State Consumer Disputes Redressal Commission
Idrish Mohammad Khan S/O Ishak Mohammad ... vs Gopinath Hospital Pvt. Ltd. on 27 February, 2020
1 jkT; miHkksDrk fookn izfrrks"k vk;ksx] cSap la- 2] jkt0] t;iqj ifjokn la[;k %& 65@2016 bnfjl eksgEen [kku] iq= b'kkd eksgEen [kku] fuoklh edku uacj 219] tkyqiqjk] pkaniksy t;iqj ¼ jkt0 ½ ifjoknh cuke 01- xksihukFk gkWfLiVy ¼ izk0 ½ fy0 lsDVj&8] psrd ekxZ] izrki uxj] lkaxkusj] t;iqj 302033 02- MkWa0 lfpu 'kekZ lsDVj&8] psrd ekxZ] izrki uxj] lkaxkusj] t;iqj 302033 foi{khx.k le{k % ekuuh; Jh dey dqekj ckxMh] lnL; ¼U;kf;d½ ekuuh; lnL; Jherh ehuk esgrk mifLFkr %& ifjoknh dh vksj ls Jh vkj0,l0 jkBkSM+ vf/koDrk foi{kh dh vksj ls Jh egs'k pUnz xqIrk vf/koDrk fu.kZ; fnukad 27 Qjojh] 2020 jkT; vk;ksx jktLFkku t;iqj ¼}kjk Jh dey dqekj ckxM+h] lnL;] ¼U;kf;d½ ;g ifjokn bnfjl eksgEen [kku dh vksj ls xksihukFk gkWfLiVy ¼ izk0 ½ fy0 ds fo:) bl vk;ksx esa fnukad 03-06-2016 dks is'k fd;kA izdj.k ds rF; bl izdkj gS fd ifjoknh dks lu~ 2014 esa ukd ls lkal ysus esa ijs'kkuh gksus yxh] tks fd lu~ 2015 vxLr flrEcj ekg rd dkQh gd rd c<+ xbZ FkhA ifjoknh }kjk fons'k ¼ nqcbZ ½ esa jgdj vkthfodk vftZr dh 2 tkrh gS ftl dkj.k mUgksusa Hkkjr ¼ Lons'k ½ vkdj mfpr fpfdRldh; ijke'kZ ysuk mfpr le>k ,oa flrEcj 2015 esa ifjoknh Hkkjr ykSVdj vk;kA fnukad 20-10-2015 dks ifjoknh }kjk foi{kh la[;k 2 ls fpfdRldh; ijke'kZ fy;k x;k] ftl dze esa foi{kh la[;k 2 }kjk dqN ijh{k.k] ifjoknh ds fd;s x;s ,oa blh dze esa NCCT PNS tkWap gsrq lykg nh xbZ ml fizlfdzI'ku i= izn'kZ&1 gSA ifjoknh ds }kjk foi{kh dh lykg ij fnukad 20-10-2015 dks mijksDr tkap gsrq egf"kZ jeu Mk;XuksfLVd lsUVj esa tkap djokbZ mDr tkWap fjiksVZ izn'kZ&2 layXu gSA mDr tkWap esa ifjoknh dks lkbZul dh leL;k ls xzLr gksuk ik;k x;kA foi{kh la[;k 2 }kjk ukd dku ,oa xyk fpfdRlk esa Lo;a dks fo'ks"kK gksuk crk;k x;k Fkk] ftl dkj.k ifjoknh }kjk foi{kh la[;k 2 ds mDr vk'oklu ij fo'okl dj viuh chekjh dk bZykt foi{kh ls djokus dk fu.kZ; fy;k x;kA foi{kh la[;k 2 us ifjoknh dks fnukad 26-10-2015 dks foi{kh la[;k 1 gkWfLiVy esa mifLFkr gksdj mDr chekjh ds fuokj.k gsrq 'kY; fpfdRlk djokus dh lykg nh xbZA ftl lykg ds vuqlj.k esa ifjoknh }kjk 26-10-2015 dks foi{kh la[;k 1 gkWfLiVy esa HkrhZ gqvk ,oa foi{kh la[;k 2 us mDr 'kY; fpfdRlk Lo;a o vius lg;ksxh MkWDVlZ ds lkFk dh o mDr vkWijs'ku fd;s tkus ds rF; izn'kZ&4 ls lkfcr gSA fnukad 26-10-2015 dks gh 'kY; fpfdRlk ds i'pkr~ tc ifjoknh psru voLFkk esa vkWijs'ku fFk;sVj ls yksVk rc ifjoknh }kjk viuh nkfguh vkWa[k ls dqN Hkh ugha fn[kkbZ nsus dh f'kdk;r foi{kh la[;k 2 o vU; mifLFkr LVkWQ ls dh xbZ] ftlds i'pkr~ foi{kh la[;k 2 }kjk mDr f'kdk;r fjdkMZ dj lokbZ ekuflag vLirky ds vkWiFkkeksyksftLV MkWa0 /keZohj flag dks jsQj fd;k x;kA ftl ij fnukad 26-10-2015 dks vkWiFkksyksftLV us ifjoknh dh vkW[k dh jks'kuh tkus dh iqf"V djrs gq;s ifjoknh dh ,e0vkj0 vkbZ0 tkWap djokus dh lykg nh xbZA mDr lykg ij ifjoknh ds }kjk ,e0vkj0vkbZ0 fnukad 26-10- 2015 dks fl)kFkZ Mk;XuksfLVd lsUVj ij djokbZ xbZA fnukad 26-10-2015 dks ijh{k.kksa dh fjiksVZ vkus ds i'pkr~ ifjoknh dh nkfguh vkWa[k dh jks'kuh pys tkus dh iqf"V gks xbZ rFkk bl lac/a k esa dksbZ mfpr dk;Zokgh foi{kh la[;k 2 }kjk ugha dh xbZA foi{khx.k ds }kjk ifjoknh dks mlds gky ij NksMd + j vLirky ls fMLpktZ djus dh dk;Zokgh djrs gq;s fnukad 28-10-2015 dks fMLpktZ dj fn;k x;kA 3 foi{kh la[;k 2 }kjk dh xbZ 'kYp fpfdRlk ds ifj.kkeLo:i ifjoknh }kjk viuh nkfguh vkWa[k dh jks'kuh [kks nsus ls O;fFkr gksdj vkt fnukad rd vusd fpfdRldksa ,oa vLirkyksa ls ijke'kZ ,oa ijh{k.k djok;k x;k] ftlds rgr~ foi{kh gkWfLiVy ls fMLPktZ ds i'pkr~ rqjUr fnukad 28-10-2015 dks gh viuh nkWbZ vkWa[k dh jks'kuh iqu% izkfIr ds fy;s MkWa0 v'kksd iqjh ls fpfdRlh; ijke'kZ fy;k x;k ftUgksusa Hkh vkWa[k dh jks'kuh tkus dh iqf"V dhA fnukad 29-10-2015 dks MkWa0 ufyuh lsu ds }kjk Hkh mijksDr dkWEiyhds'ku dh iqf"V dh xbZA fnukad 30-10-2015 dks MkWa0 jktsUnz izlkn uS= foKku dsUnz] ubZ fnYyh esa Hkh fn[kk;k x;k ftUgksusa