Head Physicians at Panama Institutions Submit Letters of Resignation

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Head Physicians at Panama Institutions Submit Letters of Resignation

 August 25, 2024

Following the 60-month prison sentence given to neonatologist Iván Sierra Robles for the death of several babies in the Neonatology Ward of the Dr. Arnulfo Arias Madrid Hospital Complex of the Social Security Fund (CSS) in June 2013, due to the use of heparin with benzyl alcohol, the head physicians of services at various institutions are submitting their letters of resignation.  The doctors state in their letters that the decision to make their positions available or to resign from their positions is due to the fact that it represents a risk to their integrity, honor and free exercise of the medical profession, due to the fact that the current management makes them responsible for situations that are beyond their control and responsibilities.

Among the doctors who have made their positions available is Ricardo Sandoval, head of the Internal Medicine Service of the Dr. Arnulfo Arias Madrid Hospital Complex, who sent a letter to the deputy medical director, Alberto Mattatal, informing him that he is making his position available.  In the letter, dated August 21, Sandoval expressed his solidarity with his colleague Sierra Robles “in the face of the disastrous precedent and his unjust conviction, which reveals the lack of coherent processes to exercise this leadership position in a safe and diligent manner.” Sandoval indicated that they do not have the legal support of the CSS to guarantee the exercise and effectively elucidate the scope of the responsibility that comes with being a head of service. 

The situation is not limited to the Hospital Complex, as the media had access to a letter in which the head of the Child Psychiatry Service of the Omar Torrijos Herrera Pediatric Specialty Hospital, Irina Caballero, resigned from the position she held for several years in solidarity with the case of colleague and teacher Sierra Robles.  The doctor said that, despite Sierra Robles’ years of dedication to patients; he has been affected and condemned by accusations of an act that is not his responsibility, without the support of the institution to which he owes his services. The Medical Association of Panama, together with the National Medical Association and various associations, expressed on Tuesday, August 20, its concern and solidarity with neonatologist Sierra Robles.  The medical associations stressed that, while they share the pain of the affected families, it is essential to guarantee a fair trial that takes into account all the circumstances and responsibilities of those involved. 

The country’s medical community has warned of the dangerous precedent that this conviction could set, affecting the confidence and performance of those who hold senior positions in the health system.  In addition, the doctors, through a statement, make an urgent call to the judicial authorities and society to reflect on the implications of this case, urging that measures be adopted that allow health professionals to carry out their work without fear of being unfairly penalized for systemic errors.  On social media, several doctors have shown their support for neonatologist Sierra Robles. For example, infectious disease specialist and pediatrician Xavier Sáez-Llorens said that “this condemnatory ruling is a legal aberration, no matter how you look at it. No one in the neonatology unit could have known or suspected that the parenteral nutrition had been poorly prepared.”  He added that the doctor himself was the first to think of this possibility and ordered its administration to be suspended for other premature babies. Cardiologist Daniel Pichel said that he has known Sierra since he was a pediatric resident at the CSS. He has always been a studious, responsible, hard-working and exemplary humane professional with his patients.  Pichel agreed with Sáez-Llorens that Sierra was the one who realized what could be happening, thus avoiding more deaths.

Meanwhile, Sandra López Vergès, a researcher at the Gorgas Memorial Institute for Health Studies (ICGES), said that the issue is not easy and that, therefore, a complete investigation with experts should be carried out. It is important to sanction when there is malpractice, but if there is not all the information from experts, one should not judge. In this case, the doctor could be the scapegoat for an entire system. The medical community is asking the court to review the case, as they believe there are inconsistencies in the investigation. In addition, the scientific reasons for the cause of the children’s deaths have not been explained and cannot be attributed to heparin, a drug commonly used in both public and private hospitals.  Sierra Robles, in a press conference held on August 20 at the Ateneo de Ciencias y Artes, explained to the media that it was not possible to confirm that heparin with benzyl alcohol was the toxin, since the literature indicates that in order to be the toxin, the dose should have been 10 times greater than that found in the analyses.

https://newsroompanama.com/2024/08/25/head-physicians-at-panama-institutions-submit-letters-of-resignation/

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Dr. Iván Sierra Questions Conviction – Death of Newborns at CSS 

 August 29, 2024

Neonatologist and pediatrician Iván Sierra Robles argues that the charges against him do not correspond to his professional responsibilities, according to regulations. He said that his duties as head of Neonatology were mainly administrative and supervision of health and technical personnel.  The former head of the Neonatology service at the Dr. Arnulfo Arias Madrid Hospital Complex of the Social Security Fund (CSS) sentenced to five years in prison along with the pharmacist Melia Mebis Mock Sevillano, has his arguments about the tragic case that involved the death of nine newborns and left four survivors with serious after-effects.  Sierra Robles recalls that, during the afternoon of June 11, 2013, patients who were stable but under critical care for apnea requiring ventilatory support, began to suddenly and gradually deteriorate. Later, some of them presented hemodynamic instability and feeding intolerance. 

