Hi ginfreely,
Remember our previous exchanges where I talked about those who complain generally get what they want in the end? Don't get what you want complain more. If go to the newspapers sure get what you want. This is one example.
Before we talk about rabies, let's review what constitutes medical malpractice.
Medical malpractice is professional negligence by act or omission by a health care provider in which the treatment provided falls below the accepted standard of practice in the medical community and causes injury or death to the patient, with most cases involving medical error.
The important aspect of malpractice is whether the act or ommision which constitues negligence causes injury or death. Many cases of errors do not cause harm to the patient and hence would not be successfully tried in court.
A complaint is a complaint and it "looks bad" from a service point of view. Just because the organization apologizes and gives the customer what they want doesn't always mean the company was in the wrong. They just want to issue resolved.
Back to rabies. I'll tell you a funny thing. Last month I saw 2 Chinese patients who came in with dog bites. Said they were bitten by dog while walking. Small toy dogs??? They claimed that is was unprovoked???? I have 3 toy dogs myself and they would not bother biting anyone. Anyway in both cases the dog owner showed the patient their dog's rabies vaccination certificates. But these PRC Chinese were told by their friend from China that if bitten by dog MUST get rabies vaccine!
So they came to me. I asked whether the dogs were rabid and crazy? They said yes! But I said the dogs were vaccinated so the risk of the dogs having rabies is extremely low. I said I will give you tetanus shot and some antibiotics. Their "bites" were really just scratches on their hands. They insisted that they must have rabies shots! I said sorry I do not have rabies shots you have to go to the ED then. In my referral letter to ED I explained that I had given the patients advice but they insisted on rabies shots based on their experience in China.
Remember what I said about third world country patients deserve third world country doctors? Well here's one example. So much hoo-ha over a dog bite and talking about rabies vaccines. Is Singapore third world or first world?
Alright. Now let's establish what is the standard of care in a case of a patient bitten by a dog and concerned about possible rabies transmission.
http://www.health.gov.on.ca/en/pro/...uidance/gd_mng_suspected_rabies_exposures.pdf
http://www.cdc.gov/rabies/medical_care/index.html
For a quick summary go to page 9 of the 18 page guidance document from Ontario Health.
I remember the assessment bit for rabies because it was a very common question in the CCFP exams for Family doctors in Canada. First we ask what animal. Wild? Domestic? What circumstances? Unprovoked? Signs of the animal being rabid (ie kee siao). Is the owner of the animal contactable? Certificates showing animal was vaccinated? Nature of the injuries. Deep penetrating wounds are more likely to result in transmission than superficial ones. In the instance where there is evidence of valid up to date vaccination in a domestic animal the risk is virtually ZERO. In all other cases the next step is to observe the animal for signs of rabies. If the animal is suspected to be rabid, they put down the animal and run tests on its brain tissue. More so for epidemiology studies. Of course once the animal is suspected rabid we treat the patient ASAP. Rabies IgG (basically antibodies against rabies) is very expensive. Something like one thousand per vial and it takes several vials for an adult. The vaccine only has effect for 2 years. Rabies in urban areas is also extremely rare given the monitoring by environment and wildlife. Hence it is not practical nor a good use of funds to vaccinate humans every 2 years for something so rare. Having said that, rabies is almost invariably fatal. So what we have is a very rare disease, but extremely deadly. It is transmitted from one rabid animal to another but invariably results in death of the infected. Think Zombies but the Zombies die after 10 days.
Let's go back to this case involving Madam Koh. She listed other mistakes as a way to "magnify" the problem. Cholesterol tests......maybe she didn't need it cos the doctor did not feel she needed it. Patients are charged a flat fee for blood tests as far as I know. So the bill did not change whether they added Lipid panel or not. Make noise sure can do it. And it is common practice to call the lab to add it on to the battery if the blood had been drawn into a plain tube for other tests eg Electrolytes and Creatinine. Second one was about forms.....aiyah.....admin errors happen very commonly lah.
Now about the "rabies" case. First, Madam Koh did not have rabies lah. Otherwise she would be DEAD by now. Secondly the report says she was bitten by a dog. What dog? Whose dog? Where? Wild dog? Stray dog? These are important details to report if you want to be a responsible journalist to show whether there was any error in the assessment. Salma Khalik is being irresponsible as a "Health Correspondent". I have always felt she was nothing but a rabble rouser and because doctors are the nicest professionals around and we never bite she gets away with all her crap.