Hkh fjiksVZ o ifjoknh dh gkyr ns[kdj vkWa[k dh jks'kuh tkus dh iqf"V dhA blds i'pkr~ fnukad 04-11-2015 dks MkWa0 nhid tSu dks fn[kk;k x;k] fnukad 06-11-2015 dks ifjoknh ds }kjk vksds Mk;XuksfLVd lsUVj izk0 fy0 larksdck nqyZHkth gkWfLiVy] t;iqj esa fn[kk;k x;k o lhVh Ldsu o bZlhth o gkWYVj fjiksVZ djokbZ xbZA blds i'pkr~ fnukad 10-11-2015 dks ifjoknh dk esnkUrk gkWfLiVy esa fn[kk;k x;k] ifjoknh }kjk mijksDr vafdr MkWDVlZ dks fn[kkus o ijke'kZ ,oa tkWap ds i'pkr~ Hkh fdlh Hkh MkW0 us ifjoknh dh fnukad 26-10-2015 dks foi{khx.k dh vksj ls dh xbZ nks"kiw.kZ 'kY; fpfdRlk ds ifj.kkeLo:i xbZ nkWabZ vkWa[k dh jks'kuh Hkfo"; esa bZykt ls vk ldrh gS ckcr~ ijke'kZ ugha fn;k x;k o crk;k x;k fd laHkkouk Hkh ugha gSA ifjoknh ds }kjk fnukad 14-11-2015 dks ,-,l-th- us= fpfdRlky; esa viuk bZykt izkjEHk bl vk'kk ls fd;k fd ifjoknh dh jks'kuh vk tk;sxh] ysfdu fnukad 20-04-2016 dks MkWa0 }kjk vius fd;s x;s bZykt ds i'pkr~ No Improment with treatment and advice No active treatment require ds dFku fd;s x;sA ifjoknh ds }kjk viuh vkWa[k dh jks'kuh iqu% izkfIr ds fy;s vusd MkWa0 dh lykg yh o bZykt djok;k x;k ysfdu lHkh us ,d gh jk; izdV dh] fd foi{khx.k ds }kjk fnukad 26-10-2015 dks ifjoknh dh 'kY; fpfdRlk esa pwd@ykijokgh ds dkj.k ifjoknh viuh nkfguh vkWa[k dh jks'kuh LFkk;h :i ls [kks pqdk gSaA ifjoknh ds mDr bZykt ds fy, ifjoknh ls iwjh Qhl ,oa vU; [kpsZ olwys x;s gS vr% ;g laO;ogkj lsok dh ifjHkk"kk esa vkrk gSA foi{kh la[;k 2 }kjk fd, x, bZykt ds isVs ifjoknh ls rdjhcu 30]000@&:- olwys x;s gS ,oa foi{kh la[;k 2 dh ykijokgh iw.kZ 'kY; fpfdRlk ds ifj.kkeLo:i ifjoknh dh nkfguh vkWa[k dh jks'kuh pyh xbZ] ftlds bZykt o tkWapksa esa djhcu 1]10]000@&:-
4ifjoknh fofHkUu fpfdRldh; ijke'kksZ ifj.kkeksa ,oa tkWap o nokbZ;ksa esa O;; dj pqdk gSA ifjoknh fons'k esa VSDlh pykus dh uksdjh djrk gSA ftl uksdjh ls mudh vk; yxHkx 75]000@&:- izfr ekg gksrh gS ijUrq vc os viuh uksdjh dks tkjh j[kus dh fLFkfr esa ugha gSA ftldk dkj.k foi{khx.k }kjk ifjoknh ds bZykt esa cjrh xbZ ykijokgh gSA ifjoknh dks foi{khx.k ds ykijokgh iw.kZ d`R; ds dkj.k vlguh; ekufld o 'kkjhfjd ihM+k dk >syuk iM+ jgk gS rFkk Hkfo"; esa gksus okyh vk; ls Hkh oafpr gks x;k gS] ifjoknh us foi{khx.k ls mijksDr {kfriwfrZ jkf'k dh fMekaM tfj;s uksfVl fnukafdr 12-04-2016 dks izsf"kr dh xbZ tks fd foi{khx.k dks izkIr Hkh gks x;k gS] ysfdu blds i'pkr~ Hkh vkt fnu rd foi{khx.k }kjk uk rks mDr uksfVl dk tokc fn;k x;k gS vkSj uk gh dksbZ {kfriwfrZ jkf'k ifjoknh dks vnk dh xbZ gSA vr% ifjokn esa pkgs x;s vuqrks"k fnyok;s tk;saA ifjoknh dh vksj ls ifjokn ,oa lk{; ds leFkZu esa Lo;a ,oa jsgkuk ckuks ds 'kiFk&i= ,oa izn'kZ&1 yxk;r izn'kZ&56 nLrkost izLrqr fd;sA foi{kh dh vksj ls tokc esa dFku fd;k x;k fd foi{kh }kjk dksbZ lsoknks"k dkfjr ugha fd;k x;k gS ifjoknh us ifjokn cn~fu;rhiw.kZ :i;s ,sBus] gSjku ijs'kku djus nqHkkZoukiw.kZ] dkuwuh izfdz;k dk nq:i;ksx djus ,oa miHkksDrk vf/kfu;e ds m)s';ksa ds foijhr] dqfRlr m)s'; ls nk;j fd;k gS] tks ljljh rkSj ij gh [kkfjt fd;s tkus ;ksX; gSA ifjoknh }kjk foi{kh la[;k 2 ls fpfdRldh; ijke'kZ yh xbZ Fkh rFkk foi{kh la[;k 2 ds }kjk tkWap ds miajkr tks vko';d ijh{k.k djok;s tkus Fks mUgsa mYysf[kr dj] ifjoknh dks chekjh ls lacaf/kr ijh{k.k djok;s tkus gsrq lykg nh FkhA ifjoknh }kjk lykg ds eqrkfcd fnukad 20-10-2015 dks gh egf"kZ je.k MkbZXuksfLVd lsUVj ls tkWap djokbZ Fkh] mDr tkWap esa ifjoknh dks lkbZul dh chekjh ls xzflr gksuk mYysf[kr gSA foi{kh la[;k 2 ukd dku o xys dk fo'ks"kK gSaA ifjoknh dks egf"kZ je.k MkbZXuksfLVd lsUVj ls izkIr gqbZ fjiksVZ dk fujh{k.k djus ds miajkr ifjoknh dks mls gqbZ chekjh ds fuokj.k gsrq 'kY; fpfdRlk 5 djokus dh lykg nh xbZ D;ksa fd egf"kZ je.k MkbZXuksfLVd lsUVj dh fjiksVZ ds eqrkfcd ifjoknh dh nkfguh ukd ds vUnj esfDtyjh lkbZul ds e/; dkQh cM+k ekWal dk VqdM+k ftlls ifjoknh dks lkal ysus esa rdyhQ gks jgh Fkh ftls gVkus ds fy, 'kY; fpfdRlk djok;s tkus dh lykg nh ifjoknh us foi{kh la[;k 2 dh mDr lykg dks Lohdkj dj nkfguh