State Consumer Disputes Redressal Commission
Dr. Anugrah Tiwari vs Star Hospital And Others on 13 February, 2023
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/252/2015 ( Date of Filing : 04 Nov 2015 ) 1. Dr. Anugrah Tiwari Gorakhpur ...........Complainant(s) Versus 1. Star Hospital and others Gorakhpur ............Opp.Party(s) BEFORE: HON'BLE MR. Rajendra Singh PRESIDING MEMBER HON'BLE MR. SUSHIL KUMAR JUDICIAL MEMBER PRESENT: Dated : 13 Feb 2023 Final Order / Judgement Reserved State Consumer Disputes Redressal Commission U.P. Lucknow. Complaint Case No.252 of 2015 Dr. Anugrah Tiwari, aged about 46 years, S/o Sri Indrajit Tiwari, R/o D-34, Surankund Colony, Gorakhpur (U.P.) ...Complainant. Versus 1- Star Hospital through its Director, Dr. Vijahat Kareem, Bank Road, Gorakhpur. 2- Dr. Vijahat Kareem, M.S., Star Hospital, Bank Road, Gorakhpur. 3- Dr. S.M. Sinha, Sarla Clinic Evam Teeka Kendra, Ganga Complex, Betiyahata Chauk, Kasaya Road, Gorakhpur. ...Opposite parties. Present:- 1- Hon'ble Sri Rajendra Singh, Member. 2- Hon'ble Sri Sushil Kumar, Member. Sri PratushTipathi, Advocate for the complainant. Sri Kamal Kumar Singh Visht, Advocate for OPs. Date : 28.2.2022 JUDGMENT
Per Sri Rajendra Singh, Member- This complaint has been filed by the complainant Dr. Anugrah Tiwari under section 17 of the Consumer Protection Act, 1986 for following reliefs:-
That the respondents be directed to pay Rs.7,00,000.00 (Seven lacs) as cost/ expenditure incurred in the treatment of the patient/son of the complainant and they are further be directed to pay Rs.5,00,000.00 (five lacs) for the expenditure incurred in travelling, stay at Delhi (Gurgaon) & Lucknow and other miscellaneous expenses.
That the respondents be directed pay Rs.10 lacs as compensation for physical and mental agony of the complainant and his family and the respondents be also directed to pay Rs.50 lacs as damages for their act due to which the son of the complainant has become handicapped for life time.
That the respondents be directed to pay Rs.25,000.00 towards the cost of litigation.
Any other relief as this Hon'ble Commission thinks just and proper in the given facts and circumstances of the case.
The brief facts of the complaint case are that, that the complainant is an assistant professor in St. Andrews College, Civil Lines, Gorakhpur. On 14.11.2013, the only son of the complainant namely Mater Adwitiya, aged about 6 years (aged about 4 years at the time of incident), was suffering from fever and chest congestion due to which he had contacted respondent no.3 who advised the complainant to admit his son of the complainant for necessary treatment. Thereafter, the son of the complainant was admitted in the respondent no.1 hospital by the respondent no.3 who had initiated the process of treatment immediately after the said admission of the son of the complainant on the very same day i.e. 14.11.2013. It is very much important to submit here that the antibiotic injections were given to the son of the complainant for which a Catheter (Intravenous) wasinserted by the respondent no.3 on the left hand of the son of the complainant. It is also important to submit that after the necessary treatment, the son of the complainant was discharged by the respondentno.3 from the respondentno.1 hospital, on 1611.2013 but the Catheter (intravenous) was not removed by the respondentno.3 at the time of discharge because as per the advice of the respondentno.3, the course of the said antibiotic injection was to be continued up to 19.11.2013 which were regularly given/injected by the respondent no.3 to the son of the complainant till 19.11.2013.
On 19.11.2013, after the last injection of the said antibiotics, when the above mentioned Catheter (intravenous) was removed by the opposite party no.3 at his clinic, it was noticed by the complainant the there was a swelling on the hand of his son from where the said catheter (intravenous) was removed by the opposite party no.3 and a blackening/black spot was also there between the middle and ring finger of the son of the complainant. The complainant immediately told opposite party no.3 about the aforesaid blackening and swelling and asked the reason of the said swelling and blackening, in response to which, it was replied by the opposite party no.3 that it is a normal phenomena and a normal consequence of insertion of catheter (intravenous) which will subside automatically/gradually within two or three days.
