State Consumer Disputes Redressal Commission
Anil Sharma vs Bhagat Multispecialty Hospital on 5 March, 2024
Cause Title/Judgement-Entry STATE CONSUMER DISPUTES REDRESSAL COMMISSION, UP C-1 Vikrant Khand 1 (Near Shaheed Path), Gomti Nagar Lucknow-226010 Complaint Case No. CC/175/2014 ( Date of Filing : 30 Dec 2014 ) 1. Anil Sharma Gaziabad Gaziabad UP ...........Complainant(s) Versus 1. Bhagat Multispecialty Hospital Gaziabad Gaziabad UP ............Opp.Party(s) BEFORE: HON'BLE MR. Rajendra Singh PRESIDING MEMBER HON'BLE MR. Vikas Saxena JUDICIAL MEMBER PRESENT: Dated : 05 Mar 2024 Final Order / Judgement Reserved State Consumer Disputes Redressal Commission U.P. Lucknow. Complaint Case No.175 of 2014 Anil Sharma aged about 40 years s/o Sri Prakash Dutt Sharma, R/o 241/1, Gali no.3A, Areya Nagar, District, Ghaziabad. ...Complainant. Versus 1- Arogya Hospital, Mulispecialty Hospital & IVF Center, Sec.6, Vaishali, Ghaziabad, U.P. through its Director/Manager. 2- Dr. S.S. Bhagat, Surgeon, Bhagat Multispecialty Hospital & Advanced Laparoscopic Center, 13/88, Vasundhara, Ghaziabad, U.P. 3- Branch Manager, O.I.C. Ltd., CB, 17, 57/204, Manjusha Building, Nehru Place, New Delhi. 4- Branch Manager, United India Insurance Co. Ltd., 42-C, 3rd Floor, Moolchand Commercial Complex, New Delhi. ...Opp. parties. Present:- 1- Hon'ble Sri Rajendra Singh, Presiding Member. 2- Hon'ble Sri Vikas Saxena, Member. Sri A.K. Mishra, Advocate for complainant. Sri Manish Mehrotra, Advocate for opposite party no.1. Sri Adeel Ahmad, Advocate for opposite party no.2. Sri Alok Kumar Singh, Advocate for opposite party no.3 Sri Prasoon Kumar Rai on behalf of Sri Anchal Mishra, Advocate for opposite party no.4. Date: 27.03.2024 JUDGMENT
Per Sri Rajendra Singh, Member- This complaint has been filed by the complainant against the opposite parties under Section 17(A) of The Consumer Protection Act 1986.
The brief facts of the complaint case are that, that the complainant is well educated employed person of standard higher class established family. The complainant has two young sons, who were very careful, gloomy and brilliant student and always came first in the school. The complainant's son late Dev Sharma aged 9 years was feeling problem and pain in his left little finger, as such the complainant consulted the opposite party no.2, hospital on 06.05.2014. In the hospital, the opposite party no.2 charged ₹ 500/- and prepared OPD slip. The opposite party no.2 examined the son of the complainant and after examination, the doctor wrote his diagnosis, symptom and directed for x-ray, CBC and ESR pathological tests by giving some medicines. As per advice, the complainant did all the tests at Sona Dynastic Centre on 07.05.2014 and returned with report to the opposite party hospital and consulted opposite party no.2 who after examining the report told that everything is normal except there is swelling in the finger and it requires to be removed by a small surgery. The operation date was fixed in the first week of June and he has written some medicines by giving advice to take it regularly. As per emergency told by the opposite party no.2, the complainant got his son admitted in the hospital of opposite party on 01.06.2014 in the morning at about 9 AM. The opposite parties conducted some tests prior to operation and fixed time for the operation in the evening.
At about 6 PM the doctor, opposite party no.2 took the patient into operation theatre. At about 7:25 AM he came out of the operation theatre and told that it was a very small operation and is fully successful. The doctor shifted the patient to the general ward of the hospital and on medical slip it has been mentioned that at 8:10 PM everything is normal. At about 8:15 PM the doctor allowed the complainant and other family members to see the patient one by one. The complainant's father, mother and the patient's mother, maternal uncle and other family members met the patient found him normal but he was complaining pain in the finger. The son was weeping so the complainant asked the doctor who told that this is normal phenomena after the operation. He told that the staff will come and give medicines. At about 8:30 PM a nurse named Shashi gave two injections stating that the patient will get relief by it. At about 9 PM Dr. Sachin Mittal came and checked the patient and told that everything is normal and satisfactory. He also gave some injection. After getting the injection, the son of the complainant started breathing very fast and within a few minutes the patient became silent. The doctor told that the patient sleeping and he asked the family members to go outside the room. The family members came out of the room.
At about 9:30 PM, the opposite parties shifted the patient into Critical Care Unit. The complainant was feeling very uncomfortable so he went into the Critical Care Unit and saw his son who was totally silent and his body was cold and its colour was also changed. The complainant asked the junior doctor present in the room who after seeing the pulse of the patient told that the patient is no more. The complainant was shocked and tried to consult the opposite party doctor but he was not ready to talk showing himself busy. The staff and guards were misbehaving with the complainant therefore the complainant gave information to the police. At about 10 PM, the SHO Sri Rashid Ahmad and CO Shri Ranbir Singh came. The local Parshad Shri Amol Vashishth also came and thereafter FIR was lodged against the opposite party doctor. The opposite parties were whispering each other. They did not tell the current condition of the patient and also did not show any treatment record. All the treatment records were hidden by the opposite parties but with the help of the police some papers were obtained.
The complainant's son was young, healthy and as per medical report everything was normal. The opposite parties conducted very small operation of a finger but the complainant's son died due to serious negligence committed by the opposite parties during post-operative care and by mistake of untrained staff. The opposite parties have done operation of complainant in a very hurried manner without any arrangement and proper pathological tests. The opposite parties doctor also committed serious mistake to left the immediate operated patient under custody of innocent untrained staff. The untrained nurse without consulting doctor and having no knowledge gave high doses of injection and also did not write the name of the medicines and condition and problem the patient. The doctor Shri Sachin Mittal also gave some injection during routine visit at about 9:30 PM within a gap of only 15 minutes. Due to this the complainant son collapsed immediately after administration of the injection. After death of the patient the opposite parties tried to hide their mistake and shifted the patient in ICU and made the wrong endorsement on BHT showing treatment till 1 AM at the late night. The opposite parties had hidden correct position of the complainant's son and committed forgery in the treatment records and declared the patient dead at about 1 AM in the night. It clearly shows that the opposite parties doctor is not only committed negligence in post-operative care but also murdered the complainant's son. The opposite parties committed unfair trade practice and manipulated the treatment records.
The opposite party had full opportunity to diagnose and rectify the mistakes immediately, after giving wrong and double high doses of injection by the staff but they were not present. The complainants son died at 9:30 PM which is apparently supported by the Post-Mortem Report. In the Post-Mortem Report the symptom of dead body shows 'blood stained froath (from right nostril), lumbar condition, anaphylaxis and death about 3/4th day before which clearly proves that the death of the patient was a result of reaction of high doses of medicines but the OPs no.1 &2 concealed their mistake, put the patient in ICU till 1 AM and declared death at 1 AM in the late-night. The opposite parties charged more than ₹ 80,000 for the treatment, operation and medicines are as well as boarding charges of the hospital. The complainant has paid more than ₹ 8000/- on medicines, surgical test as well as transportation. The death of the young son is is irreparable loss not only to the complainant but also to the family members especially the old grandfather and mother. This is irreparable loss cannot be quantified in rupees but it is necessary for a lesson to the opposite parties who were performed their duty in a very careless manner without following medical ethics, and responsibility. The opposite party has committed negligence which is apparently proved from record and report of the doctors. So the complainant very humbly prayed for the following reliefs:
the opposite parties be directed to pay ₹ 85 lakhs against the inseparable loss of the young son, harassment, pain and mental agony of the family members including the mother, the father, the grandfather and the grandmother.
The above parties be directed to make payment of ₹ 15 lakhs against total treatment and other expenses along with 18% interest from the date of filing of the complaint The opposite parties be directed to make payment of ₹ 55,000/- towards litigation expenses.
The opposite party-1 has filed his written statement stating that the present complaint petition as filed by the complainant is beyond the pecuniary jurisdiction of this Hon'ble Commission. The conduct of the complainant in relation to the answering opposite party has been most deplorable, in as much as law was taken by the complainants in their own hands and to the utter prejudice of the answering opposite party. The complainant, due to ulterior motive snatched the case sheet and hospital records from the hospital in a most shocking manner. A criminal complaint was lodged at the instance of the complainant, as a consequence of which the answering opposite party and the doctors had to remain in police custody and subsequently released on bail. Detailed statement of the case was also recorded from the answering opposite party at the office of the Chief Medical Officer. In the circumstances the answering opposite parties are also being illegally prevented to state their defence for want of all records which were their own.
As per the admitted case of the complainant in his own pleadings, the patient was well examined, properly diagnosed, all appropriate tests were carried out and even post surgery, the attendants of the patient found the patient in normal condition except for pain. A bare perusal of the allegations contained in the complaint petition revolve around the post-operative and administration of an injection and deteriorated condition of the patient thereafter. Despite the unfortunate passing away of the patient, the incident is not at all attributable to any medical negligence on part of the Hospital or the doctors or its staff. The patient Master Dev Kumar Sharma was brought to Arogya Hospital, Vaishali on 01.06.84 at around 9:40 AM with the complainant of swelling over left little finger and was admitted at the hospital (opposite party-1) under the treatment of Dr. S.S. Bhagat vide admission number 234. The patient was seen by treating doctor in his private OPD earlier and advised for surgery for the removal of swelling over left little finger. The patient, thereafter, underwent required investigations including CBC, ESR, HBSAG, HIV BT, CT, PT, APTT, INR and then after pre-anaesthesia check up by one Dr. Sachin Mittal was taken up for surgery at 6:30 PM and the surgery was done satisfactorily and the patient was shifted to post-operative room at 7:15 PM where he was kept for two hours.
The parents including mother and father of the patient and other relatives met him in the post-operative period and found the child to be OK, except some minor pain on the operation site, for which he was attended by Dr. Sachin Mittal again and advised treatment for pain. Dr. Sachin Mittal at about 8:10 PM on 01.06.2014 in the post-operative room advised in the best interest of the patient, for administration of injection Emset 2 mg IV Stat and injection Tramadol 50 mg in 500 ML IVF slowly. The same was administered as per standard medical protocol by fully experienced, trained medical and paramedical staff in proper parameters as mentioned above. Throughout proper management of the patient was being done. Subsequently the patient was shifted to ward at 9:15 PM, two hours after keeping him on observation. At about 9:45 PM the patient was found to be in a state of arrest and was immediately shifted to ICU and CPR was started by Dr. Sudesh Prakash along with Dr. Sudesh Prakash, Dr. Sachin Mittal, which is the immediate treatment of choice when such a inherent risks /complication occurs.
The opposite party no.2 has filed his written statement stating that the son of the complainant was examined and diagnosed properly before the operation. Required tests were conducted. Minor operation was conducted by the answering respondent alongwith qualified and trained paramedical staff. The patient was 9 years hence, as per the standard medical procedure it was mandatory to conduct surgery under General Anesthesia. The operation took 20-25 minutes. There was no bleeding from the wound and the operation was done successfully.
The patient recovered from General Anesthesia within specified and standard time. After operation the patient was shifted to recovery room at about 7.20 p.m. under supervision of qualified and trained duty doctor and paramedical staff. The vitals of the patient were normal. He was conscious and was talking to his family members. The answering respondent left the hospital at about 8.30 p.m. No complaint of any sort was made either by the patient or complainant in rest of operation.
He got call from the hospital at 9.30 p.m. and he rushed to the hospital and saw that the patient has been shifted to ICU.
The Hon'ble Supreme Court has specifically said that the negligence is "judged by this standard, a professional may be held liable for negligence on one of two findings: either he was not possessed of requisite skill which he professed to have possessed, or he did not exercise, with reasonable competence in the given case, the skill which he did possess."
There was improvement in the condition of the complainant as is evidence from medical records. There is no credible evidence or document placed on record by the complainant to prove case of negligence.
The Hon'ble Supreme Court has said that "every surgical operation involves risks. It would be wrong and indeed bad law, to say that simply because a misadventure or mishap occurred, thereby the hospital and the doctors are liable."
It is settled principle that every surgical operation involve risk. When a person who is ill and is going to be treated in a hospital no matter what care is taken, there always exists some risk. Simply because a mishap had occurred, neither the hospital nor the doctors cannot be made liable.
The Hon'ble Supreme Court in case of Ponam Verma vs. Ashwin Patel & ors.,(1996) 4 SCC 332, held that negligence as a tort is the breach of a duty caused by omission to do something which a reasonable man would do or doing something which a prudent and reasonable man would not do. Therefore, the whole concept is performing or not performing an act which a prudent and reasonable man would perform or not perform. It again depends, in the case of a profession, upon the skill which is expected from such persons.
The opposite party no.3 Oriental insurance company has also filed its written statement in which it is stated that loss of young son at an early age is really very unfortunate but no way it can be attributed that said loss has occurred on account of some medical negligence and deficiency in service.
It is submitted that treating doctors and hospital has provided best medical care. There was no medical negligence or deficiency in service.
The opposite party no.4 United India Insurance Co. Ltd. has filed its written statement stating therein that in case the Hon'ble Commission fixed liability on the opposite party. The liability of answering opposite party will be limited to the extent of the policy as per law. And the assessment of surveyor if any would the final as per law.
In case of any liability of payment comes upon the opposite parties (doctor/hospital) they will make the payment to the complainant. Later on they may claim the amount from answering opposite party i.e. United India Insurance Company Ltd. by filing claim form of the insurance company and the insurance company will decide their claim according to the terms and conditions of the policy of insurance issued to them.
The complaint is false, vexatious and concocted one and has simply been filed to extract money from the answering opposite party. Hence, deserves to be dismissed with special cost in favour of the answering opposite party.
We have heard the counsel of the appellant Sri A.K. Mishra, Ld. counsel for the opposite party no.1 Sri Manish Mehrotra, Ld. counsel for the opposite party no.2 Sri Adil Ahmad, Ld. counsel for the opposite party no.3 Sri A.K. Singh and counsel of the opposite partyno.4, Mr. Prasoon Kumar Rai. We have seen the pleadings, evidences and documents on record.
At this stage it is pertinent to mention that as per the leading medical literature "ANAPHYLAXIS", the most apparent cause of unfortunate death of the patient in the present case, is a well-known medical complication in medical science. "ANAPHYLAXIS" involves a range of signs and symptoms from hives, wheezing and angioedema to cardiovascular collapse and death. In the circumstances the occurrence of an "ANAPHYLACTIC REACTION" is a well-known inherent risk to several treatments and "not at all any act of negligence" on the part of the treating doctor. The complainant is therefore put to strict proof by the answering opposite party to prove his case by expert evidence and not by basing his case on presumptions and omissions. The attendants were immediately and in a most transparent manner duly informed that after the occurrence of the complication, CPR was being done on the patient to revive his condition. All best efforts were put by the doctors and the hospital throughout. Nevertheless to the utter shock of the answering opposite party instead of appreciating the real issue, the attendants of the patients started building up in numbers and misbehaved and manhandled the doctors and staff and forcibly took away the case sheet of the patient. In the circumstances the hospital admission had to call the local police to control the situation.
The answering opposite party most vehemently preached before this Hon'ble Commission that the complainant should be directed to produce all the illegally snatched hospital records before this Hon'ble Commission and the answering opposite party reserves its right to amend, altar and file additional written statement after the hospital records are made available to them through this court. As far as answering opposite party is concerned, they duly exercised their duty of reasonable care and skill while administering treatment on the patient and even after the occurrence of the known complication managed the patient to the best of their ability. There is no medical negligence as has been wrongly alleged by the complainant. It is well settled principle of medical negligence and law as laid down by Hon'ble Supreme Court of India that the doctor discharges duty of reasonable care and skill and the patient still dies or suffers a permanent disability, no finding of medical negligence can be recorded by a court.
It is stated that the patient was shifted to the post-operative ward after surgery was done satisfactorily and not to the general ward as wrongly and falsely stated by the complainant. The patient was continuously being monitored in the recovery area and all the vitals were being monitored. The answering opposite party is a well equipped and multispecialty hospital and all complications are timely and properly evaluated as was done in the present case. It is a strongly denied that the attendants of the child were ever asked to leave the patient's site, as has been wrongly alleged by the complainant. It is mentioned that the patient was shifted in ward no 205 on second floor at 9:20 PM and his vitals were noted and recorded and appropriate medical advice was given. As soon as the patient was found in a state of arrest; the child was immediately shifted to ICU; CPR was immediately started as per medical protocol and the consultant in charge Dr SS Bhagat and Dr Sachin Mittal promptly attended the patient along with one Dr Sudesh Prakash , senior anaesthetist and critical care expert. In the care of expert doctor, CPR was continued as per protocol; patient was intubated and ventilator was started while the CPR was being done. Throughout the critical condition of the patient was communicated and well understood by the attendants but unfortunately despite best care the patient could not be revived.