ukd esa vk;s mDr ekWal ds VqdM+s dks 'kY; fpfdRlk ls gVkus dh lgefr nh ftl ij foi{kh la[;k 2 us fnukad 26-10-2015 dks gh 'kY; fpfdRlk dj ifjoknh dk vkWijs'ku lQyrkiwoZd dj fn;kA ifjoknh us psru voLFkk vkus ij f'kdk;r dh fd mldh nkfguh vkWa[k ls dqN Hkh fn[kkbZ ugha ns jgk gS rks foi{kh la[;k 2 us ifjoknh dh mDr f'kdk;r dks ntZ dj vkWIFkkseksyksftLV MkWa0 /keZohj flag tks lokbZ ekuflag vLirky esa fpfdRld gS] dks jsQj fd;kA ifjoknh us foi{kh la[;k 2 dh lykg ij fnukad 26-10-2015 dks gh mDr MkWa0 /keZohj flag dks ijhf{kr djok;k ftlus ifjoknh dks ,evkjvkbZ djokus dh lykg nhA ifjoknh us mDr MkWa0 /keZohj flag dh lykg ij gh fnukad 26-10-2015 dks fl)kFkZ MkbZXuksfLVd lsUVj ij tkap djokbZA MkWa0 /keZohj flag ds lq>k;s vuqlkj foi{khx.k us ifjoknh dks vkS"kf/k nsdj bZykt izkjEHk fd;k ,oa ifjoknh dks foi{kh vLirky dh ,EcqysUl ls gh ,evkjvkbZ djkus HkstkA ifjoknh ds }kjk 'kY; fpfdRlk ds miajkr tks f'kdk;r dh xbZ mldk vfoyac mipkj foi{khx.k us esMhdy izsfDVl ,oa esMhdy lkbZUl esa mYysf[kr izfdz;k ds rgr gh vkjEHk dj fn;kA ifjoknh us 'kY; fpfdRlk ds miajkr viuh nkfguh vkWa[k dh jks'kuh pys tkus dh f'kdk;r dh rks foi{khx.k us vfoyac vius Lo;a dh ,EcqysUl ls loZizFke ifjoknh dks vkWIFkkseksyksftLV MkWa0 /keZohj flag dks ijhf{kr djok;k] mudh lykg ds eqrkfcd mls nokbZ miyC/k djokbZ rFkk mlds miajkr vius Lo;a ds lk/ku ls ,evkjvkbZ djokdj vius gkWfLiVy esa j[kdj fnukad 28-10-2015 dks fMLpktZ fd;k ijUrq mlls iwoZ ifjoknh dh bPNkuqlkj ifjoknh dks foi{khx.k us MkWa0 v'kksd iqjh dks Hkh ifjf{kr djok;k fdlh Hkh MkWa0 us ;g ugha dgk fd 'kY; fpfdRlk dh otg ls vkWa[k dh jks'kuh xbZ gSA MkWa0 jktsUnz izlkn us Hkh viuh fjiksVZ esa ;g dFku ugha fd;k gS fd 'kY; fpfdRlk ds dkj.k ifjoknh dh vkWa[k dh jks'kuh xbZ gSA MkWa0 nhid tSu us Hkh ;g jk; O;Dr ugha dh gS fd ifjoknh ds vkWa[k dh jks'kuh foi{khx.k ds }kjk dh xbZ 'kY; fpfdRlk ds dkj.k pyh xbZ gksA vksds Mk;XuksfLVd fjlpZ lsUVj izk0fy0 larksdck nqyZHkth gkWfLiVy esa fn[kkus o flVh Ldsu o bZlhth dh fjiksVZ tks izn'kZ&16 ds :i esa is'k dh xbZ gSa] mlds 6 voyksdu ls Hkh ;g izdV ugha gksrk gS fd ifjoknh ds vkWa[k dh jks'kuh foi{khx.k }kjk dh xbZ 'kY; fpfdRlk fd;s tkus esa dh xbZ fdlh ykijokgh ds dkj.k pyh xbZ gksA flVh Ldsu] bZlhth dh fjiksVZ ifjoknh dh vka[k dh jks'kuh pys tkus ds dkj.kksa dk nLrkost ugha gSA esnkUrk gkWfLiVy fjiksVZ esa Hkh ;g mYys[k ugha gS fd foi{kh ds }kjk ifjoknh dh 'kY; fpfdRlk fd;s tkus ds nkSjku foi{khx.k us dksbZ fpfdRlh; nkf;Roksa ds fuoZgu djus esa ykijokgh cjrh gks ftlds dkj.k ifjoknh dh vka[k dh jks'kuh pyh xbZA ifjoknh us ln~Hkkoh fu;r ls ifjokn izLrqr ugha fd;k gSA foi{khx.k us ifjoknh dk bZykt tkuh ekuh fpfdRlh; iz.kkyh ls lEikfnr fd;k gS vkSj ifjoknh ds }kjk vka[k dh jks'kuh pys tkus dh f'kdk;r fd;s tkus ij izR;sd izdkj ds iz;kl djrs gq, vka[k dh jks'kuh ds fo'ks"kK ds ikl ys tkdj ifjoknh dh chekjh ds fy, fpfdRlk djok;s tkus ds Hkjld iz;kl fd;s gSA foi{khx.k us esMhdy lkbZUl esa Kkr ,oa chekjh ds fy, esMhdy lkbZUl esa mYysf[kr leLr fpfdRldh; iz.kkyh dks viukrs gq, lko/kkuhiwoZd ifjoknh ds }kjk dh xbZ chekjh dh f'kdk;r dk fu;ekuqlkj bZykt fd;k gSA ifjoknh bl vk;ksx ds le{k LoPN gkFkksa ls ugha vk;k gSA ifjoknh dh nkfgus vkWa[k dh jks'kuh pys tkus esa foi{khx.k dk dksbZ nks"k ugha gSa vkSj u gh foi{khx.k }kjk ifjoknh ds 'kY; fpfdRlk fd;s tkus ls dksbZ ykijokgh cjrrs gq, lsoknks"k fd;k x;kA foi{khx.k us dksbZ lsoknks"k ugha fd;k gS vkSj u gh foi{khx.k us vuQs;j VªsM izsfDVl dh gSA vr% ifjokn [kkfjt fd;k tk;saA foi{kh dh vksj ls tokc ,oa lk{; ds leFkZu esa MkWa0 lfpu 'kekZ dk 'kiFk&i= izLrqr fd;kA i{kdkjku vf/koDrkk dh cgl lquh ,oa i=koyh dk voyksdu fd;kA fo)ku vf/koDrk ifjoknh us ifjokn esa vafdr rF;ksa dks nksgjkrs gq, fyf[kr cgl dh vksj /;ku fnykrs gq, ifjokn Lohdkj djus dk fuosnu fd;kA foi{kh vf/koDrk us U;kf;d n`"VkUr ,oa fyf[kr cgl ds tfj;s tokc ,oa vafdr rF;ksa dks nksgjkrs gq, ifjokn [kkfjt djus dk fuosnu fd;k ,oa blds leFkZu esa U;kf;d fu.kZ; is'k fd;sA 7