The next day, Sierra Robles recounts, the newborns developed coagulation disorders, accompanied by bleeding, which required multiple transfusions of blood components in the following days, thus saturating the hospital’s blood bank. Fortunately, the four surviving patients began to show signs of improvement within a week.  The doctor learned that the event was related to total parenteral nutrition through the head nurse and floor supervisor, who explained that, the previous night, all ventilators had been used and several deaths of previously stable patients had occurred.  From that moment on, infectious causes were investigated, as the doctor indicated that they were still dealing with problems related to the KPC bacteria (Klebsiella Pneumoniae Carbapenemase). However, the nurse in charge of one of the intermediate areas gave him a clue by telling him that only the two patients with parenteral nutrition had become complicated in her area.

Upon reviewing again who the complicated ones were, it was observed that most of them were receiving total parenteral nutrition. Of course, the order was given to suspend nutrition, he emphasized.  Initially, patients were treated by their attending physicians with the support of inter-consultants. The medical director subsequently set up a situation table to handle the emergency.  At that time, CSS authorities considered two hypotheses: infectious and toxic. The first was ruled out seven days later, after obtaining negative cultures and serological tests.  However, the toxic hypothesis became relevant six days later, when Hildaura de Patiño, a pharmacologist and professor at the University of Panama, and Sierra Robles himself presented the possibility of benzyl alcohol poisoning to the situation table. After a review of the medication bank in the Neonatology ward, it was discovered that the heparins contained benzyl alcohol. It was at this point that the problem began.

Sierra Robles stressed that at the time of the event, the use of heparin in parenteral nutrition of neonates was valid. It was also used for blood gas tests in infants.  At that time, the only heparins with sanitary registration contained benzyl alcohol. All hospitals, both public and private, and the company that produced total parenteral nutrition, used them either for parenteral nutrition or blood gas tests, but it is unknown why this happened only in the CSS.  The doctor stressed that the former director of the Specialized Institute of Analysis of the University of Panama, Vasko Duque, stated that the scientific literature indicates that the concentration at which benzyl alcohol can be toxic to a specific organism is not known with certainty, so one cannot speculate on the exact toxic concentration.  In addition, Duque said that although benzyl alcohol may be toxic, its toxic concentration cannot be determined with certainty due to variability among organisms.

Even in the cases reported in the United States, it could not be confirmed that benzyl alcohol was the direct cause of the deaths; however, there was a suspicion that when benzyl alcohol was used, these deaths occurred. For this reason, it was recommended to avoid the use of heparin with benzyl alcohol as a preservative in low birth weight neonates or in pregnant women.  At that time, Duque added to his statement that only what was formally requested was analyzed, and in this case, benzyl alcohol was analyzed at the request of the CSS medical department. Meanwhile, Gladys Guerrero, who was a member of the technical team that conducted the investigation, said she does not believe that either hypothesis prevailed. Both were investigated equally.  The difference between them is that, in the case of the infectious hypothesis, no agent involved could be determined, while, in the toxic hypothesis, it could not be concluded whether any medication, parenteral solution, enteral feeding or parenteral nutrition was the cause. 

Sierra Robles does not feel that he is the only one to blame for this tragedy. He believes that the judicial process has not identified all the people who could be responsible in the case and that his conviction may be based on a lack of sufficient evidence and that there could be other people involved who have not been adequately investigated.  The lawyer and former general secretary of the Public Prosecutor’s Office, Rolando Rodríguez, was consulted about the case of the newborns. He said that after the Supreme Court’s ruling, the doctor has the right to request a review of the case. If the result is not in his favor, he can go to the enforcement judge and request that his sentence be replaced with community service.  This case underscores the importance of vigilance in the administration of medications and solutions in medicine to prevent similar incidents in the future.

https://newsroompanama.com/2024/08/29/dr-ivan-sierra-questions-conviction-death-of-newborns-at-css/