There is no question of any medical negligence in the present case. The patient was treated as per standard medical protocol and thereafter even the complications were well-managed with the best efforts of the doctors. The patient's attendants themselves and were accompanying the child throughout the post-operative period till 9 PM about one hour 45 minutes after the surgery and the attendants themselves were satisfied with the condition of the patient. The patient was shifted to the ward only after he was completely okay and still was accompanied by the patient's attendants. All care and treatment as per well settled standard medical norms were extended to the patient during his stay at the hospital by highly qualified and well experienced doctors and paramedical staff and not by any untrained staff as has been falsely asserted by the complainant has ever been employed in the hospital. Medication as per dose as instructed by the treating doctors were applied on the patient. Patient was shifted to the ward only after being sure that the condition of the patient was stable. If any suspension of collapse or instability of the patient would have been observed the patient would not have been shifted to the ward rather either would have been stabilised in the post-operative ward or shifted to the ICU. No forgery of treatment records have been done, child was not declared dead at 1 PM. At 10:45 PM, one hour after the CPR started, the attendants were duly informed regarding the unfortunate death of the patient.
It is submitted that the attendants are themselves have forcibly taken away the medical records and later submitted the same to police and not provided by the treating doctors. The treatment record was taken away at the time of incidence itself and no question arises of any manipulation of the same by the answering opposite party of the treating doctor or any other doctors in the hospital. It is pertinent to testify that the blood drained froth from the right nostril/lung congestion is only attributable to the CPR done while trying to revive the child. In the post-mortem report mentioned the cause of death being "Anaphylaxis". It is a complication well-known to medical science. All efforts were made to manage the same as per best standards available. It is vehemently and categorically denied that the complainant has been charged more than ₹ 80,000/- for the treatment and another ₹ 8000/- medicines and investigations by the hospital, which is totally false and the answering opposite party wishes to state before this Hon'ble commission that the patient had cash/facility from Paramount TPA for which hospital had preauthorization . The complainant, throughout, grossly abused the process of law in harassing the answering opposite party by multiple and baseless litigations; on one hand the attendants of the patient/complainant were physically and verbally most aggressive with the answering opposite party staff and they damage the hospital property, disturbed the other patients and forcibly snatched and took away the hospital records. The present petition of the complainant is totally divide of merits and hence liable to be dismissed by this Hon'ble Commission.
In the present case the opposite party no.1 has stated in his written statement that that the most apparent cause of unfortunate death of the patient in the present case is a well-known medical complication in medical science, "ANAPHYLAXIS". In the circumstances the occurrence of an ANAPHYLACTIC REACTION is a well-known inherent risk to several treatments and not at all any act of negligence on the part of the treating doctor. As per medical literature submitted by the opposite party - anaphylaxis involves a range of signs and symptoms from hives, wheezing and angioedema to cardiovascular collapse and death. More than 80% of the patients will present with cutaneous symptoms (e.g. hives, pruritus, facial swelling). Anaphylaxis may result in respiratory failure, shock, multiorgan system failure, and disseminated intravascular coagulation. Between 5% and 20% of patients may experience a recurrence of anaphylaxis 8 - 12 hours after the initial presentation. Prolonged symptoms can last up to 32 hours despite treatment. Although BOHLKE and colleagues estimated the rate of anaphylaxis in children at 10.5 per 1 lakh persons - years. The Rochester epidemiology project showed a rate of 75.1 per 1 lakh persons- years in children aged nine years and 65.2 per 1 lakh%- yes in children aged 10-19 years old. Furthermore anaphylaxis appears to be more common in boys until the age of 15 years: a female preponderance then continues through adulthood. Anaphylactic reaction is an uncommon cause of sudden death. In many cases, no specific macroscopic or microscopic findings were detected at autopsy.
We have also seen an article on anaphylaxis which is quoted hereinbelow.
Overview Anaphylaxis is a severe, life-threatening allergic reaction. It can happen seconds or minutes after you've been exposed to something you're allergic to. Peanuts or bee stings are examples. In anaphylaxis, the immune system releases a flood of chemicals that can cause the body to go into shock. Blood pressure drops suddenly, and the airways narrow, blocking your breathing. The pulse may be fast and weak, and you may have a skin rash. You may also get nauseous and vomit. Anaphylaxis needs to be treated right away with an injection of epinephrine. If it isn't treated right away, it can be deadly.
Anaphylaxis is a severe, potentially life-threatening allergic reaction. It can occur within seconds or minutes of exposure to something you're allergic to, such as peanuts or bee stings. Signs and symptoms include a rapid, weak pulse; a skin rash; and nausea and vomiting. Common triggers include certain foods, some medications, insect venom and latex.
Anaphylaxis requires an injection of epinephrine and a follow-up trip to an emergency room. If you don't have epinephrine, you need to go to an emergency room immediately. If anaphylaxis isn't treated right away, it can be fatal.
In most cases, people with allergies develop mild to moderate symptoms, such as watery eyes, a runny nose or a rash. But sometimes, exposure to an allergen can cause a life-threatening allergic reaction known as anaphylaxis. This severe reaction happens when an over-release of chemicals puts the person into shock. Allergies to food, insect stings, medications and latex are most frequently associated with anaphylaxis.
A second anaphylactic reaction, known as a biphasic reaction, can occur as long as 12 hours after the initial reaction.
Call 911 and get to the nearest emergency facility at the first sign of anaphylaxis, even if you have already administered epinephrine, the drug used to treat severe allergic reactions. Just because an allergic person has never had an anaphylactic reaction in the past to an offending allergen, doesn't mean that one won't occur in the future. If you have had an anaphylactic reaction in the past, you are at risk of future reactions. lergies or asthma hold you back.
Anaphylaxis symptoms occur suddenly and can progress quickly. The early symptoms may be mild, such as a runny nose, a skin rash or a "strange feeling." These symptoms can quickly lead to more serious problems, including:
Trouble breathing Hives or swelling Tightness of the throat Hoarse voice Nausea Vomiting Abdominal pain Diarrhea Dizziness Fainting Low blood pressure Rapid heart beat Feeling of doom Cardiac arrest People who have had a severe allergic reaction are at risk for future reactions. Even if your first reaction is mild, future reactions might be more severe. That's why it's important to carry self-injectable epinephrine if you are at risk, and 911 should be dialed in the event of a very serious reaction.
The best way to understand anaphylaxis and the things that can trigger this severe allergic reaction is to see an allergist who will help you manage your condition.
Diagnosis If you have a history of allergies and/or asthma and have previously had a severe reaction, you are at greater risk for anaphylaxis.
Allergists are specially trained to review your history of allergic reactions, conduct diagnostic tests (such as skin-prick tests, blood tests and oral food challenges) to determine your triggers, review treatment options and teach avoidance techniques. Talk with an allergist if:
You're unsure whether you have had an anaphylactic reaction.
Your symptoms are recurring or are difficult to control.
You're having trouble managing your condition.
More tests are needed to determine the cause of your reactions.
Desensitization or immunotherapy could be helpful in your case.
Daily medication is needed.
You need intensive education on avoidance and anaphylaxis management.
Other medical conditions complicate your treatment.
Management and Treatment An anaphylactic reaction should be treated immediately with an injection of epinephrine (adrenaline). Doses, available by prescription, come in an auto-injector that should be kept with you at all times. Two injections may be necessary to control symptoms. Here are some tips for reducing the risk of anaphylaxis:
1- Know your trigger. If you've had anaphylaxis, it's very important to know what triggered the reaction. An allergist can review your medical history and, if necessary, conduct diagnostic tests. The most common triggers are:
Food: including peanuts, tree nuts such as walnuts and pecans, fish, shellfish, cow's milk and eggs.
Latex: found in disposable gloves, intravenous tubes, syringes, adhesive tapes and catheters. Health care workers, children with spina bifida and genitourinary abnormalities and people who work with natural latex are at higher-risk for latex-induced anaphylaxis.
Medication: including penicillin, aspirin and non-steroidal anti-inflammatory drugs such as ibuprofen, and anesthesia.
Insect sting: with bees, wasps, hornets, yellow jackets and fire ants being the most likely to trigger anaphylaxis.
2- Avoid your trigger. Avoidance is the most effective way to prevent anaphylaxis. An allergist can work with you to develop specific avoidance measures tailored specifically for your age, activities, occupation, hobbies, home environment and access to medical care. Here are some general avoidance techniques for common triggers:
Food allergies. Be a label detective and make sure you review all food ingredient labels carefully to uncover potential allergens. When eating out, ask the restaurant how food is prepared and what ingredients are used. If you have a child with a history of anaphylaxis, it's imperative to make sure that school personnel are informed of the child's condition and a treatment plan is provided, including the administration of epinephrine.
Medications. Make sure all of your doctors are aware of any reactions you've had to medications so that they can prescribe safe alternatives and alert you to other medications you may need to avoid. If there are no alternative medications, you may be a candidate for desensitization, a treatment that introduces a small dose of the medication you are allergic to. As your body becomes more tolerant to the medication, the dosage can be increased over time. While the treatment is effective, it's only temporary and must be repeated if the medication is needed again in the future.
Insect stings. To help prevent stinging insects, avoid walking barefoot in grass, drinking from open soft drink cans, wearing bright colored clothing with flowery patterns, sweet smelling perfumes, hairsprays and lotion during active insect season in late summer and early fall. An allergist can also provide a preventative treatment called venom immunotherapy (or venom allergy shots) for insect sting allergy. The treatment works by introducing gradually increasing doses of purified insect venom, and has been shown to be 90 to 98 percent effective in preventing future allergic reactions to insect stings.
3- Be prepared. Prompt recognition of the signs and symptoms of anaphylaxis is critical. If you unexpectedly come into contact with your trigger, you should immediately follow the emergency plan outlined by your doctor including the self-administration of epinephrine. If there is any doubt about the reaction, it is generally better to administer the epinephrine. Be sure to keep your epinephrine auto-injector up to date. If an expired auto-injector is the only one available in an emergency situation, administer it promptly anyway. Teachers and other caregivers should be informed of children who are at risk for anaphylaxis and know what to do in an allergic emergency.
4- Seek treatment. If a severe reaction does occur and epinephrine is administered, you should be transported to the nearest emergency facility by ambulance for additional monitoring.
5- Tell family and friends. Family and friends should be aware of your condition, your triggers and know how to recognize anaphylactic symptoms. If you carry epinephrine, alert them to where you keep it and how to use it.
6- Wear identification. Wear and/or carry identification or jewelry (bracelet or necklace) noting condition and offending allergens.
7- See a specialist. Allergists are specially trained to help you take control of your symptoms, conduct diagnostic tests and review treatment options so you can live the life you want.
8- Seek additional resources. Additional information on allergies and anaphylaxis is available on the ACAAI Web site or the Food Allergy Research & Education (FARE) at www.foodallergy.org.
9- In addition, helpful information can be found on the Food Allergy & Anaphylaxis Connection Team (FAACT) website www.Food AllergyAwareness.org.
Be S.A.F.E. Action Guide Allergists and emergency physicians have teamed up to create the Be S.A.F.E. action guide to help you remember steps to take during and after an allergic emergency.
Seek immediate medical help.
Call DOCTOR and get to the nearest emergency facility at the first sign of anaphylaxis, even if you have already administered epinephrine, the drug used to treat severe allergic reactions. If you have had an anaphylactic reaction in the past, you are at risk of future reactions.
Identify the Allergen.
Think about what you might have eaten or come in contact with - food, insect sting, medication, latex - to trigger an allergic reaction. It is particularly important to identify the cause because the best way to prevent anaphylaxis is to avoid its trigger.
Follow up with a specialist.
Ask your doctor for a referral to an allergist/immunologist, a physician who specializes in treating asthma and allergies. It is important that you consult an allergist for testing, diagnosis and ongoing management of your allergic disease.
Carry Epinephrine for emergencies.
Kits containing fast-acting, self-administered epinephrine are commonly prescribed for people who are at risk of anaphylaxis. Make sure that you carry an epinephrine kit with you at all times, and that family and friends know of your condition, your triggers and how to use epinephrine. Consider wearing an emergency medical bracelet or necklace identifying yourself as a person at risk of anaphylaxis. Teachers and other caregivers should be informed of children who are at risk for anaphylaxis and know what to do in an allergic emergency.
Now in this case it has been stated by opposite party that anaphylactic reaction is a well-known inherent risk to several treatments and not at all any act of negligence on the part of the treating doctor. Now the question arises when the opposite parties came to know about anaphylaxis? From where it has been confirmed that the patient developed anaphylaxis or how the treating doctor came to know that in the case of anaphylaxis or what treatment has been given to treat the anaphylaxis. As we have seen in the above article that some medicine may be given in case of anaphylaxis but we do not find any documents showing that there was anaphylaxis and it has been treated or they try to tried this anaphylaxis.
In this case Emeset Inj has been given to the patient on 01.06.2014 . First at 5 PM Emest 3 mg has been given and thereafter at 8:10 PM Emeset 2 mg has been injected. What was the need of giving this injection twice within three hours. No satisfactory reply has been given by the opposite parties.
Emeset Injection 4ml is an antiemetic medicine commonly used to control nausea and vomiting due to certain medical conditions like stomach upset. It is also used to prevent nausea and vomiting caused due to any surgery, cancer drug therapy or radiotherapy.
Emeset Injection 4ml will not relieve other side effects associated with cancer treatments. It is given under the supervision of a doctor and may be used alone or with other medications. Your doctor will give you appropriate dose depending on what you are taking it for. It is important that you keep having the injections until your doctor decides it is safe to stop them. After this, your doctor may prescribe tablets instead of the injections.
The most common side effects of taking this medicine include injection site pain, headache, and constipation. These symptoms should disappear when you stop taking the medicine. But,t if these side effects bother you or do not go away, consult your doctor who may be able to suggest ways of preventing or reducing them.
Before taking this medicine, tell your doctor if you have heart or liver problems or a blockage in your stomach or intestines. Also, tell your doctor about other drugs you are using, especially medicines to treat epilepsy, heart problems, cancer, and depression. These may affect, or be affected by, this medicine. If you are pregnant or breastfeeding, ask for advice from your healthcare team.
USES OF EMESET INJECTION Treatment of Nausea Vomiting BENEFITS OF EMESET INJECTION In Treatment of Nausea Emeset Injection 4ml blocks the action of chemicals in the body that can make you feel or be sick. It is often used to prevent nausea and vomiting that may be caused by cancer chemotherapy and radiation treatment (in adults and children aged 4 years and older). It is usually taken both before and after chemotherapy or radiation. This medicine helps you recover more comfortably from these treatments. It is also effective at preventing nausea and vomiting after an operation (in adults only). The dose will depend on what you are being treated for but always take this medicine as it is prescribed.
SIDE EFFECTS OF EMESET INJECTION Most side effects do not require any medical attention and disappear as your body adjusts to the medicine. Consult your doctor if they persist or if you're worried about them Common side effects of Emeset Injection site pain Constipation Diarrhea Fatigue Headache Can any other injection may be given in place of Emeset? Five MG dose has been given to a child of nine years old within three hours. Whether the patient was suffering from vomiting or not? The patient may be given oral EMESET in place of injection. No satisfactory answer given by the opposite party insured.
The opposite party have stated that everything was normal. The child was shifted to post-operative room wear at 8:50 PM injection Emeset 2 mg was administered with tramadol 50 mg in 500 ML IVF slowly. There is no statement regarding effectiveness of the Emeset injection. It is stated that at 9:45 PM the patient was found to be in a state of arrest and thereafter shifted to ICU and CPR was started. Why it happened? Nothing has been stated about this aspect. When everything was normal then after giving two injections, Emeset and tramadol, why the condition of the child deteriorated. Who was present with a child when the injections were administered. No certificate had filed by the opposite parties and they have said that all the documents were snatched by the complainant aside and the treated anarchy and chaos in the hospital. But the certificate is issued after the death of the child and it can be made afterwards so it was duty of the opposite parties to issue the death certificate in this case. It has been said that at 8:30 PM the National named Shashi came and administered both the above-mentioned two injections and after that the son of the complainant started breading very fast and within few minutes the patient became silent. Thereafter they shifted the patient to the ICU but no medical record of ICU or ECG or any other record has been filed. So it is clear that some negligence has been done by the opposite parties and they cannot take proper care of the patient after such a minor operation. Why all these matches were given to the patient is not clear. What was found in the operation and whether it has been sent to the biopsy or not, not clear. Post-operative care is very important in cases of all the operation and it is the duty of Dr and present a staff to provide all the post-operative care to the patient so that no complication may arise. Pre-and post-operative care are very necessary in case of any surgical operation and it is the duty of the concerned Dr, anaesthesia Dr and all the paramedical staff to look after all the stages of preoperation and post-operative care.
Pre-Operative Assessment and Post-Operative Care in Elective Shoulder Surgery.
