For context, TCN first reported the news here, followed by the reaction of the Croatian Health Ministry who ordered an inspection into the medical assistance to the reporter. Understandably, the way the hospital staff treated the dying journalist did not go down well in Croatia, causing public outrage.
At Index, his premature death prompted many of his colleagues to examine the extent to which the poor reaction of the Croatian healthcare system was responsible for this tragic outcome.
It is simply unacceptable that Matijanić, a man with so many serious underlying diseases, which brought him at particular risk for a severe form of covid-19, despite persistent inquiries and even a trip to the hospital, did not manage, over several days, to receive thorough and adequate examination and/or hospitalisation and to receive medicine intended for the prevention of severe forms of disease meant precisely for people of his health profile, which Minister Vili Beroš stated that “we have verified it exists” in stocks in the health system.
Questions arise as to how much and in what ways the health care system is responsible for Matijanić’s death. In cooperation with several medical experts, Index took to list the key mistakes in order.
Firstly, the main culprit for Matijanić’s death, just like for the death of many other patients with covid-19 and other diseases, was a poorly managed health care system, where a part of the doctors and medical staff are its victims, along with regular citizens who need help.
The system did not properly advise Matijanić about vaccination
Matijanić claimed that doctors advised him not to get vaccinated because he had several autoimmune diseases, primarily Sjogren’s syndrome and suspected sarcoidosis, as well as dermatopolymyositis, hypergammaglobulinemia and airway abnormalities, including interstitial lung disease, a condition for which sarcoidosis and Sjogren’s disease are among the most common causes.
The advice is contrary to scientific conclusions, as studies have shown that people with autoimmune diseases tolerate vaccines well. For example, the Sjogren’s Syndrome News page cites the recommendations of the American agency for disease control and prevention, the CDC, according to which most patients with this diagnosis are recommended not only to get vaccinated but also to get booster vaccines.
At the same time, studies have shown that people with autoimmune diseases are a risk group for several reasons, among others because they can get infected more easily, they often have lung diseases, they usually take immunosuppressive drugs, and their reaction to covid-19 can be exaggerated and misdirected, commonly referred to as a cytokine storm.
The fact is that the vaccine against covid-19 in patients with autoimmune diseases, especially in people with dermatopolymyositis, could cause more pronounced side effects, but according to the conducted studies, the risk of side effects is still much lower than from not vaccinating. The doctors who knew about his underlying diseases should have monitored his condition and, in accordance with the development of knowledge and recommendations, should have updated him with them and recommended vaccination with additional monitoring measures. People with such underlying illnesses require more than “routine procedures”.
The fact that there are few of them in the population emphasizes, even more, the need for more detailed and expert care. Finally, even if someone in the system had recognised that his condition was such that vaccination was not recommended for him, they should have officially and in writing informed Matijanić about this and then followed it with special attention and updated the recommendations in accordance with the new findings and changes in Matijanić’s condition.
On the contrary, it turned out that Matijanić, who went to nursing vocational school and was not an anti-vaxxer, was simply not adequately “guided” by the system in this regard.
Matijanić should have been kept in the hospital with his diagnoses
Matijanić’s partner Andrea Topić says that she took him to the Emergency Infectious Disease Department on August 2 thinking that he would be kept there. It is questionable why they didn’t do that when they knew about all the diseases he had, but they just let him go home. Topić believes that it is possible that Matijanić’s covid-19 developed even before August 2 as his home antigen test already showed he was positive that morning, and a few days earlier he complained to the immunologist about weakness and malaise.
A person with Matijanić’s diagnoses should have been admitted to the hospital if he was confirmed to have covid-19 and if he had symptoms such as elevated temperature, weakness, malaise, wheezing, and cough. On the contrary, in patients suffering from interstitial lung disease, these symptoms – no matter what caused them directly (e.g., a common cold) – are a sign that an acute deterioration (exacerbation) has occurred, and this is always an indication for detailed hospital treatment and, typically, hospitalisation.
