This is one of the saddest tragedies I’ve ever read regarding the healthcare services in Malaysia. As a Plastic Surgeon who has experience dealing with extravasation injuries (inadvertant injection into surrounding tissue rather than the vein) in newborns, here are a few thoughts.

Finding veins for cannulation in newborn babies is hard enough, it’s even harder in premature babies. Hence, extravasation injuries do happen in paediatric intensive care units. I think the first failure here is that the supervising specialist failed to give his/her junior doctor the support required. Giving instructions over the phone in a situation like this is simply not good enough. Secondly, why did the nursing/medical staff fail to adequately monitor the drip site after the cannula was inserted? This should be standard practice in any reputable intensive care unit; particularly as babies’ veins can be very difficult to cannulate. Extravasation injuries can/will happen in babies – but if it is picked up early enough, then effective treatment can be instituted to prevent a subsequent disaster like this!

I also cannot understand this nonsense reasoning that the soft tissues of the forearm died from infection. If the forearm soft tissues were so severely infected as to die-off, it would have spread to the rest of Yok Shan and she would have died from fulminant sepsis. (Google “necrotising fasciitis” to see what I mean)

I believe the greater likelihood was that the infusion of antibiotics was given into the muscle; and that the tissues died from “compartment syndrome”. Muscles are surrounded by a sheath with limited capacity for stretch. Significant trauma to the muscle (eg: injection in this case) results in swelling. As the surrounding sheath cannot stetch, the muscle swelling causes pressure within the sheath to rise, and cuts-off the blood flow to the muscle. Thus leading to death of the muscle within about 6 hours. Sadly, there is a cure for this if caught in time. A simple surgical release of the surrounding sheath (called a “fasciotomy”) will allow the internal pressure to be released and restore circulation to the muscles. The key is in having a high index of suspicion for this condition to allow early diagnosis when treatment can still be instituted.

Reading some of the other reports, it would appear that Yok Shan’s father even noticed that his daughter’s hand had gone white after the attempted antibiotic injection! Why did the medical/nursing staff fail to notice this when even a non-medically qualified person did?

So here’s my overall take:
1) Was the junior doctor negligent for putting the drip in the wrong place? No – this can easily happen.
2) Was the senior specialist negligent for failing to provide his/her junior adequate support? Yes – the specialist is being paid to do a job – and he/she did not fulfill his/her duty of care.
3) Were the medical/nursing staff negligent in failing to monitor the drip site? Yes – it should be routine, particularly in paediatric intensive care where even 10mls can be a large volume in a tiny baby.
4) If it had been a case of “compartment syndrome”, could early diagnosis and surgical fasciotomy saved Yok Shan’s forearm? Yes, very likely – but I guess we’ll never know now.
5) Was this caused by infection rather than compartment syndrome? Possibly, but it’s very much less likely.

My thoughts are with Yok Shan’s parents at this difficult time. May she grow up a happy and fulfilled child even with such a terrible tragedy in her early age.