To ginbitchy, you do not understand the protocols and decision making process in administering rabies IgG. Madam Koh was bitten by a dog yes, but it does not mean she NEEDED a rabies vaccine! And on hindsight which is 20/20 we know she definitely DID NOT HAVE RABIES AND DID NOT NEED THE VACCINE. In fact if she was given the vaccine as per your recommendation, that itself would have been a case of medical error as well. (see guidelines on when to administer rabies PEP)
Now the patient was probably seen at the OPD and advised to have a tetanus shot. She got a Typhoid vaccine instead. Note that it was the polyclinic itself that recognized the error and then informed the patient and apologized. If the OPD did not say anything Madam Koh would not know about this error at all. I actually think NHGP should be acknowledged for being honest and truthful and having the patient's best interest above all else. Even risking this bad publicity.
What is a typhoid vaccine?
http://www.cdc.gov/vaccines/vpd-vac/typhoid/
Typhoid vaccines protect you from Salmonella Typhi. A bacterial infection that causes bloody diarrhea and other complications. It is passed through contaminated food (by feces). It is not common in developed countries. We recommend taking it if patients are traveling to areas that are endemic or are going backpacking in the wild. In Singapore all food handlers have to be immunized with Typherix (typhoid vaccine) injection into muscle every 3 years. There is another vaccine called Vivotif which is taken orally on days 1, 3, 5, 7. Most clinics I know have stopped giving the oral form because patients could be unreliable and not take their doses. Whereas with the shot, the nurse or doctor injects and that's it.
Ok so Madam Koh got a Typhoid vaccine instead of a Tetanus vaccine. NHGP called her back probably to tell her the mistake and that they would need to give her a Tetanus shot because she did not receive it. Note that NHGP called her back THE NEXT DAY. Very fast.
Would the fact that Madam Koh got a Typhoid vaccine constitute medical malpractice? No. We give the shot to lots of people. All the waiters and waitresses you see at restaurants have had it. Literally thousands. Very safe. If anything....free vaccine, extra protection for travel next 3 years! Yay!
Would the fact that Madam Koh did not receive a tetanus shot constitute medical malpractice? Well if she got tetanus within the few hours between the mistake and her finally getting her shot then perhaps yes. But note that all Singaporeans have had their immunizations with Tetanus. We generally recommend a booster every 10 years. Or in any possible contaminated injury then and the last immunization date is unsure then we give another. No harm getting more. It doesn't sound like the wound was particularly serious or contaminated otherwise she would have been sent to the ED for toilet and suture at the very least and maybe intravenous antibiotics. So the likelihood is extremely low. On hindsight, there is no mention of any medical complications. So there you go, the answer is no medical malpractice as the patient was not harmed.
Now note here that in the report it states that Madam Koh DID NOT SUBSEQUENTLY GET A TETANUS JAB. Now I am 100% sure this was not on the advice of the health care professionals. It was the typical ngiau Singaporean mentality want to complain and angry and want blood and want dunno what, want nurse to be struck off and never work as nurse kind of complaint and demand to the point the patient would REFUSE proper medical management. Ginfreely, trust me this happens all the time. Well Madam Koh has a right to refuse treatment. But she would have to take responsibility for her choices as well.
Read the rest of the report.
There was an error. Errors occur very frequently everywhere in every industry. In this case I would say it is a serious error but not a particularly dangerous one and one that would not have led to medical malpractice.
Madam Koh just wanted to make a fuss of this. NHGP investigated and found no true lapses in care resulting in malpractice. Madam Koh requested for a refund. They gave it to her but not a full one. Why? Because I am pretty sure this Madam Koh wanted COMPENSATION. Would probably have said things like want to sue lah, bring to court lah, say things like wait I got the typhoid shot then I died how? How can you give me wrong vaccine? SOOOOO DANGEROUS!!!! Wait I die how? I got little kids you know? I die then who take care of them? How you all be doctor and nurse one? She can hire a lawyer go to court and waste all her money. The Medical Malpractice Insurance people know the case is totally defensible. NHGP also knows it.
Sigh. Doctors and nurses are human also. Humans make mistakes. NHG did not cover this up. Kudos to them. They called the patient the next day and offered to give her the right injection and probably spent a good deal of time explaining it all to her. But she goes to the press. And this SENIOR HEALTH CORRESPONDENT has no story better to report on but this type of crap. There are better stories to report on just that she would step on bigger shots' toes.
Singaporeans are 3rd world country people with 3rd world country mentality. The press is also the same.
I think Singaporeans just too angry and unhappy with life too much so every thing don't go right they make a MOUNTAIN of it. And it doesn't help that the more you curse and swear and make a scene the more likely the company or restaurant or whatever will bend over to let you screw their backside even more.
KPKB enough you will at least get refund. Remember that ginfreely.
