An 83-year-old man was in the Intensive Care Department of Queen Mary Hospital in 2016. He was suspected of having an air embolism in the blood vessel due to the wrong method of the nurse on duty removing the hemodialysis catheter. He died 3 days later.
The cause of death inquiry continued today (8th). The male nurse involved appeared in court to testify, saying that shortly after removing the catheter for the deceased, he needed emergency treatment for convulsions and slow heartbeat.
Some doctors believed that this was caused by the male nurse pulling out the throat while the deceased was still sitting. The male nurse frankly said that he did not know that he needed to pull his throat under the condition of "high neck and low feet".
The deceased Qi Zhi (83 years old) was admitted to the intensive care unit of Queen Mary Hospital on May 27, 2016 due to myocardial infarction.
During this period, it was suspected that the on-duty nurse removed the three-chamber hemodialysis catheter while he was still sitting, causing the patient to develop a vascular air embolism, the heart stopped for 3 to 5 minutes, and died 3 days later.
He Nuoxi, a male nurse who pulled out the throat of the deceased Qi Zhi, said that he did not know beforehand that he had to take a high-neck posture when removing the catheter.
(Photo by Liu Anqi)
Zhiqi was still not sober at the time
He Nuoxi, a nurse at the Intensive Care Unit of Queen Mary Hospital at the time, confessed that he first came into contact with the deceased Qi Zhi on May 26, 2016.
At that time, Qi was admitted to the ICU due to heart failure. He had to lie in bed at the beginning, but slowly he did not use the ventilator and stopped the cardiotonic medicine.
The doctor also allowed him to sit on the bed and was allowed to eat liquid food at night. He had a good appetite and his condition seemed to improve.
However, the explanation is that although Qi does not need to use a ventilator anymore and is more stable than before, it does not mean that his heart failure is "good", because Qi's mind is still not sober, and he will still "wild" and struggle.
Qi Ba’s throat was confirmed by the doctor verbally
After that, he left work at 9 pm on the same day and was on duty again at 6:30 the next day. At that time, Qi's spirit became more tired and his appetite deteriorated.
After the doctor's assessment, he believes that Qi can be transferred out of the intensive care unit ward, but he must first remove the catheter from his body and notify his family.
He received the verbal confirmation from the doctor at 10:15 and went to the ward to remove the catheter from his neck for Qi.
At that time, Qi was sitting in the armchair by the sick side. After He Zhihui Qi and obtained consent, he first disinfected the neck catheter interface and then cut the thread with scissors. After that, he pulled out the throat while pressing the opening with gauze to stop the bleeding. The process It takes 1 to 2 minutes.
After pulling the throat, I saw Qi face blue, white lips and convulsions
Soon after, He found that Qi seemed to want to remove the monitoring device from his body for a moment. After that, Qi became blue and whitish, lips and convulsions, low blood pressure and slow heartbeat, which seemed to be the state before cardiac arrest.
He and his colleagues immediately brought Qi back to the bed for emergency procedures. The two doctors Liu Lishan and Wei Zhenwei who had just passed by also stepped forward to assist.
After Liu Xianghe learned about the situation, he suspected that Qi was sitting and pulling out his throat and causing air to enter his blood vessels. He then performed an ultrasound for Qi and found that his heart appeared to have a lot of air.
Saved the report in the system but failed to submit
He said that after writing a report on the computer at 5 o'clock on the day of the incident, he left after the Medical Malpractice Notification System (AIRS) thought he had pressed the Submit button.
It was not until the next day that he received a call from the manager and learned that he had only pressed Save, and then he pressed the submit button to submit, and the computer system also had relevant records.
I don’t know how to extubate the tube with the head and feet low.
As for the correct posture to remove the neck catheter, He said to himself: "I don't know how to stretch the catheter with the head high and the feet low."
When asked if he had received relevant teaching before, He said: "I'm not too sure that the actual situation is something like that." Magistrate He Junyao stepped up and asked: "Is there definitely a teacher? It might be possible?" He agreed. .
It is also said that he has dealt with similar cases of pulling the throat in the past, but he did not know that there were relevant guidelines when the case occurred, and no one in the impression told him to read the guidelines.
Case Number: CCDI-303/2016(LW)
Eighty-year-old Weng was suspected of being pulled out of the wrong throat and was admitted to the hospital. During the examination, he fell down and turned to the ICU. Suspected of sitting and having his throat pulled out.
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