Pre-operative assessment is required prior to the majority of elective surgical procedures, primarily to ensure that the patient is fit to undergo surgery, whilst identifying issues that may need to be dealt with by the surgical or anaesthetic teams. The post-operative management of elective surgical patients begins during the peri-operative period and involves several health professionals. Appropriate monitoring and repeated clinical assessments are required in order for the signs of surgical complications to be recognised swiftly and adequately.
This article examines the literature regarding pre-operative assessment in elective orthopaedic surgery and shoulder surgery, whilst also reviewing the essentials of peri- and post-operative care. The need to recognise common post-operative complications early and promptly is also evaluated, along with discussing thromboprophylaxis and post-operative analgesia following shoulder surgery.
INTRODUCTION Pre-operative assessment is necessary prior to the majority of elective surgical procedures, in order to ensure that the patient is fit to undergo surgery, to highlight issues that the surgical or anaesthetic team need to be aware of during the peri-operative period, and to ensure patients' safety during their journey of care. In addition, unnecessary cancellations or complications due to inappropriate surgery may be avoided, in addition to costs both to the patient and health service [1]. The post-operative management of elective surgical patients begins during the peri-operative period and involves the surgical team, anaesthetic staff, and allied health professionals. Appropriate monitoring and repeated clinical assessment are required, along with support for all major organ systems, including cardiorespiratory function, renal function and fluid and electrolyte balance, and awareness for signs of early surgical complications such as bleeding and infection [2].
This article examines the literature regarding pre-operative assessment in elective orthopaedic surgery and shoulder surgery, whilst also reviewing the essentials of peri- and post-operative care. The need to recognise common post-operative complications early and promptly is also evaluated.
PRE-OPERATIVE ASSESSMENT Most patients undergoing elective surgery are subjected to routine history checks and clinical examinations by medical staff at the time that a decision is taken by both clinician and patient to undergo surgery. For most procedures other than those which are very minor, a formal pre-operative assessment consultation is usually led by a specialist nurse or a member of medical staff, and generally includes a review of the patient's case notes, a detailed history and clinical examination, and additional tests and investigations.
History Salient points in the history in patients who are presumed to be healthy is to identify any as-yet undetected illnesses which could have an adverse affect on the forthcoming surgery and peri-operative care. The history should focus on the indication for surgical procedures, allergies, and undesirable side-effects to medications or other agents, known medical problems, surgical history, major trauma, and current medications.
Common conditions which can affect peri-operative care include ischaemic heart disease, congestive cardiac failure, chronic respiratory disease, diabetes mellitus and liver or renal dysfunction [3]. As anaesthetic drugs can have pronounced adverse effects on cardiovascular and respiratory systems, it is worthwhile enquiring about chest pain, dyspnoea, ankle swelling and palpitations. The presence of a cough, sputum production and any indication of airway obstruction will provide invaluable information. An excellent indicator of cardiorespiratory function is tolerance of exercise [4]. A smoking history should also be taken as smokers are difficult to anaesthetise due to their upper airways being sensitive to the dry gases used during anaesthesia, and their risk of hypoxia is greater. Assessment and documentation of alcohol intake is required, as induction of liver enzymes by alcohol may shorten the action of anaesthetic drugs and may identify the risk of potential alcohol withdrawal. The use of recreational drugs such as intravenous opiates should also be recognised, as such patients may have poor venous access, may be at risk of septicaemia, and may pose a risk to the surgical team. Patients on long term steroids require adequate cover intra-operatively in order to avoid a hypotensive crisis [4].
In elective shoulder surgery, a detailed history is important not only in arriving at the correct diagnosis, but also in decision-making between the clinician and patient. The history may be considered one of the most valuable yet least effectively used tools in clinical medicine [5]; and poor history taking and physical examination may lead to both inappropriate diagnostic testing and surgery. Patients with shoulder pathology usually present with pain and/or loss of function, which should be explored along with the patient's premorbid status and demands, and the likely functional demands aimed for in the future. A comprehensive interview regarding the patient's pain and functional deficit is required, exploring components such as site, onset, duration, character and radiation of the pain, including features of neural irritation. The degree of dysfunction should also be clarified and how this impacts on the patient and their activities of daily living (ADL), especially as lower pre-operative ADL measurements have been associated with higher post-operative mortality in patients undergoing elective orthopaedic surgery [6]. Table 11 below displays how shoulder function can be assessed [5].
Table 1.
Assessment of Shoulder Dysfunction Which movements are limited? This can help isolate the structure Consider the following if movements are limited by:
▪ pain: tendinopathy, impingement, sprain/strain, labral pathology ▪ mechanical block: labral pathology, frozen shoulder ▪ night pain (lying on affected shoulder): rotator cuff pathology, anterior shoulder instability, ACJ injury, neoplasm (particularly unremitting pain) ▪ sensation of 'clicking or clunking': labral pathology, unstable shoulder (either anterior or multidirectional instability) ▪ sensation of stiffness or instability: frozen shoulder, anterior or multidirectional instability Physical Examination A general systems examination is performed to identify abnormalities of the cardiorespiratory system which would require further assessment. In particular, cardiac murmurs, additional heart sounds, and abnormal chest signs in patients with no previously documented pathology require investigation and/or referral to an appropriate specialist. Review of the gastrointestinal (GI) system identifies any abdominal masses and previous surgical scars. Skeletal malformations such as kyphoscoliosis can be detected on examining the musculoskeletal system. Local skin abnormalities should be documented and any issues should be highlighted to the surgical team.
Observations including heart rate and blood pressure are recorded. Brief examination of the airway provides valuable information regarding the feasibility of intubation. Several factors must be considered when assessing the airway. These include whether the patient is obese, has a short neck and small mouth, or whether or not there is any soft tissue swelling at the back of the mouth or if there are any constraints to neck flexion or extension. Cervical spine stiffness should be followed up with a plain radiograph to aid the anaesthetic team in decision-making regarding intubation.
Specific examination of the shoulder involves inspection, palpation, movement and special tests which may be able to narrow down the diagnosis. Previous scars, skin abnormalities, erythema, bruising and shoulder symmetry are to be noted on inspection [5]. Palpation of the shoulder should reveal any specific tenderness around the joint, in addition to crepitus, especially with movement. Passive and active range of movement should then be assessed, comparing both sides.
Special tests of shoulder joint function involve Hawkins test for subacromial impingement, with the humerus abducted to 90 degrees and 30 degrees anteriorly in the line of the scapula. The elbow is then flexed to 90 degrees and the glenohumeral joint internally rotated. Pain constitutes a positive test. This test has a sensitivity of 91-92% and specificity of 25-43% [7]. The empty can test can also be used for detecting a torn rotator cuff, specifically for a supraspinatus tear. Pain and/or weakness signify a positive test when the patient resists a downward pressure with the arm in 90 degrees of abduction in the plane of the scapula. Sensitivity for this test is 18.7% with specificity being 100% [7]. The apprehension test can be used to test for anterior shoulder instability, following anterior shoulder dislocation and subluxation, with a sensitivity of 91.9% and specificity of 88.9%. The active compression test (O'Brien's test) for acromioclavicular joint (ACJ) arthritis and labral pathology can also be utilised. With the arm flexed to 90 degrees and the elbow fully extended, the arm is then adducted about 15 degrees medially. The arm is internally rotated so that the thumb points to the floor, the patient then resists the downward force applied by the clinician. The arm is then supinated so the palm is facing upward and resisting another downward force. The test is positive and diagnostic of ACJ pathology if pain is elicited over the ACJ or on top of the shoulder in the thumb down position and reduced or eliminated in the palm up position. Sensitivity for this test is 100% with specificity of 96.6% [7].
Investigations Most patients admitted for elective surgery undergo a range of routine pre-operative tests. Some of these tests are guided by the patient's clinical needs, whilst others are done as a matter of routine. The purposes of routine pre-operative tests are to assess whether the patient may have any pre-existing health problems, to identify any medical conditions unknown to the patient, the prediction of post-operative complications and the establishment of a reference for comparisons [8] if tests need to repeated at a later date.
Chest Radiographs Overuse of pre-operative chest x-rays (CXR) has in the past led to inappropriate wastage of resources [9]. Unexpected abnormalities are rare and seldom lead to changes in further management [10]. In many cases, the radiologist's report of the pre-operative chest radiograph is not available until after surgery [11], and the absence of achest radiograph pre-operatively has not been shown to be associated with an increase in post-operative morbidity or mortality [12].
Little evidence exists advocating the use of pre-operative chest X-rays prior to elective orthopaedic surgery. Radiographs should be sought when clinically indicated, or as requested by an anaesthetist. Chest x-rays should, however, be included in routine pre-operative tests for patients with a hip fracture [13]. The National Institute for Clinical Excellence (NICE) does not recommend routine pre-operative chest X-rays for otherwise healthy patients unless cardiac surgery is to be performed, but states that the decision depends upon the clinical history (e.g. chronic obstructive pulmonary disease (COPD), asthma) and the pathology requiring surgery [8, 14].
Electrocardiograms (ECGs) ECGs can identify, amongst other things, underlying ischaemic heart disease, previous infarction, and abnormalities in heart rhythm. No clear consensus exists whether pre-operative ECGs should be performed. ECGs may provide the major, and perhaps only, indication as to whether the patient has previously suffered an unrecognised myocardial infarction, which within the preceding 6 months is a risk factor for life-threatening cardiac complications in the peri-operative period [15].
Barnard et al. [16] recommend pre-operative ECGs in those over 60 years of age undergoing major surgery and in those displaying signs and symptoms of cardiovascular (ischaemic heart disease/hypertension) or respiratory disease. In patients with known or suspected coronary artery disease, ECGs should be performed pre-operatively, immediately post-surgery and on the first two days after surgery. In addition, patients with unstable coronary syndromes, significant arrythmias or severe valvular heart disease scheduled for elective non-cardiac surgery should have surgery cancelled or delayed until the cardiac issue has been clarified and treated [17]. NICE guidelines for pre-operative tests and investigations in otherwise healthy patients state that pre-operative ECGs should be performed in patients younger than 60 years of age if they are asthmatic or a smoker, and in all those patients above the age of 80 years [14].
Full Blood Count For those patients in whom anaemia is suspected, a full blood count (FBC) is recommended. Whether or not a patient requires a pre-operative FBC also depends on the complexity of the surgery to be performed. For those patients attending only for minor surgery it can be argued that an FBC is not required [16]. It is required however if the proposed operation is expected to cause anything greater than minor blood loss [4] and also in those patients over the age of sixty who will be undergoing major surgery [14]. Pre-operative FBC also acts as a baseline for comparison with post-operative testing.
Biochemistry Pre-operative serum biochemistry testing generally includes assessment of urea & creatinine and electrolytes. Abnormalities of serum potassium concentrations should be highlighted to anaesthetic staff pre-operatively and corrected where possible, due to a risk of cardiac arrest with agents such as suxamethonium [16]. NICE recommends pre-operative renal function in patients older than 40 years undergoing major surgery [14]. In addition to NICE, Barnard [16] recommends a dipstick urine test in those older than 16 years to screen for evidence of diabetes. Pre-operative liver function tests should be performed in those with established cirrhosis or a history of liver disease, or excessive alcohol intake [18].
Coagulation Screening Coagulation testing is often routinely undertaken in anticoagulated patients or patients to be started on anticoagulants. The activated partial thromboplastin time (APTT) is used to monitor unfractionated heparin, whereas the International Normalised Ratio (INR) is used for the monitoring of coumarin anticoagulants such as warfarin. Rohrer et al's study from 1988 suggested that blanket use of routine coagulation testing in the pre-operative setting is unnecessary [19], and may result in needless further testing and perhaps a delay in surgery. This is also the viewpoint of NICE [14]. Thus pre-operative clotting screens should only be performed in selective groups, namely those with a history of a bleeding disorder, liver disease, or malnutrition, or patients on anticoagulants (warfarin, heparin) [18].
Pre-operative care specific to shoulder arthroplasty includes the features mentioned above, but in addition shoulder X-rays are necessary and essential. Such radiographs may include a true anterior/posterior (AP) and an axillary view [20]. These allow for careful consideration regarding which prosthesis is to be used.
POST-OPERATIVE CARE WITH RECOGNITION OF COMPLICATIONS The mainstays of post-operative care in general are regular assessment, selective monitoring and timely documentation [2]. Further principles of post-operative care involve reviews of the major body systems, namely respiratory, cardiovascular and renal systems. Furthermore, sepsis must be controlled and sufficient pain relief must be provided. Specific post-operative neurovascular assessment following shoulder surgery is also of vital importance. In order for a patient to be discharged from the post-operative recovery room and back to the ward, certain criteria need to be met [21] (see Table 22).
Table 2.
Criteria for Patients to be Discharged from the Post-Operative Recovery Room • The patient is fully conscious, responding to voice or light touch, able to maintain a clear airway and has a normal cough reflex • Respiration and oxygen saturation are satisfactory (10-20 breaths/minute and SpO2 92%) • The cardiovascular system is stable with no unexplained cardiac irregularity or persistent bleeding • The patient's pulse and blood pressure should compare with normal pre-operative values or should be at a level corresponding to planned post-operative care • There should be adequate control of pain and vomiting with suitable analgesic and anti-emetic regimens prescribed • Temperature should be within acceptable limits ( 36°C) • Oxygen and fluid therapy should be prescribed when required Open in a separate window The first post-operative assessment should take place following a patient's return from theatre. This acts as a baseline against which the patient's condition can be assessed at a later date and identifies any problems that may have occurred on transfer from the operating department. This assessment should include the intraoperative history and post-operative instructions, circulatory volume status, respiratory status and cognitive state. Common causes of confusion in the postoperative period include infection, hypoxia, sedatives and other medications such as anticholinergics [22].
Monitoring Monitoring of patients allows routine data to be collated and trends established, therefore making it more straightforward to detect any clinical deterioration. It also allows a patient's response to treatment to be evaluated. Common parameters include temperature, pulse rate, blood pressure, respiratory rate, urine output, peripheral oxygen saturation and pain scores [2].
These variables should be measured multiple times during the day, depending on the type of surgery involved. Other examples of monitoring include ECGs, arterial blood gas analysis (ABGs) and central venous pressure (CVP) monitoring [23]. In addition, assessment of drainage and bleeding should also be performed routinely [24].
Cardiovascular Monitoring As the main significant post-operative complications in general surgical patients are cardiovascular and respiratory in nature, it is sensible that cardiorespiratory monitoring be made a priority [25]. In general, maintaining a patient's heart rate and blood pressure within normal limits will result in a satisfactory outcome. However, there are no clinical studies to indicate what is normal with respect to heart rate and blood pressure for individual patients in the post-operative period [2].
Hypertension is common post-operatively and can be due to various causes including pain, anxiety and discontinuing antihypertensive medication. Guidelines by The American College of Cardiology/American Heart Association [26] recommend deferring surgery if the diastolic pressure is above 110 mm Hg and systolic is above 180 mm Hg. No such guidelines exist in the UK however.
Hypotension is also common post-operatively and has been defined as a systolic blood pressure below 90 mmHg [27]. Causes include hypovolaemia due to bleeding or dehydration, or drug therapy.
Myocardial ischaemia in the first 48 hours after an operation is the single most important predictor of serious cardiac events, including cardiac death, myocardial infarction, unstable angina, congestive heart failure and serious arrhythmias [2]. High risk procedures with a risk of cardiac event greater than 5% include cardiac and vascular surgery, or major pelvic/GI surgery in the presence of pre-existing vascular disease. The majority of elective orthopaedic surgery is classed as intermediate risk, with a cardiac risk of less than 5% [28].
Respiratory Monitoring Pulmonary complications are an important and common cause of post-operative morbidity and mortality and are particularly common after major abdominal and thoracic surgery. Risk factors for the development of post-operative pulmonary complications include high body mass index (BMI), smoking status and the presence of COPD [29]. Others include pre-operative respiratory illnesses, Intensive Care Unit (ICU) stay and mechanical ventilation in the post-operative period [30]. In order to adequately observe respiratory function and to identify post-operative respiratory complications the respiratory rate, heart rate and conscious level should be monitored routinely. Indicators of respiratory complications include respiratory rate 10 or 25 breaths per minute; pulse rate 100 beats per minute and reduced conscious level.
Patients in whom there is a suspicion of post-operative pulmonary complications should have an arterial blood gas analysis, a sputum culture and ECG. A CXR should be performed on suspicion of major collapse, effusions, pneumothorax or haemothorax. Generally accepted diagnostic criteria for respiratory failure, pulmonary infections and acute respiratory distress syndrome (ARDS) are summarised in Table 33 [2].
Table 3.
Diagnostic Criteria for Certain Respiratory Complications Respiratory failure:
type 1 - PaO2 8kPa (60 mm Hg), PaCO2 6.6kPa (50 mm Hg) type 2 - PaO2 8kPa (60 mm Hg), PaCO2 6.6kPa (50 mm Hg) Atelectasis:
pulmonary collapse clinically or on x-ray which may be subsegmental, segmental, lobar or pulmonary, without evidence of respiratory infection Respiratory infection:Any two of the following on two or more days:
pyrexia 38°C positive sputum culture positive clinical findings abnormal chest x-ray - atelectasis/infiltrates ARDS:
acute onset bilateral infiltrates on chest x-ray if PaO2 (kPa) / FiO2 is ≤ 26 Post-operative pulmonary complications can therefore be recognised early if vital signs are recorded accurately in the post-operative period. Any deterioration in these values should then necessitate the need for further investigations such as x-rays and ABGs.