By the next day, i.e. 20.11.2013, the size of the aforesaid blackening was bigger than it was on the last day, therefore, the complainant again contacted opposite party no.3 in the afternoon and made a complaint to him in this regard but again he took it very casually and prescribed an ointment namely "T-Bact" for local application which was used/applied by the complainant as directed by the opposite party no.3 but instead of getting relief, the said blackening and swelling became bigger and worse in the evening of the very same day, hence the complainant again took his son to the opposite party no.3 for examination and advice and only then the opposite party no.3 has carefully examined the son of he complainant and it was opined by him that it is a case of "Cellulitis" and referred it to the opposite party no.2 for the necessary treatment because as per t he opposite party no.3 the further treatment can be continued in this regard by an expert surgeon only. Thereafter, the complainant immediately contacted to the opposite party no.2 on the very same day i.e. 20.11.2013 who had examined the son of the complainant in a very casual manner and instructed a junior doctor to do a dressing over the place of said blackening which was done by the said junior doctor and it was assured by the opposite party no.2 that everything will be alright.
When the complainant enquired in detail from the opposite party no.2 about the disease of this son as he wanted to know that whether it is a case of cellulitis or not; the opposite party no.2 got annoyed and replied in a very rude and a very overconfident manner that he is an old, experienced and reputed doctor and he has no time to waste for such irrelevant queries and he has already done the needful in this case. The opposite party no.2 instructed the complainant to come on the next day for necessary dressing and it was assured by him that it was not a case of cellulits and the things will be alright after three or four dressings.The complainant came back home and was under the bona fide belief that he has rightly been advised by the opposite party no.2 who is a very senior surgeon of the locality. At this juncture, it is very much important to submit that on the same night (on20.11.2013) the brother-in-law of the complainant who is a senior government doctor in the state of Madhya Pradesh and was posted in Bhopal, had a talk with the complainant regarding the health condition of the son of the complainant. The complainant had narrated all the things to his brother-in-law who after hearing all situation told the complainant that as per the symptoms, it is a clear case of 'Gangrene' and advised him to leave immediately for a better and higher centre like King George Medical University or Sanjay Gandhi Post Graduate Institute of Medical Sciences because the delay could be dangerous for life in this case.
The complainant got surprised and shocked because none of the previous treating doctors (opposite party no.2 & 3) had informed him about this dangerous situation and none of them had taken it seriously and the complainant had not been advised properly/ accordingly by them, hence, he contacted to the respondent no.3 telephonically who told to the complainant that in the next morning he will contact to the opposite party no.2 and thereafter the necessary further course of action will be decided. Thereafter, the complainant has got the bona fide reason to believe that the opposite party no.2and 3 were not taking the case of his son seriously, because the time factor was very important and precious in this condition/case and they are advising the complainant not to worry and to wait and watch, therefore, the complainant immediately rushed to Lucknow through his own vehicle and reached Lucknow on 21.11.2013. In Lucknow the complainant contacted the doctors of KGMU, where the son of the complainant was admitted and his 'Doppler Test' was conducted on the advise of the concerned doctors which revealed that the flow of blood was almost absent in the middle finger of the son of the complainant and it was a case of 'thrombosis in the digital arteries' and it was diagnosed by them as Gangrene in left hand. Thereafter, the complainant was advised by the concerned treating doctors of KGMU to go to a higher centre for further management. After this, the complainant immediately managed some air tickets for Delhi and went to Medanta Hospital, Gurgaon and the very next morning i.e. 22.11.2013.