01. CIVIL COURT CASES 562 (SC) Mukesh Tyagi Vs. Fortis Escorts Heart Institute & ors.
02. 2018 (2) WLC (SC) civil 693 Dr. s.k. jhunjhunwala Vs. Mrs. dhanwanti Kumar & anr.
03. Supreme Court of India civil appeal No. 1385/2001 Decided on 10.02.2010 Kusum Sharma & others Vs. Batra Hospital & medical research centre & others ;g izdj.k fpfdRlh; vlko/kkuh dk gSA ifjoknh dh ukd esa lkW;ul dh leL;k Fkh foi{kh la[;k 1 ds gkWfLiVy esa foi{kh la[;k 2 dks 20-10-2015 dks fn[kk;k rks vkWijs'ku dh lykg nh x;hA fnukad 26-10-2015 dks vkWijs'ku djok;k] tc mldks gks'k vk;k rks mldh nkWfguh vkWa[k dh jks'kuh xk;c Fkh blds ckn ifjokn esa vafdr iSjk la[;k 4] 5] 6 ds fpfdRldksa o vLirkyksa esa fn[kk;k ijUrq mDr vkWa[k esa jks'kuh vkus dh dksbZ mEehn ugha FkhA ifjoknh ds ,d vkWa[k dh jks'kuh pyh x;h rFkk ;g jks'kuh lkW;ul ds vkWijs'ku ds ckn x;hA bl izdkj ifjoknh vius ftEes tks rF; Fks og lkfcr djus esa lQy jgk gSA vc iz'u mRiUu gksrk gS foi{khx.k dk \ bl laca/k esa II (2009) CPJ 61 SC NIZAM INSTITUTE OF MEDICAL SCIENCES Vs. PRASANTH S. DHANANKA esa ekuuh; loksZPp U;k;ky; us fuEu fu/kkZfjr fd;k gS %&
(ii) Medical Negligence--Burden of Proof -- Initial burden to prove medical negligence discharged by complainant - Burden shifts on hospital/attending doctors to satisfy Court that there was no lack of care or deligence.
(2004) 8 SCC page 56 SAVITA GARG (SMT) Vs. DIRECTOR, NATIONAL HEART INSTITUTE esa ekuuh; loksZPp U;k;ky; us fuEu fu/kkZfjr fd;k gS %& D. Consumer Protection Act, 1986 - Ss. 22, 18, 12 and 13 -Mecical negligence -- Burden of proof -Held, once aclaim petition is filed and the complainant has successfully discharged the initial burden that the hospital/clinic/doctor was negligent, and that as a result of such negligence the patient died, then in that case the burden lies on the hospital and the doctor concened who 8 treatedthe patient to show that there was no negligence involved in the treatment - Reasons for, given - Torts - Medical negligence--Burden of proof ekuuh; loksZPp U;k;ky; }kjk fu/kkZfjr fl)kUrksa dks /;ku esa j[krs gq, vc foi{kh dks fl) djuk gS fd mlus iw.kZ Skill ,oa lko/kkuh ls bZykt fd;kA foi{kh la[;k 1 futh vLirky gS rFkk foi{kh la[;k 2 E.N.T. Lis'kfyLV gS blfy, nksuksa foi{khx.k dks High Skill and Care dk mi;ksx djuk gksxkA ;g izdj.k fpfdRlh; vlko/kkuh dk gS bl laca/k esa ekuuh; loksZPp U;k;ky; ds eq[; :i ls nks fu.kZ; gSA bl lac/a k esa (2005) 6 Supreme Court Cases 1 JACOB MATHEW Vs STATE OF PUNJAB AND AN OTHER esa ekuuh; loksZPp U;k;ky; us fuEu fu/kkZfjr fd;k gS %& J. Tort -Negligence - Medical Negligence -When actionable - Test for Approach to be taken in dealing with cases of - Rationable for differential treatment of medical profession, discussed in extenso - Duties undertaken by doctors enumerated - Held, in a claim of medical negligence, it is enough for defendant to show that standard of care and skill attained was that of the ordinary competent medical practitioner exercising an ordinary degree of professional skill - Test for medical negligence laid down in Balam case, (1957) 2 All ER 118, 121 D-F [set out in para 19 herein], held, applicable in india -Further explained in detail when deviation from normal medical practice would amount to evidence of medical negligence - various issues clarified as to (1) state of knowledge by which standard of care is to be determined, (2) Standard of care in case of charge of failure (a) to use some particular equipment, or (b) to take some precaution, (3) enquiry to be made when alleged negligence is (a) due to an accident, or (b) due to an error of judgment in choice of a procedure or its execution--Considerations to be kept in mind by any forum trying issue of medical negligence, specified - Medical Practitioners 9 K. Tort -Negligence - Professional negligence--when actionable--Test for--Held, a professional may be held liable for negligence either (1) wnen he was not possessed of the requisite skill which he professed to have possessed, or (2) when he did not exercise, with reasonable competence in the given case, the skill which he did possess--Standard to be applied would be that of an ordinary competent person exercising ordinary skill in that profession--Test for professional negligence laid down in Bolam case, (1957) 2 All ER 118, 121 D-F [set out in para 19 herein], held, applicable in India - Professional negligence distinguished from occupational negligence.