Fluids & Electrolytes The standard principles of fluid balance in the post-operative patient are to correct any pre-existing deficits, to replace unusual losses (e.g. from surgical drains, pyrexia) and to use the oral route wherever possible as there is not infrequently a delay in commencing oral intake after surgery. Particular patient groups susceptible to fluid or electrolyte disturbances include the elderly, those with pre-existing cardiovascular/cerebrovascular/renal disease and patients who have suffered a peri-operative myocardial ischaemic event [2].
In order to detect fluid and electrolyte abnormalities, patients must have their vital signs checked regularly. Hypotension, tachycardia, oliguria, confusion and tachypnoea may all be indications of hypovolaemia but also have other causes, including sepsis. Whenever a post-operative patient is hypovolaemic, it is important that haemorrhage be considered and to actively exclude this before attributing hypovolaemia to another cause [31].
Potential causes of hypovolaemia include haemorrhage, diarrhoea and vomiting, polyuria and fluid losses via drains. On the other hand, causes of fluid overload include excessive intravenous fluid administration and poor renal or cardiac function [32]. This should be avoided as consequences may include pulmonary oedema. It is thus important to regularly check patients' vital signs when administering intravenous fluids, so that it can be recognised early if the patient is getting too much or too little.
Sepsis Sepsis is the systemic inflammatory response to infection and represents a progressive response to infection leading to a generalised inflammatory reaction and eventually end-organ dysfunction and/or failure [2]. The development of systemic sepsis in a post-operative patient marks a serious decline in their condition. Therefore, early identification of patients at risk of developing sepsis and subsequent management is paramount [2] (see Table 44). Matot et al. [33] explain that some of the clinical features to look out when identifying sepsis include fever, signs of peripheral vasodilation, altered mental state, leucocytosis/neutropenia and unexplained tachycardia, tachypnoea or hypotension. Early identification and appropriate treatment of sepsis improves outcome [34]. Without prompt intervention, severe sepsis may ensue, which has a mortality rate of 20-50% [35].
Table 4.
Systemic Inflammatory Response Syndrome: SIRS The SIRS response is defined by the presence of two or more of the following:
▪ temperature 38°C or 36°C ▪ heart rate 90 beats/min ▪ respiratory rate 20 breaths/min or PaCO2 4.3kPa ▪ white cell count 12,000 cells/mm3, 4,000 cells/mm3 Sepsis ▪ SIRS plus documented site of infection Severe sepsis ▪ Sepsis associated with organ dysfunction, hypoperfusion or hypotension (septic shock) Neurovascular Assessment Following shoulder surgery, particularly highly invasive procedures such as total shoulder arthroplasty, reverse shoulder arthroplasty, or hemiarthroplasty, a thorough neurovascular assessment should be conducted. Circulation, sensation and movement (CSM) are evaluated by assessing the shoulder, elbow and wrist [20]. Motor and sensory examination findings may be difficult to determine in the immediate post-operative period however, as regional blocks are frequently used. As a result, regular assessments are encouraged to demonstrate return of function. Assessment of all major nerves of the upper limb should be conducted, including the axillary nerve which is the most common nerve to be injured during shoulder surgery [36].
Pain Control Post-operative pain can have a significant effect on patient recovery. Since the introduction of Patient-Controlled Analgesia (PCA) in the early 1980s, the daily management of post-operative pain has been enhanced. Patients using PCAs administer and titrate the dose to their own needs using a small microprocessor-controlled pump. Morphine is the most commonly used intravenous drug for PCA, however other opioids have been used. The most frequently observed adverse effects of opioid-based PCA are nausea and vomiting, pruritus, respiratory depression, sedation, confusion and urinary retention [37].
Other options available for post-operative analgesia include intrathecal and epidural analgesia. These may be provided either by using opioids, local anaesthetics or a combination of both. Intrathecal opioids are relatively straightforward to administer and can provide pain relief for twenty four hours or more after a single injection of intrathecal morphine. Epidural analgesia has been shown to be more effective than parenteral opioid administration and intravenous PCA for major surgery [38]. However, this route of administration increases the risk for complications related to the indwelling epidural catheter, including dislodging, kinking or migration within the epidural space.
Opioids are commonly used in the post-operative period. Commonly used agents include morphine, fentanyl and pethidine. Intravenous infusion administration results in a more constant blood level however [39]. Oral opioids can be very effective and can be used to rapidly wean a patient off parenteral therapy, thereby allowing earlier discharge from the hospital. Oxycodone as a controlled-release tablet can provide good pain control for up to 12 hours.
Other methods of providing analgesia also exist. A Cochrane review in 1998 concluded that paracetamol can be used for post-operative pain relief. Several reviews have since supported this, suggesting that paracetamol can provide effective pain relief for up to four hours post-operatively with few adverse side effects [40, 41]. Non-steroidal anti-inflammatory drugs (NSAIDs) can also be added to opioid treatment post-operatively as this can reduce morphine requirements and opioid-related side effects in the early post-operative period [42].
Wound infiltration with a local anaesthetic is a simple, safe, and attractive technique in the control of post-operative pain. Several randomised, controlled studies involving minor surgical procedures have discovered that wound infiltration with local anaesthetic provides superior analgesia, better pain scores, and superior reduction in opioid consumption compared with placebo [43, 44]. Long-acting local anaesthetics such as ropivacaine or bupivacaine are preferred as the analgesic effect is longer.
Interscalene brachial plexus blocks, either alone or combined with a general anaesthetic, are also a useful technique which can be employed to provide excellent post-operative analgesia for patients undergoing shoulder surgery [45]. Fredrickson et al. in 2010 [46] discovered during their review that continuous interscalene block incorporating a local anaesthetic infusion combined with PCA is the most effective analgesic technique following both major and minor shoulder surgery.
Thromboprophylaxis Thromboprophylaxis after elective shoulder surgery is a debatable issue as venous thromboembolic events (VTE) are so rare. There are no large-scale randomised trials published on rates of VTEs, although these are thought to be very low. The risk of a pulmonary embolism (PE) ranges from 0.2% to 2% in the literature with mortality rates of 1% [47]. Jameson et al. [47] discovered that since the introduction of NICE guidelines in 2007 recommending the use of chemical agents in shoulder surgery, rates of VTE events did not change. As such, chemical VTE prophylaxis may not be required in shoulder surgery. Despite this, NICE continues to recommend thromboprophylaxis for high-risk shoulder surgery, extrapolating data from hip and knee replacements.
SUMMARY This article has reviewed the pre-operative assessment especially in shoulder surgery. It draws attention to the mainstays of this assessment, which are a detailed history and clinical examination must be conducted, and additional tests and investigations be requested which are specific to the needs of the individual. The evidence behind such tests has been presented.
The fundamentals behind routine post-operative care have also been discussed. Post-operative care begins once the procedure has ended, with the patient being reviewed in the anaesthetic recovery room, then have their vital signs monitored once they are deemed safe enough to be transferred from the recovery room to the ward. Post-operative monitoring, along with a system-based approach, then allows complications to be recognised early and acted upon. Post-operative neurovascular assessments should also be carried out following shoulder arthroplasty in order to recognise any complications promptly. Finally, thromboprophylaxis and post-operative analgesia following shoulder surgery has also been discussed, demonstrating that several options exist to provide post-operative pain relief.
ACKNOWLEDGEMENTS ABBREVIATIONS ABG = Arterial blood gas ACJ = Acromioclavicular joint ADL = Activities of daily living AP = Anterior/posterior APTT = Activated partial thromboplastin time ARDS = Acute respiratory distress syndrome BMI = Body mass index COPD = Chronic obstructive pulmonary disease CSM = Circulation, sensation, movement CXR = Chest x-ray CVP = Central venous pressure ECG = Electrocardiogram FBC = Full blood count GI = Gastrointestinal ICU = Intensive care unit INR = International normalised ratio NICE = National institute for clinical excellence NSAID = Non-steroidal anti-inflammatory drug PCA = Patient controlled analgesia PE = Pulmonary embolism VTE = Venous thromboembolic event REFERENCES
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27. Kassavin DS, Kuo YH, Ahmed N. Initial systolic blood pressure and ongoing internal bleeding following torso trauma. J Emerg Trauma Shock. 2011;4(1):37-41.
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30. Mathew JT, D'Souza GA, Kilpadi AB. Respiratory complications in postoperative patients. J Assoc Physicians India. 1999;47(11):1086-8.
31. Kelley DM. Hypovolemic shock: an overview. Crit Care Nurs Q. 2005;28(1):2-19.
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Now we came to know that no proper communication has been made between the doctor and the patients or any attendant. It was duty of Dr to inform the patient shall ward about all the things regarding the operation or treatment. The relation between doctor and patient is very sensitive.
First of all we have to see the doctor - patient relationship (DPR). This relationship is very important for all types of treatment of a patient by a doctor.
"Medicine is an art whose magic and creative ability have long been recognized as residing in the interpersonal aspects of patient-physician relationship."
Hall et al.,1981 A doctor-patient relationship (DPR) is considered to be the core element in the ethical principles of medicine. DPR is usually developed when a physician tends to a patient's medical needs via check-up, diagnosis, and treatment in an agreeable manner. Due to the relationship, the doctor owes a responsibility to the patient to proceed toward the ailment or conclude the relationship successfully. In particular, it is essential that primary care physicians develop a satisfactory DPR in order to deliver prime health care to patients.
The physician-patient relationship is a foundation of clinical care. Physician-patient relationships can have profound positive and negative implications on clinical care. Ultimately, the overarching goal of the physician-patient relationship is to improve patient health outcomes and their medical care. Stronger physician-patient relationships are correlated with improved patient outcomes. As the relationship between physicians and patients becomes more important, it is essential to understand the factors that influence this relationship.
Frameworks for Physician-Patient Relationships Throughout history there has been much debate regarding the "ideal" physician-patient relationship. In 1992, Ezekiel and Linda Emanuel proposed four models for the physician-patient relationship: the paternalistic model, the interpretive model, the deliberative model, and the informative model. These models differ based on their understanding of four key principles: the goals of physician-patient interactions, the physician's obligations, the role of patient values, and the concept of patient autonomy.
Factors that Influence the Physician-Patient Relationship Although there are several factors that influence physician-patient relationships, the dynamic shared and sense of trust between physicians and patients are two critical components to their overall relationship.
Dynamic Between Physicians and Patients The dynamic between physicians and patients refers to the communication patterns and the extent to which decision making is shared between both parties. Effective physician-patient communication is an integral part of clinical practice and serves as the keystone of physician-patient relationships. Studies have shown the approach taken by physicians to communicate information is equally important as the actual information that is being communicated. This type of communication incorporates both verbal and nonverbal interactionsbetween physicians and patients.iEffective communication has been shown to influence a wide array of outcomesincluding: emotional health, symptoms resolution, function, pain control, and physiologic measures such as blood pressure levels. When miscommunication occurs, it can have severe negative implications in clinical caresuch as impeding patient understanding, expectations of treatment, treatment planning, decreasing patient satisfaction of medical care, and reducing levels of patient hopefulness.
In addition to having effective communication, it is important that medical decisions stem from a collaborative process between physicians and patients. Decision makingis a process in which patients should be involved from the very beginning, and the result is a decision which reflects the physician's medical knowledge as well as the patient's values and beliefs.ivCollaborative communication and decision making have been correlated with greater patient satisfaction and loyalty. Working from a collaborative framework along with effective physician-patient communication can also strengthen a physician's ability to utilize a personalized health care model through patient empowerment.v Trust Between Physician and Patients "....'patients must be able to trust doctors with their lives and health,' and that maintaining trust is one core guidance for physicians..."
Birkhäuer et al, 2017 Trust is a fundamental characteristic of the physician-patient relationship. Patients must trust that their physicians will work in their best interests to achieve optimal health outcomes. Patients' trust in their physicians has been demonstrated to be more important than treatment satisfactionin predictions of patient adherence to recommendations and their overall satisfaction with care.iStudies have also shown that trust is additionally a strong predictor of a patient continuing with their provider.iiTrust extends to many different aspects of the physician-relationships including, but not limited to: physicians' willingness to listen to patients, patients' believing that physicians value patient autonomy and ability to make informed decisions, and patients feeling comfortable enough to express and engage in dialogue related to their health concerns.
Physician-Patient Relationships Influence on the Future of Healthcare The idea of viewing physician-patient relationships as a core element of quality health care is not something new, however understanding and assessing the factors that influence this relationship is just beginning. Effective physician-patient communication has been shown to positively influence health outcomes by increasing patient satisfaction, leading to greater patient understanding of health problems and treatments available, contributing to better adherence to treatment plans, and providing support and reassurance to patients. Collaborative decision making enables physicians and patients to work as partners in order to achieve a mutual health goal. Trust within all areas of the physician-patient relationship is a critical factor that influences communication between both parties. As health care transforms into a more personalized and patient-centered model, the physician-patient relationship will significantly shape health outcomes. The personalized health care model encourages collaboration among physicians and patients in order to create shared health goals and the cultivation of a health plan to address identified problems. By understanding the factors that influence patient-physician relationships, in the future, health care providers will be able to address some of the barriers that prevent the adoption of more personalized approaches to health care.
Now let us see the oath taken be a doctor before entering the nobel profession of the Medical World. The tradition in medical school includes taking the Hippocratic Oath usually at graduation. The purpose of this review is to examine what that oath has been, what forms it currently has, and the implications for physicians in today's healthcare environment. The changes in health economics affect physicians as they try to follow the oath's allegiance to the individual patient's needs. At times, this goal conflicts with the perspective of the financial world's controls of insurance companies and medical groups and institutions. This difference of the physicians' ethical perspectives from the business leaders regarding the philosophy of the value of the individual's health and life may be related to some aspect of physician burnout.
Many populations in the world know of the Hippocratic Oath for physicians as they begin the journey to care for patients. In this current era of medicine the frequency of students' taking the oath has increased to nearly every one compared to the early twentieth century; however, few medical students and physicians actually know that the translations of the ancient words have become less complete, as well as quite varied from the classical translations. With more and more medical students taking an oath, the content actually has been simultaneously thinned. Certainly, the part addressed to faith in the Greek deities, in whom the ancient physicians believed, does not exactly apply for different locations and religions. It does honor the history of medicine and the bond with principles of the selfless tradition of healing. Now the act of saying the oath with peers has been viewed as a process of getting the diploma from medical school rather than a devoted allegiance to the purpose of medical education, namely, the best care of each patient by a competent physician. A true physician focuses his or her care of each patient not only on the use of skilful and current techniques but also on the recognition of the unique needs and welfare of the patient. This professional devotion of the compassionate physician to the patient may be eroded as the concept of the oath faces challenges from the increasing demands and restrictions by corporate entities. The years of education and training lead to the agreement with a code of ethics in medicine that emphasizes behavior to earn the trust of patients. Some of the burnout of physicians may indicate the loss of autonomy and the need to free physicians to return to the core content of the oath, i.e., to uphold the highest standards of care for the safety and health of each patient.
As per guidelines of MCI, Every member should get it framed in his or her office it should never be violated in its letter and spirit.
"I solemnly pledge myself to consecrate my life to service of humanity.
Even under threat, I will not use my medical knowledge contrary to the laws of Humanity.
I will maintain the utmost respect for human life from the time of conception.
I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient.
I will practice my profession with conscience and dignity.
The health of my patient will be my first consideration.
I will respect the secrets which are confined in me.
I will give to my teachers the respect and gratitude which is their due.
I will maintain by all means in my power, the honour and noble traditions of medical profession.
I will treat my colleagues with all respect and dignity.
I shall abide by the code of medical ethics as enunciated in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002.
I make these promises solemnly, freely and upon my honour."
Whether this oath has been complied with properly by the doctor. We know that the human body is a very complex body. The doctor spent years to study the course of MBBS/MD/MS and any other specialised fields . Despite of all the facts they should be cautious during treatment of a patient because it is the patient who paid them for their livelihood. It is the utmost and noble duty of a doctor to adhere with the oath taken by him.
Hippocrates is considered to be the father of medicine. Before being taught medicine, his disciples were made to swear an oath to the Gods of healing of Greek pantheon: Apollo, Asclepius, Hygeia, and Panacea. This was to help them understand the gravity of their situation and what is expected from their conduct as healers. The oath has been in existence from 400 BC. Hippocrates was a philosopher as much as a physician. He considered healing to be a scientific art. The oath sets the standards of conduct at a time when healers were considered near divine and no laws or litigations existed. The oath became universal only toward the early 19th century. Before that, different cultures had their own oaths. In India, Charaka Samhita had a physician oath. In it, physicians can refuse to treat people who were not favored by the king. This shows that oaths were a product of the sociocultural factors of the times they were created. It seems difficult to follow the same oath without keeping in touch with changing times.