The fact that he did not feel any better even when his temperature dropped can only be an argument in favour of the fact that something was not right.
The doctor should have taken his case much more seriously
As was reported by Index, recordings of Matijanić’s calls to medical professionals show that none of them took his situation seriously enough.
Among other things, the KBC doctor on duty should have reacted urgently when Matijanić told him that he had not been vaccinated and that he had autoimmune diseases. First, he should have asked in more detail about his autoimmune diseases, because patients suffering from them belong to the risk group when it comes to covid-19. The insistence that “Matijanić was not immunocompromised” because he had only started corticosteroid therapy a day before is a result of confusing the terms “immunocompromised” and “immunosuppressed”.
Matijanić’s immune system was certainly long-term compromised in the sense that it reacted unusually, attacking its own tissue, which is a consequence of autoimmune diseases. Therefore, the doctor on duty should have recommended that he come to the hospital so that his condition could be assessed and monitored. Even though Matijanić stated that he was coughing and had a lot of phlegm, the doctor said that it probably would not be serious since it was omicron, regardless of all Matijanić’s conditions, and without having asked about them in more detail. Indeed, omicron causes severe disease in fewer people in the population than some previous variants of the virus. However, due to his characteristics, Matijanić did not fit into the “general population”, but into a specific group of people in whom even a common cold is a potential trigger for life-threatening conditions (e.g., exacerbation of interstitial lung disease).
There is no doubt that in each of his contacts with the health care system, Matijanić had to be admitted or referred for a detailed diagnostic evaluation and appropriate treatment, ideally at the very beginning, but also in every further stage of the disease.
To date, it has been proven certain: 1) that drugs with an antiviral effect intended to prevent the development of a severe form of the disease and intended specifically for people like Matijanić are effective; 2) that anti-inflammatory drugs such as corticosteroids and some others are reasonably effective in those with advanced disease; 3) that supportive treatment – oxygen therapy (including the most dramatic forms such as mechanical ventilation or ECMO device), anticoagulants and possibly antibiotics where there is a basis for this due to bacterial superinfection, are effective and extremely important and that they help reduce mortality.
Overall, if Matijanić had been referred to the hospital at any stage of his condition and treated as recommended by the guidelines, it can be said with high certainty that he would have survived this covid-19 episode.
Problematic administration of corticosteroids
Due to an autoimmune disease, Matijanić took the corticosteroid Decortin, but only for a brief time. The doctor on duty at KBC Split, whom he called, knew about it but did not react, only stating that he could not be immunocompromised since he had been taking it for such a brief time. As already stated, this was wrong – though Matijanić may not have been immunosuppressed since he did not take therapy that reduces the immune response in people with autoimmune diseases, he was immunocompromised due to his underlying diseases.
When the ambulance finally came for the first time, Matijanić’s partner Andrea Topić asked the team if it could be Decortin that made him sick, and the answer was no. Moreover, they also gave him an injection with a strong dose of Solumedrol, which is also a corticosteroid.
What is controversial about that? As previously reported by Index, corticosteroids are used in the treatment of covid-19, but mostly only in an advanced stage, around the 7th day of severe disease, to reduce the excessive reaction of the immune system, the so-called cytokine storm. Since they are immunosuppressants, they reduce the body’s reaction to viruses, so if they are given too early, they can increase the multiplication of the virus. Due to the above, they should only be given to patients with covid-19 in a hospital, under constant medical supervision and with oxygen, and not at home.
In other words, the emergency doctor should have taken Matijanić to the hospital after the first visit if she believed that his disease had progressed so much that he needed corticosteroids. Also, she should have been aware of how serious the situation was because, unlike the doctor on duty from KBC, who did not get enough information, she had access to Matijanić’s discharge letter.
