The death of three people who were connected to different dialysis machines due to similar causes in around the same time has left doctors baffled. The incident took place in a hospital in Puducherry.
Nephrologists are of the opinion that death of patients on dialysis because of power fluctuations is ‘nearly impossible.’ The equipment for hemodialysis is state of the art, they say.
A special committee has been constituted to look into the incident. The committee’s response is yet to be in as are the autopsy results.
The nephrologists say that the couldn’t even fathom what could have gone wrong.
Electrocution is a probable cause that’s cited-given how the patients died soon after the power was back on. But the nephrologists say that it’s absolutely impossible. All the machines have a battery back up of at least 20 minutes. If the power isn’t back up in that duration, the blood merely gets returned and the process is halted.
Another point the doctors make is that the patient doesn’t come in direct contact with wires or power connections.
As per Rajan Ravichandran, senior nephrologist at Sapiens Health Foundation, the last time such an electrocution took place was in 1975- a time when such machines were quite primitive.
Another probable cause is the contamination of water that comes into the dialysis unit. However, judging by the violent reactions of the patients, nephrologists think it strange. In case of contamination, it would take time for it to have effect on the patient.
This brings into the picture yet another possible cause- that of a chemical imbalance in the solution which goes into the patient. However, if there are chemical imbalances the machine would auto cut off. An alarm will also be sounded.
Another historic instance that Dr.Ravichandran gives involves certain patients in a dialysis unit in a hospital in Mumbai drying because of skewed water-minerals ratio. However, in those days, the concentrate used to be mixed manually, and a technician’s mistake led to the tragedy.
This wouldn’t have been possible in the Puducherry case since the modern machines had their own mixing units.
As for the idea that clots may have formed which then traversed up the patients’ blood vessels, the doctors dismissed this too, saying the machines are prepared for such an eventuality . In fact, a blood clot won’t even move up the tube. An alarm would stop the machine, thereby ensuring that no clots move up the tube.
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