N. Tort -Negligence-Definition and meaning (jurisprudential and forensic), discussed in estenso -Words and phrases The jurisprudential concept of negligence defies any precise definition. In current forensic speech, negligence has three meanings. They are: (i) a state of mind, in which it is apposed to intention; (ii) careless conduct; and (iii) the breach of a duty to take care that is imposed by either common or stature law. All three meanings are aplicable in different circumstances but any one of them does not necessarily exclude the other meanings. (Paras 10 and 11) Negligence is the breach of a duty caused by omission to do domething which a reasonable man guided by those considerations which ordinarily regulate the conduct of human affairs would do, or doing something which a prudent and reasonable man would not do. Negligence becomes actionable on account of injury resulting from the act or omission amounting to negligence attributable to the person sued. The essential components of negligence, as recognised, are three:
"duty", "breach" and "resulting damage", that is to say:
(1)the existence of a duty to take care, which is owed by the defendant to the complainant;
(2)the failure to attain that standard of care, prescribed by the law, thereby committing a breach of such duty; and (3)Damage, which is both causally connected with such breach and recognised by the law, has been suffered by the complainant.10
(4) If the Claimant satisfies the court on the evidence that these three ingredients are made out, the defendant should be held liable in negligence.
2010 (I) RLW 722 (SC) Kusum sharma & ors. Vs. Batra Hospital & Medical Research Centre & ors. esa fpfdRlh; ykijokgh ds laca/k esa ekuuh; loksZPp U;k;ky; us fuEu fn'kk&funsZ'k fn;s gS%& "On scrutiny of the leading cases of medical negligence both in our country and other countries specially the United Kingdom, some basic principles emerge in dealing with the cases of medical negligence. While deciding whether the medical professional is guilty of medical negligence following well known principles must be kept in view:
I. Negligence is the breach of a duty exercised by ommission to do somethingwhich a reasonable man, guided by those considerations which ordinarily regulate the conduct of human affairs, would do, or doing something which a prudent and reasonable man would not do.
II. Negligence is an essential ingredient of the offence. The negligence to be established by the prosecution must be culpable or gross and not the negligence merely based upon an error of judgment.
III. The medical professional is ecpected to bring a reasonable degree of skill and knowledge and must exercise a reasonable degree of care. Neither the very highest nor a very low degree of care and competence judged in the light of the particular circumstances of each case is what the law requires.
IV. A medical practitioner would be liable only where his conduct fell below that of the standards of a reasonable competent practitioner in his field.
V. In the realm of diagnosis and treatment there is scope for genuine difference of opinion and one professional doctor is clearly not negligent merely because his conclusion differs from that of other professional doctor.11
VI. The medical professional is often called upon to adopt a procedure which involves higher element of risk, but which he honestly believes as providing greater chances of success for the patient rather than a procedure involving lesser risk but highest chances of failure. Just because a professional looking to the gravity of illness has taken higher element of risk to redeem the patient out of his/her suffering which did not yield the disired result may not amount to negligence.
VII. Negligence cannot be attributed to a doctor so long as he performs his duties with reasonable skill and competence. Merely because the doctor chooses one course of action in preference to the other one available, he would not be liable if the course of action chosen by him was acceptable to the medical profession. VIII. It would not be conducive to the effciency of the medical profession if no doctor could administer medicine without a halter round his neck.
IX. It is our bounden duty and obligation of the civil society to ensure that the medical professionals are not unnecessarily harassed or humiliated so that they can perform their professional duties without fear and apprehension.
X. The medical practitioners at times also have to be saved from such a class of complainants who use criminal process as a tool for pressurising the medical professionals/hospitals, particularly private hospitals or clinics for extractine uncalled for compensation. Such malicious proceedings deserve to be discarded against the medical practitoners.
XI. The medical professionals are entitled to get protection so long as they perform their duties with reasonable skill and competence and in the interest of the patients. The interest and welfare of the patients have to be paramount for the medical professionals.
ekuuh; loksZPp U;k;ky; }kjk fu/kkZfjr fl)kUrksa dh jks'kuh esa ;g ns[kuk gS fd foi{khx.k us iw.kZ Skill ,oa lko/kkuh ls dk;Z fd;kA 12 bl izdj.k esa vkxs c<+us ls igys fpfdRlh; fyVªspj ij fopkj djuk gksxkA ifjoknh ds lkW;ul Fkk ftls Oxford concise colour medical dictionary ds ist 694 ij fuEu izdkj crk;k x;k gS%& sinus 1. an aiir cavity within a bone especially any of the cavities within the bones of the face or skull (see paranasal sinuses) 2. any wide channel containing blood, usually venous blood. Venous sinuses occue for example in the dura mater and drain blood from the brain. 3. a pocket or bulge in a tubular organ especially a blood vessel; for example the carotid sinus.
4. (sinus tract) an infected blind ending epithelium lined tract leading from a focus of infection to the surface of the skin or a hollow organ. See pilonidal sinus.
blls lacfa /kr vU; 'kCn Paranasal sinuses Oxford concise colour medical dictionary ds ist 560 ij fuEu izdkj crk;k x;k gS%& Paranasal sinuses The air filled spaces, lined ith mucous membrane within some of the bones of the skull. They open into the nasal cavity via the meatuses and are named according to the bone in which they are situated. They comprise the frontal sinuses and the maxillary sinuses (one pair of each) the ethmoid sinuses (consisting of many spaces inside the ethmoid bone) and the two sphenold sinuses. See illustration.
Pilonidal sinus ds ckjs esa Oxford concise colour medical dictionary ds ist 588 ij fuEu izdkj crk;k x;k gS%& Pilonidal sinus A short tract leading from an opening in the skin in or near the cleft at the top of the buttocks and containing hair. The sinus may be recurrently infected, leading to pain and the discharge of pus. Treatment is by surgical opening and cleaning of the sinus.
blds ckn Rhinitis ds ckjs Oxford concise colour medical dictionary ds ist 661 ij fuEu izdkj crk;k x;k gS%& Rhinitis Inflammation of the mucous membrane of the nose. It may be caused by virus infection (acute rhinitis see (common cold) or an allergic reaction (allergic rhinitis see Hay Fever). In atrophic rhinitis the mucous membrane becomes thinned and fragile. In perennial (or vasomotor )rhinitis there is overgrowth of and increased secretion by the membrane.
