Dr. Mahira R Toor

The events surrounding Manoo's death. I wrote them down a few days after she died.

Manoo (Dr. Mahira Raza Toor), 35 years of age, had developed a multinodular goitre (thyroid gland enlargement with multiple nodules). It started with her first pregnancy 7 years ago. Over the period of 2 years it had grown significantly.

October 2009, Manoo consulted Dr. Khawaja Azeem, Professor of Surgery, Mayo Hospital Lahore in his private clinic. He advised a few investigations (thyroid scan, chest X-Ray, thyroid function tests, complete blood count and urine complete) and surgical removal of the goiter.

All her investigations were done from Shaukat Khanum Memorial Hospital, Lahore. Thyroid scan showed enlargement of both lobes. No extra thyroid tissue was identified. CXR showed deviation of trachea (wind pipe) and clear lung fields. Thyroid function tests, complete blood count and urine complete was normal.

On second consultation, operation was scheduled in SurgiMed (a private hospital). A package deal of Rs 72,000 was agreed. Operation was cancelled due to the absence of his operating assistant.

Manoo reported to SurgiMed on 2nd November following Dr. Khawaja Azeem's advice for the operation.

Dr. Khawaja Azeem was the surgeon, Dr. Aftab was the assistant surgeon and Dr. Khawar was the anaesthetist. Manoo was taken to operation theater by 4pm. By 8pm Dr. Khawaja Azeem came out of theater to inform the family that operation had been a success and showed them the removed thyroid and advised it to be sent for further analysis to Shaukat Khanam Memorial Hospital.

He left after that.

He was called back an hour later because Manoo did not wake up. According to Dr. Khawar he had given her naloxone (an antidote to opiates, like morphine) thinking it was sedation due to drugs after ex-tubation (removal of tube passed in wind pipe during operation).

Following that Manoo had fits. Professor Naeem Kasoori, a Neurologist at SurgiMed was called to the scene. He advised diazepam and phenytoin (drugs used to stop fits) and an urgent CT Scan of the brain. After the scan she was transferred to intensive care unit in the same hospital. No abnormality was reported on CT Scan.

Manoo remained unconscious with minimal response to painful stimuli. She was breathing spontaneously then. An NG tube (a tube passed from nose into stomach) and a urinary catheter was passed. She was started on antibiotics, phenytoin and intravenous fluids on regular basis.

No explanation was offered despite repeated questioning to Dr. Khawaja Azeem and Dr. Khawar for her current condition. Everything went well according to them. A repeat CT scan of the brain, thoracic inlet and chest, apart from chest infection was reported normal. Doppler ultrasound scan of the arteries of the neck showed normal flow.

On 10th post operative day, when Manoo's condition stabilised she was sent for an MRI scan of the brain outside SurgiMed in a diagnostic center of Shaukat Khanum Memorial Hospital.

MRI scan of the brain showed extensive anoxic bilateral demyelination in parietal and occipital lopes with intact brain stem. (brain damage on both sides of brain due to lack of oxygen).

Manoo remained for 17 days in ICU of SurgiMed under care of Dr. Khawaja Azeem and Dr. Nameem Kasoori. Apart from spontaneous eye opening and some movement of her left arm there was no significant improvement despite a cocktail of antibiotics and drugs to stop her fits.

Due to growing tension among family members, Manoo's caring physicians and possible long term disability she was transferred to Sheikh Zaid Hospital's once her fits were controlled.

No discharge slip was given by staff at SurgiMed. A copy of medical notes was refused on the grounds of hospital's policy. Her investigation done at SurgiMed and privately were sent with her.

Manoo was moved to ICU from neurology ward on the same day of admission under care of Dr. Nadar, Professor of Neurology and Dr. Zeeshan in charge of ICU.

2 days later Manoo was ventilated. No clear reasons were available from her notes of the events which led to it. Family was not consulted either.

Manoo developed pneumonia and urinary tract infection by resistant Klebsiella and E-Coli (Bacteria commonly associated with hospital acquired infections). She was treated with three different antibiotics and drugs to enhance brain functions.

Manoo had a tracheostomy tube (a tube surgically inserted in wind pipe) after a failed attempt at it.

By this time Manoo was intermittently ventilated. She was able to move her left arm, some movement in left leg and minimal movement in her right leg. She was opening her eyes spontaneously and it seemed she was able to recognise and fix her gaze on the left side. It seemed things were on the mend.

A repeat MRI though incomplete was reported to have improved in appearance.

On the same day, she arrested (Her heart stopped beating). A resuscitation attempt was unsuccessful.

Manoo died on 4th December 2009.

إِنَّا لِلّهِ وَإِنَّـا إِلَيْهِ رَاجِعونَ‎

Farooq.
18/12/09

Manoo's Memories

My daughter Dr. Mahira was obviously a philanthropic doctor as both her grand parent were notable "Hakeems" who treated people free and one of these senior grands was a personal physician of Maharaja of Jammu.

I use to remind her dynasty and paid her money to treat the poor. She always resisted money from saying that "Abu" your money is still enough as it takes less Rs. 10/- to treat on the average.

She served in Christian Charity Hospital and was impressed how Americans work for their minority welfare; she joined Basic Health Unit, only half a km from her residence. She worked and popularised cheap medicine. Requested dedication from staff. Her attitude did not suit the village political manipulators. A woman threatened her that she will settle score when he PMLQ will come to power. This group belonged to a minority community popular with Musharraf regime. She immediately resigned and joined Social Security hospital Sialkot, at exactly the place of current mega crime in Sialkot.

A.H.Toor
14/09/10