OATH VS BIOETHICS If the Hippocratic oath is seen through the prism of changing times, swearing to ancient Greek Gods seems a little redundant in this multiethnic, multicultural, and pluralistic world. In the time of Hippocrates, women were not allowed to become physicians. It has long since been a matter of contention for many female physicians to take an oath which was meant exclusively for male physicians. Medical education was just imparted to a few selected disciples, free of cost, in that time. This seems impossible in modern times, where the government may not be able to continue medical education for thousands of graduates without even a nominal fee structure. While the oath prohibits abortion and euthanasia,[3] abortion up to 20 weeks is legal according to the Medical Termination of Pregnancy Act and euthanasia is legal in selected countries. The oath has not taken into consideration the vegetative states, unnecessary suffering, pain, and the rights of the patients to live with dignity. These issues probably were nonexistent in ancient Greece. These issues show that the original oath has a limited role in modern sociocultural and bioethical complexities.
The oath asks the physician to treat the patient according to his best ability and judgment. It gives utmost importance to beneficence. Patient autonomy and justice, which are now considered the cornerstones of bioethical principles, have not been discussed in the oath. This renders the oath paternalistic. In the modern history, particularly in the Nazi era, scientists of the Schutzstaffel conducted experiments without informed consent. These doctors acted "according to the best of their ability and judgement." This led to a review of the oath following Second World War during the Nuremberg Trial, and new ethical principles for research, called the Nuremberg code, were proposed, as the court recognized the limitations of the Hippocratic oath in the modern era bioethics.
When the oath was formulated, there existed only a tripartite relationship in medicine: between the patient, physician, and illness. This harmony was disrupted by the advent of health insurance, malpractice issues, technology, and pharmaceutical companies.[6] The recent increase in government regulation, the proliferation of the third-payer system, and the democratization of medical knowledge all place pressures on physicians that are new to the last 40 years; their ethical implications are not satisfactorily addressed by the modern Hippocratic oath. Doctors may not be able to prescribe the best possible treatment for their patients due to economic restraints. Universal healthcare coverage is a state responsibility only in a few developed countries. The intrusion of health insurance providers and corporate hospitals affect the physician treatment paradigm, thus affecting the physicians' autonomy in treatment.
The treatment strategy is also affected by patients' choices. Due to the advent of Google and the availability of medical research articles in the public forum on the Internet, the patient has become a voracious consumer of medical data. Patients consult doctors with semi-literate opinions regarding diagnosis and treatment options. The physician has to act accordingly, keeping not only beneficence in mind but also patient autonomy or risk of suffering legal consequences.
Physicians are no more healers, and healing is no longer an art, but it is just a service rendered. Medicine, a once noble and holy profession, has been defined as "services rendered" under the Consumer Protection Act. Physicians are vulnerable to multiple civil litigations. The image of the Hippocratic gentleman is no more and has been replaced by that of a harassed general practitioner.
The oath is also seen to promote physician burnout. A recent survey showed that at least one-third of the physicians polled (i.e., 34% of 2600 doctors), agreed that the oath promotes burnout. The oath, which advocates putting patients' interests first, always leads to a denial of personal and professional limitations.
When its relevance in modern psychiatry is assessed, the oath seems to be in conflict with the existing laws. The oath assures blanket confidentiality. In the case of child sexual abuse, where the child and the family do not want to divulge information, if the psychiatrists follow the letter of the oath and keep it a secret, they would find themselves at the risk of being imprisoned. According to the Protection of Children against Sexual Offences Act, information regarding child sexual abuse should be immediately informed to respective authorities, and withholding such information may result in fine and imprisonment up to 6 months. Administering covert medication, keeping in mind the patient's beneficence, might assuage the doctor's conscience but leaves him/her vulnerable to litigations. It is considered overriding patient's autonomy and is against the new Mental Healthcare Act. The doctor might agree to provide teleconsultations for minor issues, keeping in mind the patient's beneficence. This might be moral and ethical, but the law advocates against it.
The debate regarding the relevance of the oath, and whether to follow the oath or the law, is nothing new. Its relevance in modern medicine has long since been a topic of debate, with many arguments for both sides. In 1973, the US Supreme Court rejected the oath as a guide to medical ethics and practice by stating that the oath is incapable of covering the latest developments and methods of medical practice and research. Veatch, a prominent ethicist, claimed that the oath promotes traditional paternalistic values. Despite this, studies have shown that 62 of 122 medical schools in the United States administered the Hippocratic oath or a modified version of it. Several countries have come up with their own version of the oath suitable to their cultural needs. The Hippocrates oath is used out of context by lay people and mass media to emphasise that "patients interests are above everything else to a doctor".
The oath is not legally binding. It is more of an ethical signpost. However when doctors were protesting violence against doctors, the high court reprimanded the doctors that they were neglecting their duties which was akin to criminal negligence, quoting the Hippocrates oath in its judgement. It is probably this level of importance and universality which confuses young physicians, about to take critical decisions, on whether to uphold the oath or the law.
CONCLUSION In regard to ethics and morals, Karl Menninger said: "When in doubt, be human." But, when facts change, our opinions should change. In this era of litigations, it is best to remember: "When in doubt, be rational and follow the law." Ethical violations may incur minor punishments or fees, but violating the law will lead to imprisonment and an indelible mark on our careers. People who choose medicine usually have a strong sense of ethics and a higher purpose. Very few people take medicine to earn money. For medical students who arrive at the college with a strong sense of ethical values, the oath is redundant. For those who lack these values, the oath is just an exercise in hypocrisy.
There is no arguing the fact that Hippocratic oath embodies the principles of beneficence, gratitude, confidentiality, and humility. In a recent study, 59% of the physicians polled said that the oath was very meaningful to them. It imbued in them a sense of brotherhood, gratitude, and pride about their chosen profession. This does not alter the fact that the oath lacks the nuances of modern bioethics and is in direct contradiction of the existing laws at times. It is certainly difficult to give up on an idea which has been acculturated into the branch of medicine for nearly 2000 years. But, nothing is permanent except change. Hence, it is time the medical fraternity took stock of the situation. Medicine will never give up on the spirit of the oath. No physician is suddenly going to care less about a patient's benefit because they are no longer taking an oath. Physicians should keep in mind that any oath needs constant review and re-evaluation keeping with the constant changes of the society. We should acknowledge that upholding the oath does not protect us from any legal difficulties. We should follow the existing laws until laws and ethics are no longer at loggerheads with each other.
You have taken oath before entering into this noble profession but nowadays nobody cares this Hippocratic oath taken by him. We have to see from the following case laws regarding negligence done by a doctor and the his act comes under negligence or not.
The complexity of the human body and the uncertainty involved in the medical procedure are of such great magnitude that it is impossible for a Doctor to guarantee a successful result; and the only assurance that he can give, or can be understood to have given by implication is that he is possessed of requisite skill in that branch of profession which he is practising and while undertaking the performance of the task entrusted to him, he would be exercising his skills with reasonable competence. An ordinary physician or surgeon is not expected to be either a clodhopper or feckless practitioner of profession, as much as, he is not expected to be a paragon, combining qualities of polymath or prophet as in the realm of diagnosis and treatment, there is ample scope for genuine difference of opinion; and a Doctor cannot be treated as negligent merely because his conclusion differs from that of other persons in the profession, or because he has displayed less skill or knowledge than others would have shown. The true test for establishing negligence in diagnosis or treatment on the part of a doctor is whether he has been proved to be guilty of such failure as no doctor of ordinary skill would be guilty of, if acting with ordinary care. Furthermore, a golden principle of law has been laid down by the Hon'ble Apex Court in Jacob Mathew Vs. State of Punjab, (AIR 2005 SC 3180) that no sensible professional would intentionally commit an act or omission which would result in loss or injury to the patient as the professional reputation of the person is at stake. A single failure may cost him dear in his career. Even in civil jurisdiction, the rule of res ipsa loquitor is not an universal application and has to be applied with extreme care and caution to the cases of professional negligence and in particular that of the doctors, else it would be counter productive. Simply because a patient has not favourably responded to a treatment given by a physician or a surgery has failed, the doctor cannot be held liable per-se by applying the doctrine of res ipsa loquitor. Yet, another golden principle of law has been laid down by the Hon'ble Apex Court in Indian Medical Association Vs. V.P. Santha's III (1995) CPJ 1 (SC) at para 37 that "it is no doubt true that sometimes complicated questions requiring recording of evidence of experts may arise in a complaint about deficiency in service based on the ground of negligence in rendering medical services by a medical practitioner; but this would not be so in all complaints about deficiency rendering services by a medical practitioner. There may be cases which do not raise such complicated questions and the deficiency in service may be due to obvious faults which can be easily established such as removal of the wrong limb or the performance of an operation on the wrong patient or giving injection of a drug to which the patient is allergic without looking into the out patient card containing the warning or use of wrong gas during the course of an anaesthetic or leaving inside the patient swabs or other items of operating equipment after surgery. Furthermore, it has been observed in Malay Kumar Ganguli's case (AIR 2010 SC 1162) that "charge of professional negligence on a medical person is a serious one as it affects his professional statusand reputation and as such, the burden of proof would be more onerous. A doctor cannot be held negligent only because something has gone wrong. He also cannot be held liable for mischance or misadventure or for an error in judgment in making a choice when two options are available. The mistake in diagnosis is not necessarily a negligent diagnosis." In the instant matter, thus a simple test, in the light of aforesaid observations, needs to be conducted in order to ascertain whether the Doctor is guilty of any tortious act of negligence/battery amounting to deficiency in conducting a surgery in the delivery of child and not properly attending the patient, the complainant and consequently, liable to pay damages for leaving cotton mass in the abdomen / stomach due to failure in surgery and deteriorating condition of the patient.
Now, it is required to be seen whether an expert report is necessary in each and every case relating to medical negligence or not ? It has been observed by the Hon'ble Apex Court in Indian Medical Association Vs. V.P. Santha III (1995) CPJ 1 (SC) at para 37 that "it is no doubt true that sometimes complicated questions requiring recording of evidence of experts may arise in a complaint about deficiency in service based on the ground of negligence in rendering medical services by a medical practitioner; but this would not be so in all complaints about deficiency rendering services by a medical practitioner. There may be cases which do not raise such complicated questions and the deficiency in service may be due to obvious faults which can be easily established such as removal of the wrong limb or the performance of an operation on the wrong patient or giving injection of a drug to which the patient is allergic without looking into the out patient card containing the warning or use of wrong gas during the course of an anaesthetic or leaving inside the patient swabs or other items of operating equipment after surgery. Furthermore, in B. Krishna Rao Vs. Nikhil Super Speciality Hospital 2010 (V) SCC 513 at para 40 the Hon'ble Apex Court was pleased to hold that it is not necessary to have opinion of the expert in each and every case of medical negligence. The Hon'ble Apex Court was pleased to further hold in Nizam Institute of Medical Sciences Vs. Prashant S. Dhananka and others 2009 (VI) SCC 1 that "in a case of medical negligence, once initial burden has been discharged by the complainant by making of a case of negligence on the part of the hospital or the doctor concerned, the owner then shifts on the hospital or to the attending doctors and it is for the hospital to satisfy the court that there was no lack of care or diligence".
A doctrine or rule of evidence in tort law that permits an inference or presumption that a defendant was negligent in an accident injuring the plaintiff on the basis of circumstantial evidence if the accident was of a kind that does not ordinarily occur in the absence of negligencea plaintiff who establishes the elements of res ipsa loquitur can withstand a motion for summary judgment and reach the jury without direct proof of negligence-- Cox v. May Dept. Store Co., 903 P.2d 1119 (1995).
In Byrne vs Boadle, this maxim was used for the first time where the complainant was injured by a barrel that dropped from the window of the defendant. In the abovementioned case, Pollock, C. B., said "here are many incidents from which no presumption of negligence can arise, but this is not true in every case. It is the duty of persons who keep barrels in a warehouse to take care that they do not roll out and I think that such a case will, beyond all doubt, afford prima facie proof of negligence."
This doctrine intends to help direct the court proceedings to a conclusion, especially if it is established through the implication of this doctrine's rule that the injury caused to the claimant would not have occurred or taken place if the defendant wasn't negligent. This also gives enough cause and evidence to hold the defendant liable for his negligent actions.
Res ipsa loquitur is a Latin phrase that translates to "the thing that speaks for itself". In personal injury law, this concept arises when the very occurrence of an accident suggests that someone was at fault, even if there's no direct evidence pointing to the defendant's negligence.
Trying to understand personal injury law can be a tall order. Whether it's a car accident, medical malpractice, or premises liability matter, each personal injury case is intertwined with complex legal terms, doctrines, and rules of evidence.
This article discusses the origins and use of the res ipsa loquitur doctrine, as well as the doctrine's elements. It also addresses the implications of the doctrine for personal injury claimants. Finally, it offers examples of the doctrine of res ipsa loquitur.
Origins and Use The doctrine of res ipsa loquitur can be traced back to a case involving a barrel of flour. The barrel, without any explanation, fell out of a window and injured a passerby below.
Common sense dictates that barrels don't just fall without negligence. Res ipsa loquitur evolved from such cases. The doctrine emphasizes that sometimes circumstantial evidence can be powerful enough to shift the burden of proof.
The thing speaks for itselfis the gist of the maxim Res Ipsa Loquitur Maxim. What are the essentials of this maxim.
The injury caused to the plaintiff shall be a result of an act of negligence.
There is a lack of evidence, or the evidence presented before the court is insufficient to establish the possibilities of the fault of the plaintiff or third party.
The defendant owes a duty of care towards the plaintiff, which he has breached.
There is a significant degree of injury caused to the plaintiff.
Applicability of Doctrine of Res Ipsa Loquitur.
The maxim of res ipsa loquitur came into force to benefit the plaintiff as he can use circumstantial evidence to establish negligence.
Consequently, it shifts the burden of proof on the defendant, logic being, where there is an event of unexplained cause, usually, the one that does not occur without the defendant's negligence in controlling the action which has caused the injury to the claimant or destroyed his goods.
In this scenario, the court shall presume negligence on the part of the defendant in such a case unless it includes an appropriate explanation compatible with his taking reasonable care.
In Achutrao Haribhau Khodwa and Others vs. State of Maharashtra and Others, it was considered that the maxim should not be applied in the case of general incidences of neglect and shall only be reflected when there is a significant degree of injury caused.
Section 106 of the Indian Evidence Act Section 106 of the Act provides that when any fact is especially within the knowledge of any person, the burden of proving that fact is upon him.
Res ipsa loquitur is a Latin phrase that means "the thing speaks for itself." In personal injury law, the concept of res ipsa loquitur (or just "res ipsa" for short) operates as an evidentiary rule that allows plaintiffs to establish a rebuttable presumption of negligence on the part of the defendant through the use of circumstantial evidence.
This means that while plaintiffs typically have to prove that the defendant acted with a negligent state of mind, through res ipsa loquitur, if the plaintiff puts forth certain circumstantial facts, it becomes the defendant's burden to prove he or she was not negligent.
Res Ipsa Loquitur and Evidence Law Accidents happen all the time, and the mere fact that an accident has occurred doesn't necessarily mean that someone's negligence caused it. In order to prove negligence in a personal injury lawsuit, a plaintiff must present evidence to demonstrate that the defendant's negligence resulted in the plaintiff's injury. Sometimes, direct evidence of the defendant's negligence doesn't exist, but plaintiffs can still use circumstantial evidence in order to establish negligence.
Circumstantial evidence consists of facts that point to negligence as a logical conclusion rather than demonstrating it outright. This allows judges and juries to infer negligence based on the totality of the circumstances and the shared knowledge that arises out of human experience. Res ipsa is one type of circumstantial evidence that allows a reasonable fact finder to determine that the defendant's negligence caused an unusual event that subsequently caused injury to the plaintiff.
This doctrine arose out of a case where the plaintiff suffered injuries from a falling barrel of flour while walking by a warehouse. At the trial, the plaintiff's attorney argued that the facts spoke for themselves and demonstrated the warehouse's negligence since no other explanation could account for the cause of the plaintiff's injuries.
As it has developed since then, res ipsa allows judges and juries to apply common sense to a situation in order to determine whether or not the defendant acted negligently.
Since the laws of personal injury and evidence are determined at the state level, the law regarding res ipsa loquitur varies slightly between states. That said, a general consensus has emerged, and most states follow one basic formulation of res ipsa.
Under this model for res ipsa, there are three requirements that the plaintiff must meet before a jury can infer that the defendant's negligence caused the harm in question:
The event doesn't normally occur unless someone has acted negligently;
The evidence rules out the possibility that the actions of the plaintiff or a third party caused the injury; and The type of negligence in question falls with the scope of the defendant's duty to the plaintiff.
As mentioned above, not all accidents occur because of someone else's negligence. Some accidents, on the other hand, almost never occur unless someone has acted negligently.
