Examining the Evidence
Was it a Misstep or a Medical Mystery?
Episode 22
INTRODUCTION
Ali Demir, 45, who came to the hospital's emergency department one night, died during a minor surgical procedure. The cause of death was recorded as ‘cardiac arrest’ according to the hospital. However, Ali's family could not accept this sudden death and the hospital management invited the Drug Detectives team when the police could not find a solution. Now it was up to them to unravel the mystery and find out what had caused Ali's death.
Drug Detectives began their investigation in the emergency room where Ali had been treated. The room was cold and sterile, but the remaining clues were still warm. Two different vials of lidocaine solution, 20% and 5%, sat on the medication tray. There was no record of whether the drugs had been prepared in the correct mixture. At first glance, everything looked ordinary, but there were some details that did not go unnoticed by the team.
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​An empty syringe and a stained cotton ball lying next to the two bottles attracted attention. The cotton ball had small red marks on the surface. The team took the cotton ball and sent it to the forensic laboratory for examination. They suspected that this small clue could play a critical role in solving the case.
During their investigations in the hospital, the Drug Detectives team noticed something in the corridor. Mehmet, the cleaner, was always watching them from a distance, seemingly interested in their work, but his eyes followed the team's every step. Each time he passed them, Mehmet slowed down a little and looked as if he wanted to say something. However, when he was about to speak, he would quickly move away. The team became suspicious of Mehmet's restless behavior.
One of the detectives stood next to Mehmet and asked him directly: ‘Do you know something? If there is something you need to share with us, now is the time.’ Mehmet hesitated a little, but when he realized that he could not escape their gaze, he finally confessed.
Mehmet said that he had noticed that Leyla was very nervous before Ali's death. Leyla looked stressed when she rushed into the operating room. Mehmet shared that he heard Leyla talking on the phone as she left the room and muttering, ‘Is this true, are we sure?’
Physician & Pharmacist Investigation
The team spoke to the doctor and pharmacist involved in Ali's treatment. The doctor said that he had thought that a low level of local anaesthetic would be sufficient, but that Ali deteriorated rapidly afterwards. The pharmacist said that the medicines used in the hospital were perfectly safe and that any dosage error would have been easily recognised. However, he added that Leyla was directly responsible for the preparation of the mixture.
ER Examination Clue
The Drug Detectives team had found some medicine bottles in the emergency room during their detailed investigation at the hospital. However, the case needed to be investigated in depth. Another detail came to the team's attention: there were some empty syringes in the waste bin of the emergency room.
They carefully examined the syringes and decided to send them to the forensic laboratory to determine the contents of these suspicious syringes. When the laboratory analysis was completed, one of the syringes was found to contain a %20 solution of lidocaine. This finding was highly significant as part of the incident, but this alone was not enough to confirm the cause of death.
The team had to wait for the autopsy report to understand whether the dose of lidocaine was directly related to the death. The results of the autopsy report were of great importance to learn more about the contents and quantity of the injectors.
Interview with the Nurse
As the Drug Detectives team carried out a thorough investigation at the hospital, they also had to gather information from the nurses about the incident. In particular, they needed to obtain information about the day the syringes were found and the procedures on that day. For this reason, they decided to question Elif Yılmaz, a nurse in the emergency department, among the nurses who caught the team's attention.
During the interview with nurse Elif Yılmaz, the Drug Detectives team asked her to describe the events of that day without disclosing the results of the syringe investigation. Elif gave a detailed account of what happened in the emergency department that day. She described the routines during the procedure, the drugs used and her interactions with patient Ali.
However, Elif's explanations revealed some interesting details. Elif had changed some routines in the hospital that day and performed some unusual procedures.
1. Medication administration, which is normally done at a certain time interval, was done at an early or late hour that day. For example, while Ali's medication should usually be given in the morning, 2. Elif gave these doses in the afternoon.
On that day, the hospital's database contained incomplete or contradictory information among Elif's procedure records. For example, the times or dosages of some medications did not match the hospital records.​
The team had to assess this information, but at this point they were unable to obtain any definitive information about the possible effects caused by the level of lidocaine in the syringes. At the end of the interview, they asked Elif what she thought about their findings. The nurse's answers suggested that the team should do further research. However, it was concluded that the information obtained did not provide conclusive evidence and therefore the research should continue.
Autopsy Report
The autopsy report showed a much higher than normal level of lidocaine in Ali's blood. But there was one interesting detail: Ali's liver had a problem metabolising the drug. Ali's body was unable to break down the drug properly, leading to toxic levels of the drug. The team learnt that this problem had not been noticed before. But this new information, combined with an overdose of the drug, could have had a fatal effect.
Did Ali's unknown metabolic problem cause lidocaine to reach a toxic level? Or was the only cause of death nurse Leyla's possible wrong mixture?
Last Meeting with Nurse Leyla
When nurse Leyla spoke about the night of the incident, she admitted that she was in a hurry and worried when preparing the mixture. She admitted that she knew that the solution should be 10 per cent, but at some point she became confused. However, Leyla also stated that she did not believe that the death was solely her fault. According to Leyla, Ali's body should have reacted differently to the drug.
Did Leyla's confusion trigger Ali's death, or did a metabolic problem in Ali's body make the drug effect uncontrollable?
Suspicious
Traces in Cotton
Results from the forensic laboratory confirmed that the red stains found on the cotton were Ali's. The cotton had been exposed to the patient's blood during the procedure.
Questions
The team pieced together many different clues, but the exact cause of the incident was still difficult to explain. Did the wrong mixture cause Ali's death, or did Ali's unknown health problems play a bigger role?
