There are many things that prove negligence, there are many things that should not have happened like this at Pantelimon Hospital, negligence and malpractice, but from them to premeditated murder is an extremely long distance, says Prof. Dr. Gheorghe Andrei Dan, a board-certified cardiologist and internal medicine physician.
In an interview granted to SpotMedia.ro, Dr. Gheorghe Andrei Dan analyzes the dramatic effects, but also the deep causes of the Pantelimon scandal: none of this would have happened or, in any case, would have caused such a stir only, perhaps, at a personal level, if the absolutely necessary regulatory systems existed.
Due to the generalization and extreme reaction of the media, says Prof. Dan, the patient was pushed into the arms of distrust, despair, myths. And will the ICU doctors still be able to have the freedom of thought, to act knowingly on a seriously ill patient, whom they might eventually save with a last-minute measure? Will they have the courage?
Prof. Dr. Gheorghe Andrei Dan teaches at the Carol Davila University of Medicine and Pharmacy, has coordinated the Cardiology Department, the Functional Explorations Laboratory, and the Interventional Cardiology Laboratory at Colentina Hospital. He was the president of the International Society of Cardiovascular Pharmacotherapy.
The scandal of premeditated murder accusation at Pantelimon Hospital is probably unprecedented in Romanian medicine and has, as expected, polarized society. What is your take on what happened?
Some believe that we, doctors, will continue to do our job, and things will pass. In my opinion, passivity, whether out of indifference or fear, is to blame.
I will refer, first of all, to the way this fire, this unprecedented media lynching, was ignited in 50 years of profession.
I have identified three major malignant pillars of the phenomenon:
1. Violation of the right to presumption of innocence in the absence of direct, conclusive, and very categorical evidence.
2. Public misinformation through circumstantial arguments, partial truths, and scientifically inadequate comments.
3. Generalization of conclusions and politicization of the subject.
I have also talked about the media noise created during the Covid period around the intensive care units (ICUs). Many things could probably have been prevented if legislative measures regarding the healthcare system had been taken at that time.
I have closely followed everything that appeared in the press as arguments of the prosecution. I have not noticed even a single direct piece of evidence linking the medical act, correct or not, to premeditated murder. I am interested in a BBC program that talks about suspicious deaths in hospitals, but where the evidence is of a completely different nature.
Everything I have heard is circumstantial, strictly temporal connections, and some arguments were absolutely ridiculous. For example: "he told me with his eyes to let him die." If this can be considered evidence... ?!
But the fact that the data from the infusion pump regarding the administered noradrenaline in fact, 1 ml/h, was different from that in the medical record, 20 ml/h, is not a conclusive piece of evidence?
The argument with the infusion pump is concrete but processed in a false way. The infusion rate is confused with the concentration.
In 20 ml of infusion per hour, the same amount of active substance can be contained as in one milliliter per hour. It is not the milliliters/hour flow rate that matters, but the substance concentration.
Secondly, there is no fixed protocol for the administration of noradrenaline, and noradrenaline is just a small part of a complex therapeutic protocol that is applied to a seriously ill patient. Nowhere does it say that for such a patient, 20, 10, or 5 ml of concentration X of noradrenaline should be given. The treatment is adapted to the conditions and to the patient.
The fact that this protocol was not detailed in the medical record is a concrete argument for failure to fulfill service obligations, but it does not in any way demonstrate a causal link to the death.
I have repeated to my students and to those who want to listen to me a million times that what is not written does not exist, and the failure to record in the medical record is a type of malpractice, negligence in completing medical documents. But it is not premeditated murder.
But the list of deceased patients and the prospectus of noradrenaline found at the home of one of the accused?
Of course, she was defending herself. She knew she was under scrutiny and was trying to provide an explanation and justification at least for herself. Again, there is no argument that proves the extremely serious accusation of premeditated murder.
But the statements of the nurses who were asked not to follow the dose in the medical record?
All these things are not normal. They represent service negligence and malpractice, but they do not constitute direct evidence to prove premeditation for a criminal act. It should be noted that we are dealing with a section with internal conflicts, unfortunately.
And I ask you, what would have been the motive for such an incredible, extreme, and unacceptable action by two 30-year-old women working in a state hospital who were not directly linked to the ICU occupancy rate? Especially since they were known to be under observation, because the origin of the whole problem is an old internal conflict section.
The statement that the patient is "to be left" was shocking.
All witness statements are either, so to speak, based on sources, or very strange.
I am not in a position to determine what competence the nurses had to judge the case from a medical point of view. And the fact that one doctor communicates to another that in his opinion the patient has minimal chances does not make him a criminal if the patient dies from the administered therapy.
There are many things that prove negligence, many things that perhaps should not have happened like this. First of all, that no modification of the therapeutic protocol can be made without justification in the record, that verbal instructions cannot be given without being recorded.
But from there to premeditated murder is an extremely long distance.
Have you asked what could have led them to do such a thing? Perhaps a slip-up of the type "playing God"? Meaning the desire to somehow bring divine order, to free up the ICU from people who objectively have no chance of recovery to make room for other seriously ill but viable individuals?
Intensive care is the front line in medicine. It is the most pressured of all medical specialties. ICU doctors are, in fact, anonymous heroes and are very few compared to the needs.
The exercise in such a continuously intense section strengthens you, makes you not react as you would or even a doctor from another specialty.
But this strengthening never turns into, unless we are dealing with a psychopath and, for now, we have no evidence in this regard, playing God, as you say, and a solution like: let's let these people die to empty the ward for someone else.
People do not know that intensive care units are very expensive. An ICU bed can sometimes cost as much as a ward. The number of patients cared for by an ICU doctor is much smaller than the number of patients cared for in a regular ward.
