Verdict expected today in hearing on boy’s death

Press, 19 November 1982, Page 4

Verdict expected today in hearing on boy’s death

A verdict is expected today in the High Court trial of an Australian doctor on a charge of manslaughter of a young patient at Grey Hospital last year. The defence completed its case yesterday.. Counsel will address the jury this morning and Mr Justice Roper will sum up. Dr lan Raban McDonald, aged 56, an anaesthetist, of Queensland, has pleaded not guilty to the manslaughter of a boy being operated on for appendicitis at Greymouth, who was given carbon dioxide instead of oxygen. He suffered brain damage and died a week later in the

intensive care unn at me Christchurch Hospital. McDonald is charged that on March 16, 1981, while acting as an anaesthetist he caused the death of Carl Lewis Gomulski, aged 11, by omitting without lawful excuse to perform a legal duty towards him. The Crown alleges that McDonald was guilty of a series of errors which resulted in the boy’s death. • The defence says that McDonald was not negligent and was not responsible for the fatality which was due to pathetically inadequate administration at the hospital. Messrs N. W. Williamson and G. K. Panckhurst appear for the Crown, and Messrs R. G. Collins and C. W. James, of Wellington, for McDonald. McDonald said in evidence that he realised that he had been using the wrong gas from a machine he had not prechecked and was in a theatre he had not expected to be in. He told Dr Hugh Russell Bodie that he had been using the wrong gas, that it had been corrected

and that the heart would start very soon. Carl had already improved in colour by then. “We could see on the cardiotrace that the complexes came up very swiftly after that. The cardiotrace is a box-like machine with a screen sitting on the tray on top of the anaesthetic machine. It shows the electrocardiograph tracing of the

heart beat,” McDonald said. He estimated that the anoxic period — the time the boy was deprived of oxygen - to be about four minutes. He was on an artificial circulation and turned pink before the heart restarted. On resumption of the heart beat he administered corrective medication, said McDonald who .detailed the drugs which were given. After consultation among the doctors it was decided to proceed with the appendix operation which was essential; otherwise he would have died of peritonitis. The operation was uneventful and was completed at 11.10 a.m. The boy’s condition improved steadily throughout. the operation and a second specimen of blood was taken for gas analysis. He was given a further dose of bicarbonate. At the end of the operation he was really in a good condition as regards his circulation. Carl was sucking or chewing on the tube which meant that he was getting very light in terms of anaesthesia. He had come to the stage where he would not tolerate any very painful stimulation. He kept moving his head as if he wanted to get rid of the tube. That happened at the termination of every anaesthetic and the next thing was that he coughed mightily and pulled the thing out. McDonald said that he would;have much preferred to have left the tube in and given a long-acting muscle relaxant. In that way there was full control of the airway, blood gases and respiration. “If you are trying to control a person who has had a period of cardiac arrest a further anoxic episode has to be avoided at all costs. You should avoid letting them

cough or strain as that increases the intracranial pressure — the pressure inside the skull. Dr Bodie wanted the tube removed and to see if the patient would wake up but accused thought it would be better if it was left in. Dr Bodie was in charge. About 11.40 a.m. advice was sought from Christchurch which recommended that the tube be replaced. Dr Brian Weston set, about replacing the tube but had difficulties. The long-acting relaxant which was given worked rather slowly. Two attempts had to be made to insert the tube.

lhe problem was that the relaxant had not worked properly and dt the first attempt the cords went into a spasm. In all events there was clearly a period of hypoxia and cyanosis. “I was watching and was very distressed because I feared that we had lost our advantage. As soon as the tube was passed and he was ventilated colour returned,” McDonald said. After that incident he was committed to an anaesthetic for the obstetricians in Theatre Two. He was not asked to have anything to do with the recovery of Carl. Next day he had a talk with Dr Weston who asked him about the incident and he had explained what had happened. “I told him I put myself at his disposition whether he wanted me to stay or go. I suggested that he consult his colleagues and see what their feelings on the matter were. Later that day he told me that they felt it would be better if I retired,” said McDonald.

Before returning to Brisbane he wrote a report about the carbon dioxide cylinder and associated matters and left his Australian address. In Christchurch he telephoned the intensive care unit and spoke to Professor John Gibbs, chairman of the committee, which inquired into anaesthetic accidents in New Zealand, for about an hour and a half.

Just before leaving for Australia he made a further inquiry at the intensive care unit and was told that Carl was still alive but that his condition had deteriorated dangerously and it was obvious that he .would not survive. He was never notified officially that the boy had died. Some nine months later Detective Inspector Neville John Stokes arrived at his home on Russell Island. He had received no notification of his visit. During the interview with the inspector he had not appreciated that the inspector was making inquiries in regard to criminal proceedings against him. McDonald said that he answered a long series of questions put to him by the inspector although right at the start he had explained to. him that his records were on the mainland. To Mr Williamson McDonald agreed that when Carl was placed on. the operating table he was totally reliant on acciised to be able to breath and that accused was under a duty to see that

he received oxygen in the mixture through the tube. . McDonald admitted that he had failed to give the boy oxygen for some minutes and had given him carbon dioxide instead. He denied that he had not looked when he turned on' the gas, but said that he looked and saw what he expected to see. He had deceived himself. In effect he was suffering from some mental block caused . by his previous examination . of the anaesthetic machine in Theatre Two. He had never been in Theatre One before the day of Carl’s operation. McDonald said that he accepted the statement made .. by Dr Douglas Chisholm that an anaesthetist had a pro-

found and absolute responsibility to ensure a patient's safety because he had deprived him of conscious control of his breathing. He did not suggest that his responsibility to Carl was lessened because of the state of his own health. Had he prechecked the anaesthetic machine in Theatre One he would have found the carbon

dioxide facility. On the morning of March 16 McDonald said that he knew he would be assisting Dr Bodie in general surgery. Mr Williamson: Yesterday your counsel described you as a victim of a pathetic administration system. Is that your view of the matter? — Yes. Do you suggest that the Grey Hospital had a pathetic administration system? — I was sincerely shocked to find that a cylinder of carbon dioxide could find its way into an operating suite without the knowledge of the medical superintendent and therefore presumably no appropriate regulations could

have been prescribed for its safe control as is done with dangerous drugs. Had the hospital authorities been properly advised they would have realised that it was a serious possibility that carbon dioxide was liable to accidental misuse. “While the accident is unlikely it must be regarded as a possibility. If it is possible for something to go wrong, sooner or later it will do so,” said McDonald.