Going back to the old case of the falling flour-barrel, it's a piece of shared human knowledge that things don't generally fall out of warehouse windows unless someone hasn't taken care to block the window or hasn't ensured that items on the warehouse floor are properly stored. When something does fall out of a warehouse window, the law will assume that it happened because someone was negligent. The second component of a res ipsa case hinges on whether the defendant carries sole responsibility for the injury. If the plaintiff can't prove by a preponderance of the evidence that the defendant's negligence cause the injury, then they will not be able to recover under res ipsa.
States sometimes examine whether the defendant had exclusive control over the specific instrumentality that caused the accident in order to determine if the defendant's negligence caused the injury. For example, if a surgeon leaves a sponge inside the body of a patient, a jury can infer that the surgeon's negligence caused the injury since he had exclusive control over the sponges during the operation.
In addition to the first two elements, the defendant must also owe a duty of care to protect the plaintiff from the type of injury at issue in the suit. If the defendant does not have such a duty, or if the type of injury doesn't fall within the scope of that duty, then there is no liability.
For example, in many states, landowners don't owe trespassers any duty to protect them against certain types of dangers on their property. Thus, even if a trespasser suffers an injury that was caused by the defendant's action or inaction and that wouldn't normally occur in the absence of negligence, res ipsa loquitur won't establish negligence since the landowner never had any responsibility to prevent injury to the trespasser in the first place.
Res ipsa only allows plaintiffs to establish the inference of the defendant's negligence, not to prove the negligence completely. Defendants can still rebut the presumption of negligence that res ipsa creates by refuting one of the elements listed above.
For example, the defendant could prove by a preponderance of the evidence that the injury could occur even if reasonable care took place to prevent it. An earthquake could shake an item loose and it could fall out of the warehouse window, for instance.
A defendant could also demonstrate that the plaintiff's own negligence contributed to the injury. To go back to the flour-barrel example, if the defendant shows that the plaintiff was standing in an area marked as dangerous it could rebut the presumption of negligence created by res ipsa.
Finally, the defendant could establish that he did not owe the plaintiff a duty of care under the law, or that the injury did not fall within the scope of the duty owed. For example, if the law only imposes a limited duty on the defendant not to behave recklessly, then res ipsa will not help the plaintiff by creating an inference of negligence since a negligent action would not violate the duty owed to the plaintiff.
According to the Blacks Law Dictionary the maxim is defined as the doctrine providing that, in some circumstances, the mere fact of accidents occurrence raises an inference of negligence so as to establish a prima facie (at first sight) case. It is a symbol for that rule that the fact of the occurrence of an injury taken with the surrounding circumstances may permit an inference or recipes omission of negligence, or make out a plaintiff's prima facie case and present a question of fact for defendant to meet with and explanation. It is merely a short way of saying that the circumstances attendant on the accident are of such a nature to justify a jury in light of common sense and past experience in inferring that the accident was probably the result of the defendant's negligence, in the absence of explanation or other evidence which the jury believes.
Its use in clinical negligence gained some traction before Bolam and Bolitho. Mahon v Osborne [1939] 1 All ER 535, is an early example of the application of res ipsa loquitur in a case where a surgical swab had been left inside a patient's body.
In Clarke v Worboys (1952) Times, 18 March, CA, a patient noticed burns on her buttock shortly after surgical excision of a breast tumour. The surgery involved cauterisation. The Court of Appeal held that this was a case where res ipsa loquitur applied. The outcome was not one that would ordinarily occur in the absence of negligence, and the surgical team were unable to explain how the injury was caused.
In Cassidy v Ministry of Health [1951] 2 KB 343, Denning LJ succinctly summarised the maxim's application to clinical negligence cases: "I went into hospital to be cured of two stiff fingers. I have come out with four stiff fingers and my hand is useless. That should not happen if due care had been used. Explain it if you can."
Ng Chun Pui Vs Lee Chuen Tat, the first defendant was driving a coach owned by the second defendant westwards in the outer lane of dual carriageway in Hong Kong. Suddenly the course across the central reservation and collided with a public bus travelling in the inner lane of the other carriageway, killing one passenger in the bus and injuring the driver and three others on the bus. The plaintiff could not prove that the defendants were negligent and had caused the accident. They however proceeded on the basis of Res Ipsa Loquitur and shifted the onus on the defendants to prove that they were not negligent. However, they failed to do so. And the judicial committee of the Privy Council held the defendants liable for the plaintiffs injuries. { MarkLuney and Ken Opliphant, Tort Law Text And Materials (Oxford University Press, New York, 2000) pp 173-175 } In A.S. Mittal & Anr. Vs. State Of UP & Ors., AIR 1979 SC 1570, the defendants had organised an eye camp at Khurja along with the Lions Club. 88 low risk cataract operations were undertaken during the period of the camp. It was however, disastrous as many of those who had been operated upon lost their eyesight due to post medical treatment. Proceedings against the government initiated for negligence of the doctors. Damages worth Rs.12,500/- were paid as interim belief to each of the aggrieved. The decision was on the basis of Res Ipsa Loquitur as the injury would not ave occurred had the doctors not been negligent in not having followed up with post-operation treatment. Res Ipsa Loquitur can be applied in matters where are the procedures have not been followed and is not just limited to the commission of an act.
We can define 'Medical negligence' as the improper or unskilled treatment of a patient by a medical practitioner. This includes negligence in taking care from a nurse, physician, surgeon, pharmacist, or any other medical practitioner. Medical negligenceleads to 'Medical malpractices' where the victims suffer some sort of injury from the treatment given by a doctor or any other medical practitioner or health care professional.
Medical negligence can occur in different ways. Generally, it occurs when a medical professional deviates from the standard of care that is required.
So, we can say that any kind of deviation from the accepted standards of medication and care is considered to be medical negligence and if it causes injury to a patient then the doctor who operated on him, other staff and/or hospital may be held liable for this.
Some of the common categories of medical negligence are as follows:
Wrong diagnosis - When someone goes to a hospital, clinic or medical room, etc. the first step after admittance is the diagnosis. Diagnosing symptoms correctly is critical and important to provide medical care to any patient. However, if a patient is not treated properly due to any mistake in diagnosis, the doctor can be made liable for any further injury or damages caused as a result of the wrong diagnosis.
Delay in diagnosis - A delayed diagnosis is treated as medical negligence if another doctor would have reasonably diagnosed the same condition in a timely fashion. A delay in diagnosis can cause undue injury to the patient if the illness or injury is left to worsen with time rather than being treated. Obviously, any delay in the identification and treatment of an injury can reduce the chance of recovery for the patient.
Error in surgery - Surgical operations require an enormous level of skill and it should be done with due care and caution because even the slightest mistakes can have profound effects on the patient. The wrong-site surgery, lacerations of any internal organ, severe blood loss, or a foreign object being left in the body of the patients, all this comes under Surgical error.
Unnecessary surgery - Unnecessary surgery is usually associated with the misdiagnosis of patient symptoms or a medical decision without proper consideration of other options or risks. Alternatively, sometimes surgery is chosen over conventional treatments for their expediency and ease compared to other alternatives.
Errors in the administration of anesthesia - Anesthesia is a risky part of any major medical operation and requires a specialist (anesthesiologist) to administer and monitor its effect on the patient. Prior to any medical procedure requiring anesthesia, the anesthesiologist has to review the patient's condition, history, medications, etc. to determine the most suitable of all the medicine to use. Anesthesia malpractice can happen even during the pre-operation medical review or during the procedure itself.
Childbirth and labor malpractice - Childbirth is a difficult event for a woman and it becomes worse if not handled properly by the doctors and nurses. There are many instances of medical negligence during childbirth including the mishandling of a difficult birth, complications with induced labor, misdiagnosis of a newborn medical condition, etc. Long-Term negligent treatment - Medical negligence can also occur in subtle ways over the course of a long treatment period. Usually, the negligence can take the shape of a failure to follow up with treatment, or a doctor's failure to monitor the effects of the treatment properly.
A standard of care specifies the appropriate treatment and medication procedure as per the requirements that should be taken into account by a doctor while providing the treatment to his patients. The care should not be of the highest degree nor the lowest.Here, the degree means the level of care an ordinary health care professional, with the same training and experience, would render in similar circumstances in the same community. This is the critical question in medical malpractice cases and if the answer is "no," and you suffered injury as a result of the poor treatment, you may file a suit for medical malpractice.
In the case of Dr. Laxman Balkrishna Joshi Vs. Dr. TrimbakBapu Godbole and Anr.[ 1969 AIR 128], the Supreme Court held that a doctor has certain aforesaid duties and a breach of any of those duties can make him liable for medical negligence. A doctor is required to exercise a reasonable degree of care that is set for this profession.
Dr. Kunal Saha vs Dr. Sukumar Mukherjee on 21 October, 2011 ( NC) original petition number 240 OF 1999 is one of the most important case regarding medical negligence. The brief facts of the case are-
Toxic Epidermal Necrolysis ( TEN ) is a rare and deadly disease. It is an extoliative dermatological disorder of unknown cause. A patient with TEN loses epidermis in sheet-like fashion leaving extensive areas or denuded dermis that must be treated like a larze, superficial, partial-thickness burn wound. The incidence of TEN has been reported at 1 to 1.3 per million per year. The female-male ratio is 3:2. TEN accounts for nearly 1% of drug reactions that require hospitalization. TEN has a mortality rate of 25 to 70%.
Smt. Anuradha Saha (in short Anuradha), aged about 36 years wife of Dr. Kunal Saha (complainant) became the unfortunate victim of TEN when she alongwith the complainant was in India for a holiday during April-May 1998. She and the complainant although of Indian original were settled in the United States of America. The complainant is a doctor by profession and was engaged in research on HIV / AIDS for the past fifteen years. Anuradha after acquiring her Graduation and Masters Degree was pursuing a Ph.D. programme in a university of U.S.A. She was a Child Psychologist by profession. Anuradha showed certain symptoms of rashes over her body and received treatment at the hands of Opposite Parties and some other doctors as outdoor patient uptil 10.05.1998 and she was admitted in Advanced Medicare and Research Institute Limited, Calcutta (for short, AMRI), on 11.05.1998, where she was treated by the above-named Opposite Parties and other doctors uptil 16.05.1998. As there was no improvement in her condition, she was shifted to Breach Candy Hospital, Mumbai, on 17.05.1998 by an air ambulance. She was treated in Breach Candy Hospital from 17.05.1998 evening till she breathed her last on 28.05.1998.
Our Complainant as husband of Anuradha felt that the doctors who treated Anuradha and the hospitals where she was treated were grossly negligent in her treatment and her death was occasioned due to gross negligence of the treating doctors and hospitals. Complainant, accordingly, got issued a legal notice to as many as 26 persons i.e. various doctors who treated Anuradha between end of April to the date of her death alleging negligence and deficiency in service on their part and claiming a total compensation exceeding Rs.55 crores from them. Complainant, thereafter filed the present complaint on 09.03.1999 before this Commission claiming a total compensation of Rs. Rs.77,07,45,000/- ( Seventy Seven Crores Seven Lakhs Fourty Five Thousand only). Later he also filed another complaint no. 179 of 2000 in this Commission against Breach Candy Hospital, its doctors and functionaries claiming a further compensation of Rs.25.30 crore ( though the said complaint was later on withdrawn), thereby making claim of compensation exceeding Rs.102 crores, perhaps the highest ever claimed by any complainant for medical negligence before any consumer fora established under the provisions of Consumer Protection Act, 1986 ( in short, the Act). These are some of the facts which make the present case extra ordinary.
The present complaint was filed by the complainant against the above-named opposite parties, namely, Dr. Sukumar Mukherjee, Dr. B. Haldar (Baidyanath Halder), Advanced Medicare and Research Institute Limited ( in short the AMRI Hospital ) and Dr. Balram Prasad and Dr.Abani Roy Chowdhury (physician) and Dr.KaushikNandy (plastic surgeon), the Directors of the AMRI Hospital and others claiming a total compensation of Rs. Rs.77,07,45,000/- under different heads alleging various acts of commission and omission on the part of the doctors and hospital amounting to negligence and deficiency in service. Complainant through his brother-in-law Malay Kumar Ganguly also filed criminal complaint against some of the doctors and the hospital under section 304A IPC.
The complaint was resisted by the doctors and the hospital on a variety of grounds thereby denying any medical negligence or deficiency in service on their part. Parties led voluminous documentary and oral evidence and testimonies of some of the witness were even recorded through video conferencing through a Local Commissioner. After a protracted trial and hearing and on consideration of the evidence and material so produced on record and taking note of the legal position governing the question of medical negligence, this Commission ( by a three Member Bench presided over by the then President) dismissed the complaint by an order dated 01.06.2006 holding as under:
In the result, we reiterate that Doctors or Surgeons do not undertake that they will positively cure a patient. There may be occasions beyond the control of the medical practitioner to cure the patients. From the record, it would be difficult to arrive at the conclusion that the injection Depo-Medrol prescribed by Dr. Mukherjee was of such excessive dose that it would amount to deficiency in service by him which was his clinical assessment.
Thereafter, with regard to the alleged deficiency in the treatment given to Mrs. Anuradha by Opposite Party Doctors 2, 3, 5 and 6, there is no substance. The contention against the hospital that it was not having Burns-Ward, and therefore, the deceased suffered is also without substance. Hence, this complaint is dismissed. There shall be no order as to costs.
Aggrieved by the dismissal of his complaint, the complainant filed Civil Appeal (No.1727 of 2007) in the Honble Supreme Court. It would appear that even before the said appeal was filed before the Hon'ble Supreme Court, the Supreme Court was seized of the matter in Criminal Appeal Nos.1191-94 of 2005 filed by Malay Kumar Ganguly, the complainant in the criminal complaint, against the Orders passed by the Calcutta High Court. Since the Criminal Appeals and the Civil Appeal filed by the complainant in the present complaint raised the same questions of fact and law, the Hon'ble Supreme Court heard all the appeals together and decided the same by means of a detailed judgment dated 07.8.2009. By the said order, the Apex Court dismissed the Criminal Appeals filed by Shri Malay Kumar Ganguly but allowed the Civil Appeal No. 1727 of 2007 filed by the complainant and set aside the order dated 01.6.2006 passed by this Commission dismissing the complaint and remanded the matter to this Commission for the limited purpose of determining the adequate compensation, which the complainant is entitled to receive from the subsisting opposite parties by observing as under:
So far as the judgment of the Commission is concerned, it was clearly wrong in opining that there was no negligence on the part of the Hospital or the doctors. We, are, however, of the opinion, keeping in view the fact that Dr. Kaushik Nandy has done whatever was possible to be done and his line of treatment meets with the treatment protocol of one of the experts viz.. Prof. Jean Claude Roujeau although there may be otherwise difference of opinion, that he cannot be held to be guilty of negligence.
We remit the case back to the Commission only for the purpose of determination of the quantum of compensation. We, keeping in view the stand taken and conduct of AMRI and Dr. Mukherjee, direct that costs of Rs.5,00,000 and Rs.1,00,000 would be payable by AMRI and Dr. Mukherjee respectively.
We further direct that if any foreign experts are to be examined it shall be done only through video conferencing and at the cost of the respondents.
Summary In view of the foregoing discussion, we conclude as under:
The facts of this case viz., residence of the complainant and Anuradha (deceased) in USA and they working for gain in that country; Anuradha having been a victim of a rare and deadly disease Toxic Epidermal Necrolysis (TEN) when she was in India during April-May 1998 and could not be cured of the said disease despite her treatment at two superspeciality medical centres of Kolkata and Mumbai and the huge claim of compensation exceeding Rs.77 crores made by the complainant for the medical negligence in the treatment of Anuradha makes the present case somewhat extraordinary.
The findings given and observations made by the Supreme Court in its judgment dated 07.08.2009 are absolutely binding on this Commission not only as ratio decidendi but also as obiter dicta also, the judgment having been rendered by the Supreme Court in appeal against the earlier order passed by a three Member Bench of this Commission and, therefore, no attempt can be allowed to read down / dilute the findings and observations made by the Supreme Court because the Supreme Court has remitted the complaint to this Commission only for the purpose of determination of the quantum of compensation after recording the finding of medical negligence against the opposite parties and others.
The task entrusted to the Commission may appear to be simple but the facts of the present case and the voluminous evidence led on behalf of the complainant has made it somewhat arduous. Still difficult was the task of apprortionment of the liability to pay the awarded amount by the different opposite parties and perhaps it was for this reason that the Supreme Court has remitted the matter to this Commission.
Multiplier method provided under the Motor Vehicles Act for calculating the compensation is the only proper and scientific method for determination of compensation even in the cases where death of the patient has been occasioned due to medical negligence / deficiency in service in the treatment of the patient, as there is no difference in legal theory between a patient dying through medical negligence and the victim dying in industrial or motor accident. The award of lumpsum compensation in cases of medical negligence has a great element of arbitrariness and subjectivity.