At the Emergency Infectious Diseases Department, they did not even ask about underlying diseases
When on August 5 Matijanić called the emergency department at the Infectious Diseases Department, the employee on duty did not even ask him about possible underlying diseases, even though he complained of feeling extreme weakness and severe pain in his muscles and joints. The doctor simply recommended ibuprofen for pain.
They did not call him into the hospital even when it was apparent that he was very sick
Furthermore, when on August 5 Matijanić called a medical worker at the emergency department of Infectious Diseases, after his condition significantly worsened, on the recording of the conversation it can be heard that his breathing was laboured. He also pointed out that he had Sjogren’s syndrome and the resulting interstitial lung disease, and that he was so weak that he could not even get up to go to the bathroom.
But that medical worker did not take him seriously enough either, and to all this, she advised him to urinate in a bed pan that one of the household members could empty.
His diagnoses and the fact that his breathing was laboured, that he was so weak that he could not get out of bed should have been sufficient reasons for the employee on duty to seriously advise him to go to the hospital in an emergency or to insist that the ambulance take him as soon as possible.
The emergency left him at home despite the diagnoses
When the ambulance finally arrived, the doctor refused to take Matijanić to the hospital even though he had serious autoimmune diseases in addition to covid-19, which she had to see based on the discharge letter.
There are certain doubts about whether the doctor who came with the ambulance was qualified for the job. It’s possible she was hired even though she wasn’t qualified because the hospital was understaffed, which is a chronic problem within our healthcare system.
If she was qualified, she should have known that his case needed to be referred to the hospital despite his blood oxygen saturation of 97% (a result that can change dramatically in less than an hour, as it did in the end), low blood pressure, an increased heart rate did not have to look critical. The usual practice of the ambulance is to take a patient with serious underlying diseases in combination with covid-19 and numerous complaints to the hospital to examine his condition in more detail because even minor deviations of key parameters can result in complications.
It was expected that during the summer, during the national holiday, at the height of the heat wave, the healthcare system in touristic Split was overloaded, but this cannot be an excuse for not admitting seriously ill people like Matijanić to the hospital.
In Croatia, there is a lack of necessary medicines for the seriously ill
Finally, as already reported by Index, Matijanić was told on August 2 that there are no drugs to treat the seriously ill, including Remdesivir.
Minister Vili Beroš denied this claim, with the explanation that there is enough Remdesivir or its version Veklury, and that directors must procure them from other hospitals if they lack them, and for specialist doctors to prescribe it to patients. If it is true that Remdesivir was still available on August 2 when Matijanić should have started it, it is still unclear how he never received it.
But in this context, the Ministry’s answer to the question of why there is no Paxlovid, which was approved by the American FDA at the end of 2021, and by the European EMA in January 2022, is also interesting. It is a medicine that, among others, was recently taken by US President Joe Biden and German Minister of Health Karl Lauterbach.
Since it showed excellent results in reducing hospitalisation and mortality by as much as 89%, it may have been able to save Matijanić’s life, as well as that of many other patients who have died in recent days.
Many countries procured Paxlovid outside of centralised procurement
Index asked if there was a shortage of medicines in Croatia and received the interpretation from the Ministry that “the procurement of antiviral medicines Remdesivir and Paxlovid through the EC is currently being centralised” and that the department has done everything in this regard on time. However, it is known that the procurement of medicines does not necessarily have to go through the EC. States can procure medicine approved by the European agency EMA by themselves through direct contracts with manufacturers (by the way, Paxlovid was recommended as a medicine for covid-19 in the Ministry’s guidelines back in February).
For example, Index received information that, in addition to centralised procurement, Paxlovid has already been procured by Austria, France, Italy, Germany, Belgium, Greece, Portugal, Ireland, and Spain, and that Slovenia will receive it at the end of August. Similarly, Croatia could have also bought the drug directly from the manufacturer, at least in some quantity, to bridge the period until central procurement is done and saved several lives, Matijanić’s included.
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