He did not suggest that Dr Bodie should have checked on what accused had set on the rotameters during the course of the operation. It was not the nurse’s responsibility to have monitored his rotameter settings. The boy’s heart stopped and cardiac massage begun at 10 a.m. and McDonald agreed that it was about two minutes and a half to three minutes since he had been connected to the machine. Mr Williamson: During that time Carl had been receiving carbon dioxide and nitrous oxide? — Just carbon

dioxide for much of the time because the nitrous oxide was turned off very early in the piece. McDonald agreed that it would have been about 10.6

a.m. when the carbon dioxide was turned off. The boy was given half an ampoule of atrophine about 10.2 a.m. and the other half immediately after oxygenation had been re-established.

“I then adjusted the bicar-

bonate drip and turned the carbon dioxide off: as it seemed its contribution to the problem now wouldn’t be all that great after the massive amount of oxygen I had flooded into the circle. Antrophine had first 'priority and then turn off the' carbon dioxide,” McDonald said. Mr Williamson: During the time between the cardiac arrest happening and the heart restarting there were quite a lot of actions by various people. During that oeriod did you again look at the machine at any time to see if there was anything wrong with it? — My attention at that stage was devoted to other checks and manipulations. I glanced at

the flowmeters to see that the bobbing was still at the top. You still didn't see what tube it was in? — no. McDonald agreed that at that stage the possibility of the wrong gas was the major concern for him. Everything sort of happened simultaneously. Nurse Edith Olive Forrest said: “He’s not getting enough oxygen. I’ll turn it up.” Once the cause of the problem was identified it would be corrected quickly with pure oxygen. Asked if preparations were made to change the throat tube McDonald said they had envisaged that possibility and an alternative tube had been produced but they in

fact did not change it. Mr Williamson: That would have been a last desperate measure if you knew it was perfectly in place? — Yes. McDonald agreed that Nurse Forrest was going to assist with suction during the removal of the tube when she lent across in front of the machine, and discovered the error and turned the oxygen on and she publicly said that it had not been on. Mr Williamson: It wasn’t really a question of you tumbling to it or discovering it yourself as you told Inspector Stokes was it? — No, at this stage I envisaged discarding the machine, using an ambubag and a separate source of oxygen supply. Asked it it was a period of seven and a half to eight

minutes that oxygen had not been flowing from the machine to Carl, McDonald replied that he thought that the period recorded in the notes was five minutes. McDonald agreed that when the tube was taken out after the operation that Carl was breathing spontaneously and was not being ventilated. He was present while Dr Bodie examined the boy. Accused was not asked to replace the tube at the end of the examination. That was done after Dr. Weston arrived and he inserted it.

Weren’t you alongside Dr Weston when he placed the tube back? — I was assisting Dr Tim Ewer with the placement of an intravenous needle m Carl’s left leg.

I suggest to you that you weren’t in a position to observe anything of what was happening at the time the tube was placed back in? — I was not only present but I was within four feet of the bed.

You mentioned that the procedure filled you with acute distress. Why didn’t you say something to Dr Weston about it? — I find the question astonishing. Here we have Dr Weston in serious difficulties and it would be lunacy to harass him in any way. He is doing his very best and is fully extended. He is in serious trouble in the management of a gravely ill child and the last thing you need is spectator activity. If you are not involved you shut up and if you are you do as you’re told. McDonald said that he had suggested that a nasal tube be passed through the nose into the larynx. It was less

likely to displacement and he had suggested that a shortacting powerful muscle relaxant be used, and that the cords be sprayed with a local anaesthetic. Those suggestions were made two or three minutes before the insertion of the tube was attempted. When Inspector Stokes arrived at Russell Island he was under the impression that the call was fortuitous and that he was on holiday and had been asked to interview accused as he was passing through. He did not know it was a special visit to interrogate him. About two days before he

had heard a news item on

the radio asking a detective inspector from New Zealand to contact the New South Wales C. 1.8. He had been told that the disciplinary committee of the Medical Board inquired into all medical accidents. If the explanation was unsatisfactory they would then pass matters on to the appropriate authorities. The board was empowered both to deregister and fine doctors. McDonald said he had never told Inspector Stokes that he had been advised by the Medical Defence Union not to make a statement. If he was going to make a statement he always typed it himself. He had mentioned to Inspector Stokes that he had reported the matter to the Medical Defence Union. Dr David Govett Romaine Wright, a specialist anaesthetist, of Wellington, said that the presence of carbon dioxide , capacity on an anaesthetic machine at the Grey Hospital struck him as extraordinary.

When he returned from the United Kingdom in 1956 there were carbon dioxide cylinders on machines in the Wellington Hospital Board’s district and in that year or a year later they were all removed. , They were taken off because they made no contribution to the giving of anaesthetics and in previous years, especially in the United Kingdom, there had been a series of cases which were similar to the present one.

He would have expected such an oddity on a machine to be pointed out to a locum arriving at Greymouth from Australia, said Dr Wright.

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