The foreign residence of the complainant or the patient and the income of the deceased patient in a foreign country are relevant factors but the compensation awarded by Indian Fora cannot be at par which are ordinarily granted by foreign courts in such cases. Socio economic conditions prevalent in this country and that of the opposite parties / defendants are relevant and must be taken into consideration so as to modulate the relief. A complainant cannot be allowed to get undue enrichment by making a fortune out of a misfortune. The theoretical opinion / assessment made by a Foreign Expert as to the future income of a person and situation prevalent in that country cannot form a sound basis for determination of future income of such person and the Commission has to work out the income of the deceased having regard to her last income and future prospects in terms of the criteria laid down by the Supreme Court.
There exists no straight jacket formula for apportionment of the awarded compensation amongst various doctors and hospitals when there are so many actors who are responsible for negligence and the apportionment has to be made by evolving a criteria / formula which is just going by the nature and extent of medical negligence and deficiency in service established on the part of different doctors and hospitals.
On a consideration of the entirety of the facts and circumstances, evidence and material brought on record, we hold that overall compensation on account of pecuniary and non pecuniary damages works out to Rs.1,72,87,500/- in the present case, out of which we must deduct 10% amount on account of the contributory negligence / interference of the complainant in the treatment of Anuradha. That will make the net payable amount of compensation to Rs.1,55,58,750/- (rounded of to Rs.1,55,60,000/-). From this amount, we must further deduct a sum of Rs.25,93,000/- which was payable by Dr. Abani Roy Chowdhury (deceased) or his Legal Representative as the complainant has forgone the claim against them.
In view of the peculiar facts and circumstances of the case and as a special case, we have awarded a sum of Rs. 5,00,000/- as cost of litigation in the present proceedings.
The above amount shall be paid by opposite parties no.1 to 4 to the complainant in the following manner:
(i) Dr. Sukumar Mukherjee-opposite party no.1 shall pay a sum of Rs.40,40,000/- (Rupees Forty Lakh Forty Thousand only) i.e. [Rs.38,90,000/- towards compensation and Rs.1,50,000/- as cost of litigation].
(ii) Dr. B. Haldar (Baidyanth Halder)-opposite party no.2 shall pay a sum of Rs.26,93,000/- (Rupees Twenty Six Lakh Ninety Three Thousand only) i.e. [Rs.25,93,000/- towards compensation and Rs.1,00,000/- as cost of litigation]
(iii) AMRI hospital-opposite party no.3 shall pay a sum of Rs.40,40,000/- (Rupees Forty Lakh Forty Thousand only ) i.e. [Rs.38,90,000/- towards compensation and Rs.1,50,000/- as cost of litigation .
(iv) Dr. Balram Prasad-opposite party no.4 shall pay a sum of Rs.26,93,000/- (Rupees Twenty Six Lakh Ninety Three Thousand only) i.e. [Rs.25,93,000/- towards compensation and Rs.1,00,000/- as cost of litigation] The opposite parties are directed to pay the aforesaid amounts to the complainant within a period of eight weeks from the date of this order, failing which the amount shall carry interest @ 12% p.a. w.e.f. the date of default."
Now we come to the present case. From the facts enumerated in the complaint or in the written statement it is clear that the son of the complainant aged nine years had some problem in his left little finger. The complainant consulted opposite party-2 who examined the complainant's son and wrote some tests which were done. After seeing the report the opposite party-2 told that everything is normal only there is swelling in the finger and it may be removed by a small surgery. The date was fixed by the doctor and as per advice of the opposite party-2 the complainant admitted his son in opposite party-1 on 01.06.2014. On the same day the complainant's son was operated upon in at 8:15 PM the family members met the child who was though normal but complaining pain in his finger. At about 8:30 PM a nurse came and administered two injections to the complainant's son and thereafter the complainant's son became silent. Whether operating the finger can cause death of a child?
According to the case it is clear that there is a middle felon of left little finger. We have to see the following article regarding infection of a finger.
Finger Infection Overview Injury or infection to a finger or fingers is a common problem. Infection can range from mild to potentially serious. Often, these infections start out small and are relatively easy to treat. Failure to properly treat these infections can result in permanent disability or loss of the finger.
Early recognition and proper treatment of the following main finger infections will help prevent most of the serious outcomes.
Paronychia: A paronychia is an infection of the finger that involves the tissue at the edges of the fingernail. This infection is usually superficial and localized to the soft tissue and skin around the fingernail. This is the most common bacterial infection seen in the hand.
Felon: A felon is an infection of the fingertip. This infection is located in the fingertip pad and soft tissue associated with it.
Herpetic whitlow: A herpetic whitlow is an infection of the fingertip area caused by a virus. This is the most common viral infection of the hand. This infection is often misdiagnosed as a paronychia or felon.
Herpetic whitlow is a painful infection of the fingertip area caused by the herpes virus. Small blisters form around the fleshy part of the fingertips. The condition is contagious and very common. It can be treated with antiviral medications but may come back.
Cellulitis: This is a superficial infection of the skin and underlying tissue. It is usually on the surface and does not involve deeper structures of the hand or finger.
Infectious flexor tenosynovitis: This infection involves the tendon sheaths responsible for flexing or closing the hand. This is also a type of deep space infection.
Deep space infection: This is an infection of one or several deep structures of the hand or fingers, including the tendons, blood vessels, and muscles. Infection may involve one or more of these structures. A collar button abscess is such an infection when it is located in the web space of the fingers.
Now as per note dated 01.06.2014 there is a matter over middle felona of left little finger.
Finger Infection Causes Bacteria cause most of these finger infections. The exception to this is the herpetic whitlow, which is caused by a virus. How the infection starts and is found in a particular location is what makes each specific type of infection unique. Usually some form of trauma is the initial event. This may be a cut, animal bite, or puncture wound.
Paronychia: The offending bacteria are usually staphylococcal and streptococcal organisms. Rarely, a fungus causes this infection, which usually begins as a hangnail. Often a person will attempt to bite off the piece of nail that is at the corner. This results in an open wound that allows the bacteria found on the skin and the bacteria found in the mouth to infect the wound. The infection can then spread to the surrounding tissue next to the nail and cuticle.
Felon: This bacterial infection of the finger pad, caused by the same organisms that cause paronychia, is usually the result of a puncture wound. The wound allows the introduction of bacteria deep into the fingertip pad. Because the fingertip has multiple compartments, the infection is contained in this area.
Herpetic whitlow: The offending viral organism is the herpes simplex virus type I or II. This is the same virus that causes oral or genital herpes infections. People in certain occupations are more at risk for this infection. These include dentists, hygienists, physicians, nurses, or any other person who may have contact with saliva or body fluids that contain the virus. People with oral or genital herpes may also infect their own fingers.
Cellulitis: The most common causes of this bacterial infection are staphylococcal and streptococcal organisms. This infection is usually the result of an open wound that allows the bacteria to infect the local skin and tissue. The infection can also spread to the hand and fingers by blood carrying the organisms.
Infectious flexor tenosynovitis: This bacterial infection is usually the result of penetrating trauma that introduces bacteria into the deep structures and tendon sheaths, which allows the spread along the tendon and associated sheath.
Deep space infection: This bacterial infection is usually the result of a puncture wound or deep cut that introduces the bacteria to the deep tissue. The collar button abscess is associated with the web space between the fingers. The deep structures of the hand create many potential compartments for an infection to invade.
The correct diagnosis will start with a detailed history and physical exam. People who have a localized infection will be treated differently than someone with a severe infection. Coexisting problems such as diabetes or blood vessel disorders of the arms and legs will complicate the infection and may change the degree of treatment.
Important information that your doctor will need to know will include the following:
How did the injury or infection start?
When did this first occur or begin?
Where did it occur? Home? Work? In water? In dirt? From an animal or human bite?
Is it possible that a foreign body is in the wound?
What have you done to care for this before seeing your doctor?
When was your last tetanus shot?
Any previous injuries to the area?
Any other medical problems that you may have not mentioned?
Specific information may help pinpoint the type of finger infection:
Paronychia: A history of nail biting may aid the diagnosis.
Felon: A history of a puncture wound or cut will aid the diagnosis. This would include a plant thorn. The doctor may obtain an x-ray to look for involvement of the bone or possible foreign body.
Herpetic whitlow: A history of contact with body fluids that may contain the herpes virus will aid the diagnosis. The diagnosis can often be made from the history and the appearance of the lesions. The presence of a clear fluid from the wounds may indicate a viral infection rather than a bacterial infection. A sample of the fluid may be analyzed by a Tzank smear, which will identify certain cells, indicating a viral cause.
Cellulitis: The doctor will need to consider other causes that may look similar such as gout, various rashes, insect sting, burns, or blood clot before the final diagnosis is made. An X-ray may be obtained to look for a foreign body or gas formation that would indicate a type of serious cellulitis.
Infectious flexor tenosynovitis: A history of a puncture wound or cut will aid the diagnosis. The presence of the 4 Kanavel cardinal signs is a strong diagnostic aid. A recent sexually transmitted disease may indicate a type of gonorrhea-related infection, which may resemble infectious flexor tenosynovitis.
Deep space infections: A history of puncture wound or other wound may aid the diagnosis. The finding of swelling between the fingers with a slow spreading of the involved fingers will help identify a collar button abscess.
Finger Infection Treatment - Self-Care at Home Because finger infections have the potential to become severe, home care is limited. A very minor paronychia may be managed at home if you have no other complicating medical illness, such as diabetes. All of the other infections require urgent evaluation and treatment by a doctor. Because delay in treatment may result in disability or loss of the finger, you should not hesitate to obtain medical care.
A small, simple paronychia may respond to frequent warm water soaks and elevation of the hand. However, if no improvement is noticed in 1-2 days, you should see your doctor at once.
Medical Treatment The mainstay of treatment for finger infections is antibiotics and proper wound care. This can range from a simple incision and drainage of the wound to an extensive surgical exploration of the wound to remove as much infected material as possible.
Some of the infections can be treated in a doctor's office or clinic, but several will require inpatient treatment and IV antibiotics. Because the organisms that cause these infections are similar, many of the same types of antibiotics may be used.
Paronychia: Often the wound may be treated with wound care alone. If a collection of pus is present, it will need to be drained. This may be done in several different ways. Commonly a scalpel is used to make a simple incision over the collection of pus to allow drainage. Or the scalpel may be inserted along the edge of the nail to allow drainage. If the infection is large, a part of the nail may be removed. If this procedure is required, the doctor will inject a local anesthetic at the base of the finger that will provide for a pain-free procedure. Most often, you will be placed on an oral antibiotic. You will then be instructed how to take care of the wound at home. (See paronychia.) Felon: Often, incision and drainage is required because the infection develops within the multiple compartments of the fingertip pad. Usually an incision will be made on one or both sides of the fingertip. The doctor will then insert an instrument into the wound and break up the compartments to aid in the drainage. Sometimes, a piece of rubber tubing or gauze will be placed into the wound to aid the initial drainage. The wound may also be flushed out with a sterile solution to remove as much debris as possible. These infections will require antibiotics. The wound will then require specific home care as prescribed by your doctor.
Herpetic whitlow: Antiviral drugs such as acyclovir (Zovirax) may shorten the duration of illness. Pain medication is often needed. The wound must be properly protected to prevent a secondary bacterial infection and to prevent you from infecting other sites on your body or other people. Incision and drainage is not proper and, if done, may actually delay healing.
Cellulitis: This infection is superficial, and oral antibiotics are usually sufficient. If the area is extensive or your immune system is weakened, then you may be treated in the hospital with IV antibiotics.
Infectious flexor tenosynovitis: This is a surgical emergency and will require rapid treatment, hospital admission, and early treatment with IV antibiotics. Usually, the area will need to be surgically opened and all debris and infected material removed. Because of the intricate nature of the fingers and hands, a hand surgeon will usually perform this procedure. After surgery, several days of IV antibiotics will be required followed by a course of oral antibiotics.
Deep space infections: Much like flexor infectious tenosynovitis, this can require emergency care. If the infection is mild, then only oral antibiotics may be needed. If more severe, a hand surgeon should evaluate the wound and IV antibiotics begun. Often these wounds will require incision and drainage followed by a course of antibiotics.
In the present case, as there was felon in the left little finger so Often, incision and drainage is required because the infection develops within the multiple compartments of the fingertip pad. Usually an incision will be made on one or both sides of the fingertip. Therefore we are unable to understand that in spite of giving antibiotics what was the need of giving Emeset. The most important thing is follow-up action. Whether the follow-up action by the staff was up to the mark or not. We do not find any genuine cause regarding death of the patient aged nine years. We would like to see the article on follow-up.
Next Steps - Follow-up You need to understand the doctor's instructions completely and ask any questions you have in order to thoroughly understand your care at home.
If you have been prescribed antibiotics for a finger infection, you must follow the directions and take them for the prescribed time period.
Often, your doctor will instruct you to keep your hand elevated to prevent swelling. This is important and needs to be done both during the day and night. By placing pillows next to you while sleeping, your hand can remain elevated.
Wound care will often need to be continued at home. This may include daily warm water soaks, dressing changes, and application of antibiotic ointment. The different types of wound care are extensive. Your doctor should explain in detail.
The finger or hand may be placed in a splint. This provides both immobilization and protection. It will be important to follow the instructions regarding the care of the splint. You will need to protect and properly care for the splint. You should closely monitor the finger or hand to watch for complications such as swelling or infection under the splint.
Often, you will be asked to return to the doctor's office in 24-48 hours. This may be necessary to remove packing or change a dressing. It is very important that you have close follow-up care to monitor the progress or identify any further problems.
Prevention Common sense safety practices will help prevent many of the finger wounds that become a problem. Simple things such as wearing protective work gloves may prevent injury. Wearing latex or vinyl gloves is mandatory if possible exposure to bodily fluids is expected. Avoid chewing on your nails, and wash your hands as needed. Seek early medical attention as soon as you think an infection is present.
So it is very clear that this infection was of not so much severe which can cause the death of the patient. After going through the above article, this infection can be treated very well without any risk but in this case we have seen that no detailed information has been given in the case sheet as to why it happened. It was duty of the treating doctor to tell under what circumstances it became fatal. Whether there was a reaction of the injection? Simply saying that it is a case of anaphylaxis does not exonerate the treating doctor. He was duty bound to show all the relevant stages under which it is caused because the operation was a simple minor operation. It shows the negligence of the doctor and paramedical staff that they cannot maintain the post-operative care of the patient and ultimately he passed away.
Committee on Patient Safety and Quality Improvement This document reflects emerging concepts on patient safety and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
ABSTRACT: Ensuring patient safety in the operating room begins before the patient enters the operative suite and includes attention to all applicable types of preventable medical errors (including, for example, medication errors), but surgical errors are unique to this environment. Steps to prevent wrong-site, wrong-person, wrong-procedure errors, or retained foreign objects have been recommended, starting with structured communication between the patient, the surgeon(s), and other members of the health care team. Prevention of surgical errors requires the attention of all personnel involved in the patient's care.
Potentially preventable surgical errors have received increasing attention in recent years, although they appear to occur relatively infrequently compared with other types of medical errors. The Joint Commission has collected data on reported sentinel events since 1995 with wrong-site surgery consistently ranked as the most frequently cited reason 1. In 2008, the year for which most recent data are available, there were 116 wrong-site surgery sentinel events reviewed. Although specialty specific statistics are not included on the Joint Commission's web site, no surgical specialty is immune from surgical errors 1. Classic examples in the specialty of obstetrics and gynecology include wrong procedures, such as tubal ligation without consent.
Terminology The term wrong-site surgery is used to refer to any surgical procedure performed on the wrong patient, wrong body part, wrong side of the body, or at the wrong level of the correctly identified anatomic site 2. The following terms can be used to describe the various specific errors:
Wrong-patient surgery describes a surgical procedure performed on a different patient than the one intended to receive the operation.
Wrong-side surgery indicates a surgical procedure performed on the wrong extremity or side of the patient's body (eg, the left ovary rather than the right ovary).
Wrong-level surgery and wrong-part surgery are used to indicate surgical procedures that are performed at the correct operative site, but at the wrong level or part of the operative field or patient's anatomy.
Systems Approach Particularly because of the potential for serious harm from surgical errors, vigorous efforts are required to eliminate or reduce their frequency. Preventing a surgical error appears to be amenable to a systems approach involving a team effort by all individuals participating in the surgical process. Although all members of the surgical team share this responsibility, the primary surgeon should oversee these efforts. The Joint Commission has identified the following factors that may contribute to an increased risk of wrong-site surgery:
Multiple surgeons involved in the case Multiple procedures during a single surgical visit Unusual time pressures to start or complete the procedure Unusual physical characteristics, including morbid obesity or physical deformity A common theme in cases of wrong-site surgery involves failed communication between the surgeon(s), the other members of the health care team, and the patient. Communication is crucial throughout the surgical process, particularly during the preoperative assessment of the patient and the procedures used to verify the operative site. Effective preoperative patient assessment includes a review of the medical record or imaging studies immediately before starting surgery. To facilitate this step, all relevant information sources, verified by a predetermined checklist, should be available in the operating room and rechecked by the entire surgical team before the operation begins. A briefing is important for assigning essential roles and establishing expectations. Introduction of each person in the operating room by name and role, even if team members are familiar, is recommended for improved communication. Whenever possible, the patient (or the patient's designee) should be involved in the process of identifying the correct surgical site, both during the informed consent process and in the physical act of marking the intended surgical site in the preoperative area. A formal procedure for final confirmation of the correct patient and surgical site (a "time out") that requires the participation of all members of the surgical team may be helpful. Time outs may include not only verification of the patient and the surgical site, but also relevant medical history, allergies, administration of appropriate preoperative antibiotics, and deep vein thrombosis prophylaxis.
