Iatrogenesis in the Intensive Care

1 Московский государственный медико-стоматологический университет им. А.И. Евдокимова Минздрава России, Россия, 127473, г. Москва, ул. Делегатская, д. 20, стр. 1 2 Московский городской институт естествознаний и спортивных технологий Минздрава России, Россия, 105568, г. Москва, ул. Чечулина, д. 1, к. 1 3 Астраханский государственный медицинский университет Минздрава России, Россия, 414000, г. Астрахань, ул. Бакинская, д. 121


Introduction
The problem of unfavorable outcomes in medical practice is urgent because we still lack knowledge in this area.
According to literary data, in healthcare institutions of the Ministry of Health of the Russian Federa-
The problem of evaluation of defects in medical care, unfavorable outcomes and causal relationship between them is still one of important and complex issues of forensic medical examination. Controversy was mainly observed while rendering intensive care to patients aged less than 60 years. In the vast majority of cases (84.9%), claims against health workers were related to the emergency medical care. Of the total number of forensic examinations conducted by the forensic commission, defects in medical care provided by anesthesiologists and intensivists were found in 45.6% of cases. It should be admitted that in cases (54.4%), when the council of experts did not find signs of improper medical care, principles of deontology were violated by a doctor resulting in lawsuits initiated by patients or their relatives [4][5][6][7].
The defect of medical care should be defined as its lack in the form of medical staff's activity or failure, which is a violation of the existing guidelines (procedures and standards of medical care, clinical recommendations, rules, instructions, guidelines, regulations, directives, and orders) expressed as wrong provision (failure) of medical care (prevention, diagnosis, treatment, and rehabilitation) [8].

Clinical case from the expert's practice
Records concerning the death of patient N., 19 years old, demonstrate that he was stabbed and died during the surgery. Diagnosis on admission: «Penetrating chest wound on the left and a wound of the left lumbar region penetrating into the chest cavity. The final clinical diagnosis: Penetrating knife chest wound on the left and a wound of the left lumbar region penetrating into the chest cavity. II-III degree post-hemorrhagic shock. Hemothorax. Hemoperitoneum. Wound of the left lung and the diaphragm».
Wound tracts were examined before evisceration. There is a perforating linear damage of muscles and parietal pleura in the intercostal space along the 5 th left intercostal space, from the left mid-clavicle to mid-axillary line, sutured with nodular sutures; sutures are competent. A perforating sutured injury of the upper lobe of the left lung was found. The wound entry hole is located on the front surface of the lung, and the exit hole is on the interlobular surface. The length of the ский: Проникающее ножевое ранение грудной клетки слева и поясничной области слева, проникающее в брюшную полость. Постгеморрагический шок II-III степени. Гемоторакс. Гемоперитонеум. Ранение левого легкого и диафрагмы».
Clinical data, findings of forensic medical examination and histological findings suggest that the patient has died from acute hypoxia due to aspiration of gastric contents into the respiratory tract, complicated by bronchospasm as a result of unsuccessful attempts to intubate the patient.
The following questions were raised before the council of experts: «Was the medical examination and preoperative preparation sufficient taking into account patient's state and conditions in the healthcare institution?» «Was the urgent care rendered in a full volume and at due time on patient's admission?» «Were there errors in anesthesia and intensive care? If there were, what exactly were the organizational, tactical and technical defects?» The diagnostic tests and examinations carried out on admission were sufficient for diagnosis and selection of the correct treatment strategy.
However, while preparing patient N. to the surgery, no gastric probing was performed for its empty-
Причиной смерти гр. Н. явилась рефлекторная остановка сердца на фоне развившейся острой ing and prevention of complications in the form of regurgitation of the gastric contents into the respiratory tract, although it was indicated in this case.
The plan of medical care of patient N. in the village hospital developed by the surgeon and anesthesiologist was correct and sufficient. However, there were technical difficulties (impossibility of tracheal intubation) during its implementation. The surgery was performed under general anesthesia and mask lung ventilation.
The mask ventilation with total muscle relaxation, which lasted about 1.5 hours, during anesthesia without a gastric tube resulted in a complication, i.e. regurgitation with subsequent reflex cardiac arrest.
Two penetrating wounds of the left half of the chest with an injury of the left lung and the cupula of the diaphragm accompanied by blood loss (not less than 500 ml), acute respiratory failure, hemorrhagic and pleuropulmonary shock are classified as a serious life-threatening damage.
It was a reflex cardiac arrest due to acute respiratory failure caused by aspiration of the gastric contents into the upper respiratory tract that became the cause of death of patient N., and not the injuries he had. These complications are mainly due to the defect of preoperative (anesthetic) preparation of patient N. to the surgery. Patient N. was admitted 25-30 minutes after the injury, i.e. he was hospitalized at due time.
No errors in anesthesia were found in medical records. However, the description of the intensive care in the medical records presented for examination is omitted, which objectively does not allow the council of experts to determine the adequacy of their extend and completeness [9][10][11].
«Organizational, tactical and technical defects» include the lack of serviceable equipment for tracheal intubation in the operating room.