In Medanta Hospital, the case of the son of the complainant was taken as an emergency case and immediately a team of the doctors attended the case of the son of the complainant and after the physical examination of the patient and the previous reports, the complainant was advised for immediate surgery of the affected area (palm and finger) because in the opinion of the doctors, the middle finger was completely dead and had to be amputated immediately to avoid the spread of the effect of Gangrene. It was assured by the doctors that they will try their best to save the ring finger of the patient which was also badly affected and difficult to save. Thereafter, the necessary routine tests for emergency operation were conducted immediately but the said operation could not be performed on 22.11.2013, as it was revealed in the pathological examination that the sugar level in the blood of the patient was very high. The doctors took the time of entire day to control the sugar level in the blood of the patient and thereafter the necessary emergency operation was conducted in Medanta Hospital the next day i.e. 23.11.2013, in which the middle finger of the patient was amputated and the debridement of the ring finger was done wih the hope to save the ring finger of the patient. The said debridement of the ring finger was again done in order to save the same but no fruitful result could be achieved and finally the doctors had to amputate the ring finger of the patient also, later on, in order to save the life of the patient.
Thereafter, the son of the complainant was admitted in Medanta Hospital till 16.12.2013 but the treatment and stay in Delhi was very expensive and it was unaffordable for the complainant, hence he asked for alternative/less expensive treatment/post operative management for the patient. On this query of the complainant, it was advised by the doctors of Medanta Hospital that now the things are under control but the level of post operative management can alternatively be done at SGPGI also and accordingly the patient was discharged on 16.12.2013 from Medanta Hospital and shifted to SGPGI, Lucknow from Medanta Hospital, Gurgaon. The son of the complainant was admitted in SGPGI, Lucknow for further post operative management till 10.1.2014 and thereafter, he was discharged from SGPGI and went back to Gorakhpur but regularly coming to SGPGI, Lucknow for follow up/check up after an interval of 15 days for further about two months and the treatment of the patient is still continue.
In the afore-mentioned treatment of the son of the complainant, more than Rs.12 lacs were spent by the complainant which was only due to the aforesaid negligent act of the respondents because once he opposite party no.3 himself was initially of the view that it was a case of 'Cellulitis' and referred it to the opposite party no.2 for further management, then it was the duty of the opposite party no.2 to take necessary steps to rule out the possibility of 'Cellulitis' which was not done by opposite party no.2 and the he has taken the matter very casually and in an irresponsible and negligent manner due to which the complainant fell in such a dangerous situation and if the complainant had not acted as per his own wisdom later on, it may have been dangerous for the life of his son. Similarly, when the treating doctor had been informed by the complainant about this dangerous situation and careless attitude of opposite party no.2, he also took it very lightly and advised the complainant to wait and watch and did nothing which was needful in the situation and did not advise the complainant in a fair manner which was needful in the situation, which was the duty of both the opposite parties no.2 & 3 as prudent medical men.
Due to the aforesaid negligent act of the respondents, the son of the complainant has become handicapped for his lifetime and further, the complainant and his son and family had suffered from physical and mental agony and he had suffered from pecuniary loss also, and in this way the opposite parties have committed gross negligence in service and adopted unfair trade practice therefore, the opposite parties are liable to pay the compensation accordingly to the complainant because, by such gross deficiency in service and unfair trade practice committed by the opposite parties, the complainant has been subjected to immense mental agony, harassment and pecuniary loss and it is a clear case of deficiency in service on the part of the respondents towards the complainant and the present case is completely covered by the provisions of the Consumer Protection Act, 1986.
The opposite parties no.1& 2 have jointly filed their written statement and stated that the complaint is misconceived and groundless. The State Commission has no jurisdiction. The son of the complainant was admitted in the hospital from 14.11.2013 to 16.11.2013 for the treatment under Dr. S.M. Sinha, respondent no.3. It is respectfully submitted that on 20.11.2013 the patient was referred by Dr. S.M. Sinha and when the patient reached the hospital at 8.30 p.m., the opposite party no.2 was busy in operation. When he came out from operation theatre, the junior doctor briefed him about the condition of the patient. The patient was examined and advised necessary tests and dressing was done. It was told to the complainant that it is case of "Cellulitis" and he was advised to come daily for dressing. The answering opposite party also told the complainant that if it is not cured, it will require operation. Further he was also told that if he is not satisfied, he can go to higher centre for treatment. After this the complainant and the patient never came back.