13blds ckn Rhinosinusitis ds ckjs Oxford concise colour medical dictionary ds ist 661 ij gh fuEu izdkj crk;k x;k gS%& Rhinosinusitis Inflammation of the lining of the nose and paranasal sinuses. Rhinosinusitis is a common condition caused by allergies, infection, immune deficiencies, mucocillry transport abnormalities, trauma,drugs or tumous. Various classifications exist. The European Position Paper on Rhinosinusitis and Nasal Polyps 2012 defined acute rhinosinusitis as lasting upto 12 weeks and chronic rhinosinusitis as lasting 12 or more weeks. Subgroups of the latter include chronic rhinosinusitis with and without nasal polyps and allergic fungal rhinosinusitis. Treatment may require steroids (topical or systemic) antibiotics, immunotherapy or endoscopic sinus surgery. See rhinitis, sinusitis.
blds ckn Acute Rhinitis ds ckjs Harsh Mohan Pathology Quick Review ds Inflammatory Conditions ds ckjs esa ist 317 ij fuEu izdkj crk;k x;k gS%& ACUTE RHINITIS (COMMON COLD) Acute rhinitis or common cold is the common inflammatory disorder of the nasal cavities that may extend into the nasal sinuses. It begins with rhinorrhoea, nasal obstruction and sneezing. Initially the nasal discharge is watery but later it becomes thick and purulent. The etiologic agents are generally adenoviruses that evoke catarrhal discharge.
ALLERGIC RHINITIS (HAY FEVER) Allergic rhinitis occurs due to sensitivity to allergens such as pollens. It is an lgE-mediated immune response consisting of an early acute response due to degranulation of mast cells and a delayed prolonged response.
SINUSITIS Acute sinusitis is generally a complication of acute or alleregic rhinitis and rarely secondary to dental sepsis. The ostia are occluded due to inflammation and oedema and the sinuses are full. 'Mucocele' is filling up of the sinus NASAL POLYPS Nasal polyps are common and are pedunculated grape-like masses of tissue. They are the end- result of prolonged chronic inflammation causing polypoid thickening of the mucos. They may be allergic or inflammatory. They are feequently bilateral and the middle turbinate is the common site. Antrochoanal polyps originate from the mucosa of the maxillary sinus and appear in the nasal cavity. Morphologically, nasal and antrochoanal polyps are identical.
RHINOSPORIDIOSIS Rhinosporidiosis is caused by a fungus. Rhinosporidium seeberi. Typically it occurs in a nasal polyps but may be found in other locations like nasopharynx, larynx and conjunctiva. The disease is common in India and 14 Srilanka and sporadic in other parts of the world.
Me besides the structure of inflammatory or allergic polyps, lare number of organisms of the size of erythrocytes with chitinous wall are seen in the thick walled sporangia. Each sporangium may contain a few thousand spores.
RHINOSCLEROMA This is a chronic destructed inflammatory lesion or the nore and upper respiratory airways caused by diplobacilli, Klebsiella Asia and Eastern Europe. The condition is endemic in parts of Africa, America, South Asia and Eastern Eurpoe. The condition begins as a common cold and progresses to altrophic stage and then into the nodular stage characterised by small tumor like submucosal masses.
GRANULOMAS Many types of granulomatous inflammations may involves the nose. These include tuberculosis, leprosy, syphilis, aspergillosis, mucommycosis. Wegener's granulomatosis and lethal midline granuloma.
Lohd`r :i ls ifjoknh ds lkW;ul ltZjh gqbZ] bl lac/a k esa lkW;ul ltZjh D;k gS \ lkW;ul ltZjh ds dkj.k D;k gS \ What is sinus Surgery ?
Sinus surgery is a procedure that aims to open the pathways of the sinuses and clear blockages. This is an option for people with ongoing and recurrent sinus infections, for people with abnormal sinus structure, or abnormal growths in the sinus.
A doctor will often attempt other treatments and procedures before resorting to surgery. If these don't work, surgery may be carried out.
Sinus surgery can be done with little discomfort. It is a brief procedure that has few complications.
Reasons for sinus surgery Sinusitis is an infection in the nasal passages which can cause pressure, headaches, a stuffy nose, and congestion.
The goal of the surgery is to remove whatever is blocking the drainage pathways of the sinuses. This may include removing:
thin pieces of bone mucous membranes nasal polyps swollen or damaged tissue tumors or growths blocking the nasal or sinus passage 15 A person may require sinus surgery to treat a variety of issues. Common reasons include sinusitis and nasal polyps.
Sinusitis Sinusitis is the swelling of the nasal sinuses or passages. It is some times called a sinus infection. A person with sinusitis may have the following symptoms:
pressure around the nose, eyes, or forehead a stuffy nose thick and discolored nasal drainage a cough head congestion and headaches bad-tasting post-nasal drip blocked ears or changes in hearing Nasal polyps Nasal polyps are swellings of the nasal lining inside the nasal passages and sinuses. They can vary in size but are usually teardrop-shaped Larger polyps or clusters may lead to breathing issues and can affect someone's sense of smell. They can also block a person's sinuses leading to infections.
Some people may experience no symptoms from nasal polyps. However, common ones include:
a blocked nose, leading to difficulty breathing a runny nose recurrent sinus infections post-nasal drip a reduced sense of smell or taste facial pain headaches snoring sleep apnea Other reasons Sinus surgery may also be required due to other infections, ongoing blockages, abnormal growths, and 16 other issues that cause inflammation in the nasal passages and sinuses.
Micro-telescopes and surgical instruments can then be passed down the endoscope and used to carry out the procedure. The surgeon will use these tools to remove obstructive tissues and other blockages to clear the sinuses.
The entire procedure is carried out through the nostrils and leaves little to no scarring. Some swelling may occur, but it will disappear quite quickly.
A person who has this surgery will usually only feel mild discomfort for a short period of time.
FESS can be performed frequently. It can also be carried out on an outpatient basis.
Image-guided surgery Image-guided endoscopic surgery is a newer procedure that may be recommended for severe forms of sinus blockages or after previous sinus surgeries.
In addition to using an endoscope, this type of surgery uses a near-three-dimensional mapping system to show the surgeon the position of the surgical instruments. This is done using CT scans and infrared signals.
Using this guidance, a surgeon can navigate difficult sinus passages and remove tissues and other blockages accurately.
Caldwell-Luc operation This procedure is less common and more invasive. It tends to be carried out when there is a growth present inside the sinus cavity.
The Caldwell-Luc operation aims to remove growths and improve sinus drainage. It creates a pathway between the nose and the cavity beneath the eye called the maxillary sinus. This window then aids drainage.
The surgeon makes a cut in the upper jaw, above one of the second molar teeth inside the mouth. They 17 then enter the sinus cavity through this cut. This surgery may be performed under local or general anesthetic.
lkW;ul ltZjh dh fjLd D;k gS \ Risks The complications that can occur during sinus surgery are mostly rare and include the following:
Bleeding Bleeding after surgery tends to happen within the first 24 hours. However, it can sometimes occur later, after days or even weeks. If a clot develops within the bony partition between the nasal passages, commonly called the septum, then it must be removed.
Intracranial complications The septum attaches to the roof of the nose. This thin layer of bone may be damaged during sinus surgery. However, this is a very rare complication.
