AIIMS nurse death: Distress call made to doctor but he didn’t think it was genuine

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A senior resident of the anaesthesiology department, whose services were terminated by AIIMS over the death of pregnant nurse Rajbir Kaur, told an inquiry committee that he was not present for the delivery because he did not believe the call from the gynaecology team regarding foetal distress was “genuine”.

Facing allegations of medical negligence, the senior resident defended his actions before the committee after the nurse’s death at AIIMS on February 4. Two other junior residents also faced action over her death.

The inquiry committee highlighted a number of lapses, including the fact that the C-section surgery on Kaur was conducted in an operation theatre not equipped to handle cases under general anaesthesia.

In his testimony before the eight-member inquiry panel, headed by Professor S C Sharma, head of the AIIMS ENT department, the senior resident deposed that he had, in the past, received many calls for foetal distress that were “not genuine”. So, when he received a call in Kaur’s case, he dismissed it, which led to a delay in treatment.

It is also learnt that the senior resident was absent from the maternity OT for another twin delivery, which took place before Kaur’s C-section surgery.

A senior resident of the gynaecology department, against whom the AIIMS director will issue a “memorandum of displeasure”, was asked to start Kaur’s case without full knowledge of the details.

Other lapses, the inquiry committee found, include Kaur being shifted to the back table of the maternity OT, which is typically not used for C-sections. Although the committee was told this was done to save the baby, it pointed out that the back table did not have a ready stock of emergency drugs and the OT was not fully prepared to handle such an emergency under general anaesthesia.

The committee concluded that an under-prepared OT and the absence of the senior resident of anaesthesiology were responsible for a failed intubation, which led to complications, including bradycardia or slow heart rate.

An artificial breathing tube had been mistakenly inserted into Kaur’s food pipe instead of her respiratory tract, and that food particles had entered the lungs, causing further complications. The inquiry committee pointed to the lapse as well, stating that the tube in the oesophagus could not be detected immediately because Kaur’s vitals were not linked to a monitoring system.

It is also learnt that there was chaos during the emergency, with the junior resident of anaesthesia getting little time to arrange items for intubation. Due to the chaos, two complications developed — in regurgitation, or expulsion of material from the pharynx or oesophagus; and inspiration, the process of drawing breath. The panel pointed out that the situation could have been averted had the senior resident of anaesthesia been present.