Improving Patient Safety in the Surgical Environment The Universal Protocol In 2003, the Joint Commission published "Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery" 2. The universal protocol, now included in the chapter on national patient safety goals in the Joint Commission's accreditation manual, involves the completion of three principal components before initiation of any surgical procedure 3:
1. Preprocedure verification process The health care team ensures that all relevant documents and related information or equipment are available before the start of the procedure;
correctly identified, labeled, and matched to the patient's identifiers; and reviewed and are consistent with the patient's expectations and with the team's understanding of the intended patient, procedure, and site.
The team must address missing information or discrepancies before starting the procedure.
2. Marking the operative site Procedures that require marking of the incision or insertion site include those where there is more than one possible location for the procedure or when performing the procedure would negatively affect quality or safety. According to the Joint Commission, the site does not need to be marked in cases where bilateral structures (such as ovaries) are removed 3. Although the Joint Commission does not require a specific site marking method, each facility should be consistent in the method it uses ensuring that the mark is unambiguous. Only the correct site should be marked; an "X" or "No" should never be used on the wrong site.
3. Performing a "time out" before the procedure The operative team conducts a final assessment that the correct patient, site, and procedure are identified, recognizing that this is problematic in emergency situations, such as an emergency cesarean delivery.
World Health Organization Surgical Safety Checklist Another useful tool to promote patient safety in the surgical setting is the surgical safety checklist published by the World Health Organization. The checklist is based on the successful international program "Safe Surgery Saves Lives," which incorporates validated checklists to be reviewed by the surgical team before induction of anesthesia, before skin incision, and before the patient leaves the operating room 4. It is inappropriate to place total reliance on the surgeon to identify the correct surgical site or to assume that the surgeon should never be questioned. The risk of error may be reduced by involving the entire surgical team in the site verification process and encouraging any member of that team to point out a possible error without fear of ridicule or reprimand.
Patient Involvement A relatively new but essential element of the overall process is the formal enlistment of the patient in the effort to avert errors in the operative arena. Involving the patient in this manner requires personal effort by the surgeon to educate the patient during the preoperative evaluation process. The patient, who has the greatest stake in avoiding errors, thus becomes integrally involved in helping ensure that errors are avoided.
Granting Privileges for New Procedures New techniques and new equipment are important components for developing and delivering the best quality care in the operating room, but they also represent sources of potential surgical error. Whenever possible, a surgeon who is incorporating a new surgical technique should be proctored or supervised by a colleague more experienced in the technique until competency has been satisfactorily demonstrated. In some circumstances, however, a technique may be so innovative that no other surgeon at that facility has more experience. In such situations, it may be necessary to require reciprocal proctoring at another hospital or grant temporary privileges to someone from another hospital to supervise the applicant. The surgeon performing the procedure should have already documented skills and experience in the related surgical arena.
When new equipment is introduced, all members of the surgical team must be trained on and practice with the new equipment as appropriate for the extent of their involvement, and all personnel involved must be aware of all safety features, warnings, and alarms of the device. Whenever possible, the institution's medical engineering department should inspect the equipment and verify that it is functioning properly before the equipment is put into clinical use. Any informational material (eg, user manuals, operating instructions) provided by the manufacturer of the equipment should be carefully reviewed by the principal users and should be familiar to anyone using the equipment. Labels attached to the device or plastic cards summarizing instructions for proper use may be helpful until everyone involved is comfortable with the new equipment. All necessary adaptors, attachments, and supplies should be in the room or readily available before beginning surgery with the new equipment. Any recommended protective devices, such as eye shields or special draping material, should be used for the safety of all concerned. The lead surgeon using the new equipment should have demonstrated competency in the use of the device, resulting in the granting of privileges. Leaders of each surgically oriented department will determine the specific requirements for granting privileges to their members for the use of new techniques or equipment. It is never appropriate for nonmedical, noncredentialed individuals, such as industry representatives, to perform the actual surgery. Such individuals should be excluded from the operating room if their presence would present a distraction or discomfort for any member of the essential operating room team. Additional information on requests for new privileges can be found in Quality and Safety in Women's Health Care, 2nd edition.
Stress and Fatigue A well-recognized source of human error is excessive stress and fatigue. According to the Health and Safety Laboratory, Britain's leading industrial health and safety facility and an agency of the British Health and Safety Executive, disrupted sleep patterns and inadequate sleep can result in fatigue and reduced levels of cognitive performance thus increasing the risk of an accident. Human error arising from fatigue may have catastrophic results in safety critical environments 5. Sleep deprivation can cause errors in performing even the most familiar tasks; for example, the National Highway Traffic Safety Administration reports that sleepy drivers cause at least 100,000 automobile accidents annually in the United States, resulting in approximately 40,000 injuries and 1,500 deaths 6. For this reason, many industries have already imposed strict limitations on working hours for individuals in vulnerable occupations, such as truck drivers, airline pilots and crew members, air traffic controllers, and power plant personnel. The Accreditation Council on Graduate Medical Education has enacted restrictions on resident work hours to prevent sleep deprivation, stress, and fatigue that might increase the risk of error 7 8. Although no legal restrictions have yet been imposed on the work hours of physicians in clinical practice, common sense dictates that the surgeon and the surgical team should be alert and well rested when initiating major surgical procedures. Emergency situations may be particularly hazardous as an environment for error, especially if the surgical team is stressed and fatigued already. A recent study that examined the risk of complications by attending physicians after performing nighttime procedures found an increased rate of surgical complications when physicians had slept less than 6 hours 9. Adequate backup personnel should be available to relieve individuals who detect diminished performance in themselves or others due to fatigue, so that the risk of error is not increased.
Medication Errors The surgical environment deserves heightened vigilance to prevent medication errors because medication orders often are given verbally rather than in writing, making such orders particularly vulnerable to misinterpretation or misapplication. Increased stress or confusion during urgent situations in the operating room may increase the possibility of error in prescribing, administering, or monitoring medications. For these reasons, medication error in the surgical arena may not be addressed by the safety measures (eg, electronic order entry) proved effective in other environments. It may be wise for the surgical team to agree on protocols for administering commonly used medications or treatments and to practice their implementation. Timely and effective communication between the surgical and anesthesia teams, including read backs as necessary, during the entire procedure may help avoid errors that could result from misunderstanding.
Retained Foreign Objects The Joint Commission includes unintended retention of a foreign object in a patient after surgery or other procedure as a reviewable sentinel event 10. In its statement on the prevention of retained foreign objects after surgery, the American College of Surgeons recommends consistent application and adherence to standardized counting procedures and documentation of the surgical counts, instruments or items intentionally left as packing, and actions taken if count discrepancies occur 11. Other protocols to prevent unintentional retention of foreign objects during surgery and vaginal delivery have been developed. For example, the Institute for Clinical Systems Improvement's protocol suggests that sponges, needles, and sharp instruments are counted before and after surgery and vaginal delivery. Only radiopaque sponges and soft goods should be placed on surgical trays or delivery fields. If the counts at the end of the case are either incorrect or compromised, then an abdominal or vaginal examination must be performed. If the counts are still not reconciled, radiographic imaging for retained foreign objects will need to be obtained 12.
Teaching Trainees, such as obstetric-gynecologic residents, surgical residents, anesthesiology residents, medical students, nursing students, and operating room technician students, may be part of the surgical environment in the operating room or labor and delivery suite. The education process in these environments presents special challenges in protecting patient safety. It is a fundamental principle that all trainees must be meticulously supervised and assisted when participating in surgery. Both the trainee and the supervisor should be alert, well rested, and well prepared in advance for the surgical procedure being performed. Because patient safety depends on effective communication among all members of the health care team, trainees should be conversant in the pertinent terminology before starting the procedure. The presence of noninvolved individuals as observers in the operating room or delivery suite may be a distraction to the surgical team and, therefore, should receive careful consideration before they are admitted. The current development of virtual surgery training techniques may become useful for students to learn and practice surgical skills before attempting procedures in the operating room.
Obstetric Surgery Operating on pregnant patients creates unique responsibilities in ensuring patient safety because two or more patients are involved simultaneously--the woman and the fetus(es)--each with different needs. Adequate personnel who will ensure proper attention to the condition of each patient must be present. Particular attention is needed to address administration of the different medications appropriate for the pregnant patient and her fetus(es) or the newborn patient(s), such as dosage and timing of antibiotics or analgesics for mother or newborn(s) or both. The obstetric surgeon also needs to communicate with a pediatrics team in a timely and effective manner to reduce the possibility of error in care of the neonate. The occasional use of blood transfusion opens another potential avenue for introduction of error because calling for the administration of blood products may take place under especially stressful and hectic conditions. Checklists and protocols for massive transfusion in the event of significant obstetric hemorrhage are recommended for labor and delivery units. Much obstetric surgery is by nature unplanned as the course of the delivery unfolds, and obstetric emergencies can progress rapidly, increasing the possibility of error if protocols and standardized procedures are skipped or abbreviated.
Freestanding Surgical Units In recent years, many surgical procedures traditionally performed only in hospitals or similar institutions have increasingly been performed in physicians' offices or freestanding surgical facilities. This trend has produced cost savings and convenience for patients as well as health care providers and will likely continue. However, because these facilities may not be subject to the same level of scrutiny or administrative oversight as hospitals, surgeons who use these facilities must be particularly vigilant against inadequate training of personnel, inappropriate or poorly maintained equipment and instruments, and ineffective protocols or practices, all of which may increase the likelihood of medical error and jeopardy to patient safety. According to the American College of Obstetricians and Gynecologists' Presidential Task Force on Patient Safety in the Office Setting, patients have the right to expect the same level of safety regardless of where they seek treatment 13. This task force also notes that accreditation is something more practices may seek in the future. Many states already require it if certain levels of anesthesia are used in the office or surgical center--typically moderate sedation or deeper anesthesia will trigger this requirement 13. Such requirements will likely improve the quality and safety of care provided in these settings.
Distractions Beepers, radios, telephone calls, and other potential nonessential activities and distractions in the surgical environment should be kept to a minimum, if allowed at all, especially during critical stages of the operation. Just as pilots maintain "sterile cockpits," a Federal Aviation Administration regulation requiring pilots to refrain from nonessential activities during critical parts of a flight, all members of the operating room team also should postpone nonessential conversation until surgery is finished 14. Similarly, it may be preferable to ask nonessential personnel to remain outside the operating room while surgery is being performed. Everyone on the team is mutually accountable for minimizing distractions.
Conclusion Although medical errors can occur in any aspect of medicine, the surgical environment presents additional, special challenges to safeguarding patient safety. Because these injuries can be serious, particular care is appropriate in creating checklists, systems, and routines that reduce the likelihood of wrong-patient, wrong-side, wrong-part surgical errors, and retained foreign objects. Along with these tools, communication among members of the surgical team is crucial throughout the surgical process, particularly during the preoperative phase. The wide variety of techniques, instruments, and technology used for surgical procedures makes granting privileges of surgeons critically important. Freestanding surgical units may need to be particularly vigilant in ensuring that personnel and equipment are in good condition for surgery. Protocols and procedures to identify and manage stress and fatigue in surgical personnel may help to avoid surgical errors and patient injuries. The operating room is an appropriate educational environment, but the presence of observers at any level must not be allowed to compromise patient safety. Patient safety in surgery demands the full attention of skilled individuals using well-functioning equipment under adequate supervision.
References The Joint Commission. Sentinel events statistics. Oakbrook Terrace (IL): Joint Commission; 2009. Available at:http://www.jointcommission.org/SentinelEvents/Statistics. April 30, 2010.
The Joint Commission. Universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Oakbrook Terrace (IL): Joint Commission; 2009. Available at:http://www.jointcommission.org/PatientSafety/UniversalProtocol. Retrieved April 30, 2010.
The Joint Commission. National patient safety goals (NPSG). In: Comprehensive accreditation manual. CAMH for hospitals: the official handbook . Oakbrook Terrace (IL): Joint Commission; 2010. P. NPSG-1-25.
World Health Organization. Surgical safety checklist . Geneva: WHO; 2009. Available at:http://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdf. Retrieved April 30, 2010.
Health and Safety Executive (UK). Human factors: fatigue. Available at: http://www.hse.gov.uk/humanfactors/topics/ fatigue.htm. Retrieved April 30, 2010.
National Highway Traffic Safety Administration. The dangers of drowsy driving--some startling statistics. Available at: http://www.nhtsa.dot.gov/PEOPLE/injury/ drowsy_driving1/human/drows_driving/index.html. Retrieved April 30, 2010.
Accreditation Council for Graduate Medical Education. Common program requirements: VI. Resident duty hours in the learning and working environment . Chicago (IL): ACGME; 2007. Available at:http://www.acgme.org/acWebsite/dutyHours/dh_ComProgrRequirementsDutyHours0707.pdf. Retrieved April 30, 2010.
Buysse D, Barzansky B, Dinges D, Hogan E, Hunt CE, Owens J, et al. Sleep, fatigue, and medical training: setting an agenda for optimal learning and patient care. Sleep 2003;26:218-25.
Rothschild JM, Keohane CA, Rogers S, Gardner R, Lipsitz SR, Salzberg CA, et al. Risks of complications by attending physicians after performing nighttime procedures. JAMA 2009;302:1565-1572.
The Joint Commission. Sentinel Events (SE). In: Comprehensive accreditation manual. CAMH for hospitals: the official handbook . Oakbrook Terrace (IL): Joint Commission, 2010. P. SE-1-18.
Statement on the prevention of retained foreign bodies after surgery. Bull Am Coll Surg 2005;90:15-16.
Institute for Clinical Systems Improvement. Health care protocol: prevention of unintentionally retained foreign objects during vaginal deliveries . 3rd ed.Bloomington (MN): ICSI; 2009. Available at:http://www.icsi.org/retained_foreign_objects_during_vaginal_deliveries/retained_foreign_objects_during_vaginal_deliveries__prevention_of_untentionally__protocol_.html. Retrieved April 30, 2010.
American College of Obstetricians and Gynecologists. Report of the Presidential Task Force on Patient Safety in the Office Setting . Washington, DC: American College of Obstetricians and Gynecologists; 2010.
Federal Aviation Administration. Approach and landing accident reduction: sterile cockpit, fatigue. Safety Alert for Operators 06004 . Washington, DC: FAA; 2006. Available at:http://www.faa.gov/ other_visit/aviation_industry/airline_operators/airline_safety/safo/all_safos/media/2006/safo06004.pdf. Retrieved April 30, 2010.
The statement regarding misbehaviour and manhandling is of not so much importance because there is provision regarding report to police for such things but we are concerned here to see the negligence on the part of the opposite parties. The patient's attendant may be with the patient but they don't know the treatment that was being provided by the doctor concerned. But from all the facts mentioned above we are of the opinion that the opposite parties failed to prove their innocence. For such a simple thing a person expires, having no previous history of any allergy condition or any other medical condition. The opposite parties could not prove the Genesis of the death of the patient which started from a simple operation and ultimately resulted in the death of the patient. Here circumstances speak themselves that there is negligence on the part of the treating doctor and they are liable for medical negligence in all respect.
So considering all these factors and facts of the case we are of the view that the opposite parties are jointly and severely liable to pay compensation to the complainant. So the present complaint case is decided accordingly.
ORDER The complaint case is decided partially. The opposite parties no.1 & 2 are jointly and severally directed to pay ₹ 65 lakhs towards pain, mental agony, medical negligence, loss of the son and cost of the case to the complainant with interest at a rate of 12% per annum from 01.06.2014 (date of death of the child) if paid within 30 days from the dateF of judgment of this complaint case otherwise the rate of interest shall be 15% per annum from 01.06.2014 till the date of actual payment.
The opposite parties may be reimbursed by the related insurance companies upto the amount they were insured with the opposite parties no.3 & 4.
If the order is not complied with within 30 days from the date of judgment of this complaint case, the complainant may file execution case against the opposite parties at their cost in this court.
The stenographer is requested to upload this order on the Website of this Commission today itself.
Certified copy of this judgment be provided to the parties as per rules.
(Vikas Saxena) (Rajendra Singh) Member Presiding Member Judgment dated/typed signed by us and pronounced in the open court. Consign to the Record-room. (Vikas Saxena) (Rajendra Singh) Member Presiding Member Dated 27.3.2024 JafRi, PA I/C-2 [HON'BLE MR. Rajendra Singh] PRESIDING MEMBER [HON'BLE MR. Vikas Saxena] JUDICIAL MEMBER