Mid morning of 16 November 2007, complaining of stomach pains, Jesus “Jessie” Bass, 53 walked into the St. Luke’s Medical Center so he could get the best possible health care.
Jessie was attended to and examined by Dr. Edgardo Bondoc who diagnosed him for acute appendicitis. Nonetheless, Dr. Bondoc did not refer Jessie, nor called the attention of any surgeon. In fact, Dr. Bondoc advised Jessie to go home and be an out-patient.
Jessie, however, worried about his condition, opted to be confined at the world-class medical center, convinced he would be given the necessary attention. He was alone then, as his entire immediate family lived in the United States. Upon confinement, Dr. Bondoc ordered an emergency contrasting CT Scan to rule out “possible gastro intestinal infectious diseases”. Jessie, however, waited until 7 pm before he was wheeled in for scanning. This was postponed due to alleged chills, fever and elevated blood pressure. Finally, at 11:55 pm, Jessie’s scan proceeded.
Ten minutes after injecting Jessie with a test dose of the contrast dye Optiray, a team composed of radiology technicians and 1st year Radiology resident, Dr. Gilbert N. Sy, administered the full dosage. The CT Scan followed.
Jessie was pronounced dead at 1:20 am, November 17, 2007, on the 64-slice CT Scan table, one of the most modern equipment of this world-class medical center. The National Bureau of Investigation’s official autopsy confirmed Jessie had an inflamed appendicitis.
In a fact finding meeting on 14 December 2007, Dr. Joven R. Cuanang, Senior Vice President for Medical Affairs, confirmed that the Medical Center did not have the ideal staffing at the CT Scan Unit at such unholy hour, with the most senior personnel being only a 2nd year Radiology Resident, Dr. Miguel B. Zamora.
It was noted that St. Luke’s Medical Center and the inexperienced junior team did not follow the important precautions that the OPTIRAY manufacturer indicated for its use.
a) personnel competent in recognizing and treating adverse reactions of all types should always be available; and (b) the possibility of a reaction, including serious, life-threatening, fatal, anaphylactoid or cardiovascular reactions, should always be considered.
It was further noted that the CT Scan plates recorded a time fixed at 00:03:42 while the Radiology Unit’s incident report indicated that
Jessie was given the full bolus dose at 12:15 am, and got through with the procedure 15 seconds after. How soon after the “Code Red” team responded to give him the anti-dote was never accurately determined.
The presence of such inexperienced junior staff, Dr. Sy, only a 1st year Radiology resident, with two radiology technicians, was one main reason for the wrong diagnosis of what was happening to Jessie when he was wheeled out of the CT Scan gantry gasping for air.
Not recognizing the severity of the allergic reaction to the contrast dye, the technicians even tried to question the patient before calling in a resident.
Dr. Sy admitted that he turned Jessie on his side, thinking Jessie was trying to vomit. On subsequent formal meetings, however, Dr. Sy denied his initial admission.
There was, therefore, a critical gap caused by the lack of a full experienced team, and the diagnosis of an inexperienced staff that resulted in the loss of precious time to inject the needed anti-dote, and to immediately resuscitate him to effect a reversal of the adverse reaction.
Despite subsequent claims of following protocol, or maybe because of its strict observance by young inexperienced staff, it was too late when “Code Red” was called and the first dose of anti-dote given.
Jessie, whose death on the table of one of the most modern CT Scan equipment available for medical practitioners in the Philippines, should be the first and the last to be sacrificed for the sake of many more seeking similar medical assistance, especially at the famed world class, and Joint Commission International accredited St. Luke’s Medical Center.
Unfortunately, despite the above factual incidents, the St. Luke’s Medical Center claims that it did its best and has denied any responsibility whatsoever on Jessie’s death