However, in our ICU, two categories of people enter, at least. One is the seriously ill, acute or non-acute person, who requires advanced life support.
And something completely different is the terminal patient who, from a scientific point of view, has a very low chance of survival and should be in a palliative care unit.
In Romania, legislation and concrete possibilities do not encourage anything other than vital support until the natural end of hospitalized individuals, regardless of their profile.
The prosecutors have in the file a forensic report that establishes causality between the reduction of the noradrenaline dose and death.
I am a bit baffled by the categorical statement: it is causative of death. A temporal link between stopping noradrenaline and death, but without a word about the subject of the discussion - the patient.
Unfortunately, there is little information about the patient's condition. I have great respect for forensic experts, but they cannot encompass the nuances of all specialties, including ICU care.
Among the few things I know concretely from Pantelimon Hospital is that the patient had an extremely severe pathology.
Including cardiac, your field. Heart failure and constrictive pericarditis, it seems. Were they potentially lethal?
Yes. Each of them had a great potential for severity, and in this complex patient, they seemed to indicate a very small chance of success.
For a specific medical care issue, such as the one discussed, I have not seen any expert being consulted in an absolutely appropriate manner in the investigation.
The Institute of Forensic Medicine has stated that it is the one authorized for these expertise.
Yes, and I have all the respect for my colleagues from forensic medicine. But, for example, regarding the statement that reducing noradrenaline in a patient with a blood pressure of 60 is certainly the triggering cause of death, I'm sorry, I do not agree.
From a medical point of view, I could write an entire dissertation to prove that it is not so. At least a conditional-optative was necessary. It leaves room for a medical case discussion.
Medicine cannot be done by plebiscite; an act of medicine cannot be subject to public vote.
Would we have ended up in such a situation if, like other countries such as France or the UK, for such terminal cases in the ICU, there were very precise regulations, medical commissions that meet, evaluate certain criteria, call in families, discuss, and palliative care units where these people either pass in dignity and peace the inevitable threshold towards which they are heading?
You have touched on exactly the sensitive point. None of this would have happened or, in any case, would have caused such a stir only, perhaps, at a personal level, if the absolutely necessary regulatory systems for all these layers, for the way they function, for commissions that analyze the severity of cases and extreme solutions existed. Just as a transplant committee does, for example.
There are many administrative and scriptological things that doctors are required to do, but all in a Brownian motion, lacking a precise direction.
The way of treating a palliative care patient in an intensive care unit is different from an acute patient, where every minute is crucial.
And I don't know why we have shifted, worse than ever, towards generalization, why the case has become the norm in the medical system and among doctors. Doctors are not the "medical system," but its executive beneficiaries. This confusion is what prompts me to take a stand.
And it all started right after generalization and politicization. This generalization is grotesque. Once again, the issue of "blame shifting" has reappeared: "These doctors are not to be trusted as they defend each other, and the source of all evil is the teaching body."
Where have all these things led us? Firstly, to a general loss of trust in everything, in the academic institution, in the medical institution, in the doctor, as an individual and as a profession.
I doubt that all citizens in Romania can afford to go to Istanbul, Paris, or Vienna for treatment. So, put yourself in the shoes of someone who has read all this. Maybe he or a relative needs to be admitted to an ICU where they know they might be intubated, sedated. They go as if they were going to the gallows, not to be cared for.
Just like Zola in the Dreyfus case, I stand up and say "I accuse you, I accuse you for allowing this to happen."
Wouldn't generalization be avoided if the medical profession itself acknowledged some missteps, as you have done by pointing out certain irregularities, instead of claiming that everything was perfect? This has fueled the anger.
Mistakes may have been made on the other side as well, in several ways. In my opinion, the position of the Intensive Care Society and its leaders was correct. They did not embark on a comprehensive analysis of the case but reacted bewildered by the disregard of the presumption of innocence for ... a crime!
They did not conduct an analysis, nor do I believe they had all the data, but they professionally responded to that arithmetic link: the decrease in norepinephrine led to death. It was a unilateral, incomplete response, in agreement with you.
Is the presumption of innocence ever respected?
As Anne Frank said, the things that have been done cannot be undone, but perhaps they can help us avoid repeating them in the future.
I don't think anyone argues that a treatment should not be documented in the observation chart, but everyone was shocked by the accusation of maximum and unjustified severity, by the witch hunt.
The initial court decided on pre-trial detention, the most severe preventive measure, so the judges saw in that case some data, some facts, some evidence.
Let justice do its job, but I have a rhetorical question: after all this deafening noise, after this media uproar, can we be sure that the judges will make a decision that contradicts what happened?
I have a repulsion towards any injustice; I only wish for the judges analyzing this case to be upright, independent, not influenced by any noise, as I believe a judge should be.
Unfortunately, things will not stop here, anyway.
What do you mean?
These doctors are dealing with a very hidden and sensitive argument in medical practice, which is choice. Medical choice is a very complicated matter.
When you make a decision, you make a choice. There is no set code anywhere that tells you that your choice is unique and correct. Medical choice oscillates between very subjective and very learned things.
Tomorrow, the ICU doctor who, otherwise, in front of a critically ill patient, would have made a decisive decision that could potentially harm the patient but which he considered the only lifesaving measure at that moment, do you think he will still have the courage to do so? I can tell you he won't.
Since the Covid period, I already sense apprehension among my colleagues in the ICU, fear of making decisive decisions that could expose them.
Will ICU doctors still have the freedom of thought, to act with full knowledge in the case of a critically ill patient, whom they might save with a last-minute measure? Will they have the courage? I believe not.
The consequences of this phenomenon go beyond its resolution and are very serious. This is the main reason why I took a stand. This, and the fact that the patient was involuntarily pushed into the arms of distrust, despair, and myths.
The interview transcript was conducted using the Vatis Tech application