoneal cavity – the space that contains the intestines, stomach, and liver.

The fluid then draws impurities from the surrounding blood vessels within the cavity before being drained.

Sadly, Lee’s procedure didn’t go as planned.

Collapsed During Procedure

On 2 Nov 2016, Lee was reviewed by Dr See Yong Pey, a consultant at TTSH’s renal medicine department, and admitted to surgery on 10 Nov.

Dr See was the one who carried out the catheter insertion procedure.

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Once an incision was made in Lee’s abdomen, a clear, saline solution was flushed out of his body through a tiny tube.

He was then placed in a Trendelenburg position, where the body is laid flat on the back with the feet elevated above the head, and his peritoneal cavity was filled with air.

Image: Wikipedia

Everything seemed fine, but shortly after the air was pumped into his peritoneal cavity, Lee suddenly collapsed.

The procedure was halted and the tube was removed immediately.

Lee’s pulse returned after a few minutes of resuscitation, but his pulse stopped again twice after that and he was eventually pronounced dead.

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Doctor Accused of Using Faulty Technique

So, what exactly caused his death?

According to Dr Cheng Shin Chuen, a surgeon who was nominated to look into the case, the death was down to Dr See’s faulty technique.

“Dr See most likely punctured the (vessels) unknowingly with a faulty technique. He basically passed the sharp point of the trocar (a sharp-pointed surgical instrument) all the way in, injuring the artery and vein at the same time”.

Dr Cheng said Dr See’s technique “falls short of what is an acceptable level of competency”, causing a “wholly preventable puncture” of the vessels.

However, Dr Cheng noted that Dr See had carried out the procedure shortly after two months of being granted “clinical privilege”.

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Dr See Disagrees

On the other hand, Dr See believes that it was the metal tube which had injured Lee’s blood vessels.

The doctor believes that while Lee was in the Trendelenburg position, a minor movement on Lee’s part may have contributed to his injury and death.

Lee’s underlying hypertension and IgA (Immunoglobulin A) nephropathy were also believed to be contributory factors, reported CNA.

In any case, this truly was a tragic accident.

According to the Academy of Medicine, Singapore (AMS), this is the first case of death of its kind here, with one coroner calling it a “truly unfortunate medical misadventure”.

The coroner recommenced an investigation to prevent such mishaps from occurring again in the future.

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Shawn Ambrose
Email: [email protected]