Brain fluid can leak into the nose and, in severe cases, can lead to an infection in the lining of the brain such as meningitis. While this issue is extremely rare, it is often identified and repaired while the initial surgery is taking place.
--Although eye damage is rare, surgery may cause bleeding or watery eyes.
Damage to the eye or surrounding tissue As the sinuses are so close to the eye, bleeding can sometimes occur into the eye. This happens when the thin layer of bone that separates the sinus from the eye is damaged. This is rare and, again, is usually spotted and treated while the surgery is taking place.
In extremely rare instances, visual loss and blindness have been reported. There have also been rare reports of damage to the muscles that move the eye, which can lead to temporary or permanent double vision.
Other instances may lead to a change in how the tear ducts work, causing excessive tearing.
Changes to a person's voice Sinuses affect the resonance of a person's voice. A complication of sinus surgery can sometimes lead to a change in someone's voice.18
Loss of smell or taste After sinus surgery, a person's sense of smell usually improves due to the airflow being restored. However, it can worsen in rare cases depending on the extent of swelling or infection. This is often temporary but can be prolonged.
Infection Dealing with sinus infections is the main reason why sinus surgery is done. A person with sinusitis can develop other infections in this area as a result of surgery.
However, this complication is also possible if a person doesn't undergo surgery for a long-term sinus infection.
Nasal issues Sinus surgery usually improves airflow. However, in rare cases, surgery can worsen this. Small amounts of scar tissue may also build up in the nasal passage that will require another procedure to remove.
lkW;ul ltZjh esa fotu yksl gks tkrk gS bl laca/k esa vkWa[k] ukWd dh ANATOMY ns[kh x;h tks fuEu izdkj gS %& ANATOMY The orbit and the paranasal sinuses are intimately related on three sides. The lamina papyracea separates the orbit and its contents from the ethmoid sinus. The medial wall of the orbit is formed from anterior to posterior by the frontal process of the maxilla, the lac-rimal bone, the lamina papyracea of the ethmoid, and the sphenoid bone anteriorly only to the optic nerve foramen. The lacrimal sac rests in the lacrimal groove anteriorly. The anterior and posterior ethmoidal foram-ina are located in the frontoethmoidal suture line with their associated vessels and nerves. Congenital dehis-cences are sometimes noted in the medial and superior walls of the orbit, occurring behind the trochlear fossa or supraorbital notch and the middle or outer thirds of the lamina papyracea or over the ethmoid cells poste-riorly.' The periosteum of the orbit (periorbita) is very im-portant and represents the only soft tissue barrier be- tween the ethmoid sinus and the orbital contents. The periorbita is tough and fibrous, but can be elevated easily except at the suture lines, where it passes through to fuse with the opposite side periosteum. The globe of 19 the eye occupies most of the space in the anterior orbit, while the posterior orbit is filled with muscle and loosely vascular areola tissue (oribtal fat). The orbital septum is the reflection of the periorbita into the tarsal plates. The septum is tough and holds the orbital con- tents in place. It also holds orbital effusions, such as hemorrhage and infection, in the orbit, preventing these conditions from passing directly to the lids.
The blood supply to the retina is from two sources:
(1) the choroid chorio capillaris (outer one half), and (2) the central retinal artery and branches," The blood supply is protected by various compensatory mecha-nisms so that retinal blood flow will be maintained even if the entire system is under stress. J It is extremely important to note that there are abun-dant communicating vessels from all sinuses that enter into the orbital contents and both lids. The inferior ophthalmic vein, in particular, begins as a venous net-
work along the floor and medial wall of the orbit, re- ceiving tributaries from the lacrimal sac, eyelids, and muscles of the orbit. There is free flow between these orbital veins and the ethmoid sinus, nasolacrimal duct, and turbinates. The arterial supply between the orbit and the ethmoid sinus consists of the anterior and pos-terior ethmoid arteries, which run from the orbit through a bony canal into the septum.
;fn lkW;ul vkWijs'ku ds nkSjku vkWa[k dh uoZ ds lkFk ftls fd vksfIVd uoZ dgrs gS mlesa batjh gks tk;sa rks bldh PATHOPHYSIOLOGY fuEu izdkj gS%& PATHOPHYSIOLOGY Two mechanisms for blindness that occurs during intranasal ethmoidectomy are apparent: (I) direct in-jury to the optic nerve or its blood supply, and (2) retrobulbar hematoma with increased orbital pressure that compromises vascular supply and drainage to and from the eye.
vksfIVd uoZ dks Oxford concise colour medical dictionary ds ist 539 ij fuEu izdkj crk;k x;k gS%& Optic Nerve the second cranial nerve (II) which is responsible for vision. Each nerve contains about one million fibres that receive information from the rod and cone cells of the retina. It passes into the skull behind the eyeball to reach the optic chiasm after which the visual (or optic) pathway continues to the cortex of the occipital lobe of the brain on each side (see illustration).
20Endoscopic Sinus Surgery (ESS) Oxford concise colour medical dictionary ds ist 253 ij fuEu izdkj crk;k x;k gS%& ENDOSCOPIC SINUS SURGERY (ESS) surgery of the paranasal sinuses using endoscopoes. Functional endoscopic sinus surgery ( FESS) clears inflammed tissue from routes of sinus drainage and aeration to allow the other sinuses to return normal.
,sls vkWijs'ku esa vkWa[k dks [krjk ugha gks blds Prevention nks izdkj ds gS Preoperative Prevention tks fuEu izdkj gS%& Prevention The prevention of blindness is more important than the treatment because the well-prepared surgeon will have a minimal risk of this complication occurring.
PREOPERATIVE PREVENTION It is important to select patients carefully for endo- scopic sinus surgery. All patients must be screened for potential risks of hemorrhage. A history of bleeding must be obtained, and proper laboratory studies must be evaluated (prothrombin time (PT), partial throm-boplastin time (PTT), platelet count, bleeding time, liver function) before surgery is performed. All medi-cations that might affect clotting must be stopped. As- pirin and aspirin-related or aspirin-containing com-pounds must be stopped 2 weeks before surgery. In my experience, patients on long-term steroid therapy also tend to have more problems with bleeding.
Medical problems such as untreated or poorly con- trolled hypertension should be evaluated before surgery and stabilized. Hypertension has been related to blind-ness that occurs after blepharoplasty. 9 Pathologic conditions of the eye must be uncovered preoperatively. Preoperative ophthalmologic evaluation may uncover amblyopia, glaucoma, anisocoria, or fun-doscopic abnormalities such as retinal vascular disease or diabetic retinopathy. At the minimum, a careful his-tory of eye disease should be recorded along with gross vision testing that involves the patient's ability to read fine print, with each eye being tested separately. Pa-tients who have poor retinal circulation and undetected glaucoma may not be able to tolerate even a small rise in orbital pressure.
Patients with extensive disease, long-standing chron-ic sinusitis, and/or polypoid disease, or who have un-dergone multiple previous procedures, may have ana-tomic changes related to previous surgery or disease that make them more susceptible to orbital hematoma and blindness. Extensive 21 disease can obstruct and distort anatomic landmarks, whereas chronic long-standing disease, including polyps, can actually cause gradual erosion of the lamina papyracea and directly expose the periorbita to the nasal cavity. Multiple pre-vious procedures, especially external procedures, can cause enough anatomic change and distortion to confuse the surgeon and again expose the periorbita to the nasal cavity. Freedman and Kern 10 identified these as possible factors related to increased complications during eth-moidectomy. Many of these problems can be uncovered during the preoperative examination, which should in-clude endoscopy. Palpation of the eye during endoscopy may make the surgeon aware of dehiscence in the lam-ina papyracea.
When viewed closely, the preoperative computed to- mography (CT) scan of the axial and coronal views of the sinuses may show thinning or absence of the lamina papyracea or posterior air cell, whose lateral extent is contiguous with the optic nerve. In some cases, special orbital views may delineate a dehiscence of the lamina papyracea more clearly.
The training and experience of the surgeon should be commensurate with the difficulty of the case. Ca-daver dissection and preparation study like that required for temporal bone dissection is necessary before per-forming endoscopic or microscopic surgery. If the sur-geon has a great deal of apprehension before performing endoscopic or microscopic surgery, he or she probably should not be performing that surgery. It cannot be stressed enough that the patient should be informed of all possible complications, especially blindness. Pa-tients should also be informed of the extent of their disease and the fact that the nature of their disease or previous surgery may subject them to a greater risk. There is absolutely no excuse for withholding infor-mation from a patient for fear of losing that patient.
rFkk vkWijs'ku ds le; D;k /;ku j[kuk pkfg, og fuEu izdkj gS%& Operative Prevention The decision for anesthesia depends on the operating surgeon and the patient. Surgeons must know their abilities to provide appropriate local anesthesia, and the patient must be able to tolerate a local anesthetic. A good local anesthetic is advantageous because it leads to a decrease in bleeding, to an increase in the awareness of the surgeon to increased patient discomfort at the skull base and periorbita, and because it allows patient cooperation in the case of loss of vision. However, it is my experience that the vigilant surgeon can also perform surgery safely using a general anesthetic. provided strict guidelines are adopted. These guidelines include termination of a procedure when bleeding obscures the surgeon's vision and when signs of apparent entrance into the 22 orbit are manifest (e.g., lid edema, clearly ecchymosis, proptosis, pupillary change).
The endoscopic surgeon must constantly be aware of anatomic location, and any surgical landmark that can help orient to locarion is important. The endoscope is not a binocular instrument and can cause problems with depth of field, so it is important to look with the naked eye on occasion to help gauge distance. With the en-doscope in place, there is a different orientation be-tween the right and left sides to the right-handed sur-geon. On the right side, the sinuses appear straight in front and go straight back as the procedure proceeds posteriorly. On the left side, in the superior ethmoid cells, the surgeon must stay more medially between the middle turbinate and lateral wall or scope orientation will take the surgeon straight into and through the lam-ina papyracea (Fig. 1). The eyes should be uncovered so that they can be observed and palpated at all times. Protective goggles and occlusive tape should be strictly avoided. The surgeon should consider performing sur-gery on the right side first in bilateral procedures. One study showed that more complications occurred on the right side. 10 The surgeon should be aware that the infundibular incision may lead into the lacrimal sac or trochlea if the anterior ethmoids are particularly shallow. It is im-portant that the maxillary sinus be entered with the surgical instrument lying on top of the inferior turbi-nate. Attempting to seek out and identify the natural ostia may be difficult because its position will vary, and too high an entrance attempt may put the instrument into the orbit. Once the antrostomy is safely made. the surgeon may search for the natural ostia if it has not been located and include it in the antrostomy. As an additional point of anatomy, the inferior orbital rim is usually at the same level the antrostomy should be. Establi shing the identity of the lamina papyracea is very important. A technique that has been used very suc-cessfully to identify the lamina papyracea is a maneuver in which the eye is palpated and, simultaneously, the lateral wall is carefully examined with the endoscope. This maneuver can accurately identify dehiscence of the lamina papyracea, locating periorbital or orbital fat, making the surgery much safer and more precise (Fig. 2) . The lateral or superior rim of the antrostomy is continuous with the lamina papyracea and provides a lateral boundary to dissection . Lessons also can be learned from the past. An assistant's finger on the me-dial orbital rim can perceive vibrations from the lamina papyracea and indicate entrance into the orbit. The lat- eral sphenoid sinus wall is usually never more lateral than the posterior lamina papyracea and posterior eth-moid sinus. Leaving the eyelids open can help indicate entrance into the orbit if the eyeball is seen to move during ethmoidectomy. If orbital fat is encountered, it must not be removed or tampered with. The patient should be observed closely for signs of orbital hema-toma. Orbital fat exposure often results in orbital hem-
23orrhage. In most cases, orbital changes will progress no further than lid edema and ecchymosis, especially if the eye is massaged. However, marked orbital he-matoma can occur and lead to proptosis and vision loss. If evidence of orbital hematoma is apparent, no further surgery should be performed. Anesthesia should be ter-minated, and the patient should be observed closely. Obvious orbital fat exposure with signs of hematoma merit con sideration for admiss ion because cases of gradual proptosis and blindness have occurred over 24 to 48 hours postoperatively. I I The last consideration concerns orbital packing. If a dehiscence in the lamina papyracea is apparent or or-bital fat is present, packing should be avoided. Too heavy a pack may itself contribute to increased ocular pressure . If the patient is bleed ing, an attempt to control bleeding with suction cautery should be attempted. If this is unsuccessful, a small Merocel pack for bleeding control might be helpful. The eye must be observed closely. Most bleeding can be controlled. but in this circumstance, the eye is more important. The use of Gelfoarn, cocaine pledgets ,Neo-Synephrine, or antith-rombostatic agents may be helpful. Overpacking is dan-gerous.
It is prudent to inform the patient and his or her family of any problems that occurred during surgery, stressing the potential for postoperative complications . It is also good to review the potential postoperative complica-tions with the family and discuss how they might assist in observing these complications . The recovery room and floor nurses should be informed about complica-tions that can occur, proper monitoring of the patient, and where the surgeon can be reached. Patients who do not live near the hospital (30 to 45 minutes away) should be kept in the hospital overnight for close ob- servation . Although many endoscopic ethmoidectomy patients can have surgery as outpatients, rigid guide-lines and checks must be followed before the patient is discharged.
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