The allegation leveled against the opposite party no.2 is false and misconceived. The complainant is trying to misguide the Hon'ble State Commission by creating a wrong picture. The complainant earlier hospitalised in the hospital under the supervision of Dr. S.M. Sinha. He was discharged on 16.11.2013 and after that he came on 20.11.2013. Then he was properly advised about the condition of the patient and thereafter, the patient did not ever come. The opposite party no.2 has properly advised the complainant to take care of the patient and there was no breach of duty and injury suffered by the patient as no casual connection with answering opposite parties.
The opposite party no.3 has also filed his written statement in which he has stated that the Hon'ble State Commission has no jurisdiction to try the case and the complaint is false, baseless and flagrant abuse of process of law. The complainant came on 14.11.2013 as a case of WALRI (Wheeze associated Lower Respiratory Infection) i.e. respiratory distress and he was admitted in Star Hospital, Gorakhpur and he was discharged on 16.11.2013 on the complainant's request. It is respectfully submitted that in two days time the child (patient) improved considerably and on the attendants (including complainant) request the patient was discharged on 16.11.2013. At the time of discharge of patient the answering respondent no.3 strictly advised the complainant of nebulization the patient trice and IV (intravenous) Traxol Injection to be given twice daily along with supportive treatment. Since the attendants were staying in Suraj Kund Colony, Gorakhpur they along with complainant said that since it was only a question of getting nebilization and IV injection through intracath, it could be managed by him from his home since there is pediatric Nursing Home in Suraj Kund Colony, Gorakhpur. Furthermore staying another three days more in the Hospital would have incurred more expenses. Neither during Hospital stay by him nor removed by him. It was also given by the paramedical staff. This fact is not only true in this case alone but in every case it is done by paramedical staff. Also after discharge from Star Hospital, Gorakhpur on 16.11.2013 the complainant never contracted nor showed the patient till 19.11.2013. Since the condition on 19.11.2013 was much better the attendants were advised to stop the IV injection and the intracath removed. After discharging the patient on 16.11.2013 the complainant never contacted nor showed the patient till 19.11.2013. Sincethe condition on 19.11.2013 was much better and as such it was advised to stop the IV injection and the intracath removed.
On 20.11.2013, the complainant brought the patient with signs suggestive of Cellulitis at the intracath site to which the answering respondent no.3 prescribed for local application and referred the case to surgeon for expert management. Thereafter, the complainant and patient never came to him. The complaint filed by the complainant the same are false, misconceived, frivolous, concocted and hence, vehemently denied. The complainant is trying to mislead this Hon'ble State Commission by creating a wrong picture.
The patient was discharged on 16.11.2013 on the complainant's request and the complainant was strictly advised for nebulizing the patient thrice and IV (intravenous) Traxol Injection to be given twice daily along with supportive treatment. On 19.11.2013, the condition of the patient was much better and as such, he was advised to stop the IV injection and the intracath removed. Thereafter, on 20.11.2013 the complainant brought the patient with signs suggestive of Celulitis on the intracath site to which the answering opposite party no.3 prescribed medicine for local application and referred the case to surgeon for expert management.
The complaint filed by the complainant clearly reveals that no case of negligence has been made out against the answering opposite party no.3.The complainant came along with his son (patient) on 14.11.2013 as a case of WALRI (Wheeze associated Lower Respiratory Infection) i.e. respiratory distress and he was admitted in the Hospital and was discharged on 16.11.2013 on the request of the complainant. Thereafter, he came to opposite party no.3 only on 19.11.2013 and since his condition was much better and as such, he was advised to stop the IV injection and the intracath removed. He again came on 20.11.2013 alongwithpatient with signs suggestive of Celulitis at the intracath site to which the answering opposite party no.3 prescribed for local application and referred the case to surgeon for expert management. The answering opposite party no.3 has properly advised the complainant whenever he came and did not abridge his duty to take care of patient nor there is any breach of duty and the injury suffered to the patient has not casual connection with the answering opposite party no.3.
We have heard ld. Counsel for the complainant Sri Pratush Tripathi and ld. Counsel for the opposite parties Sri kamal Kumar Singh Visht and perused the entire record. CHECKED This matter rates to intravenous catheter. First we have to see about this catheter, aim and management.
Introduction Peripheral intravenous catheters (PIVCs) are the most commonly used intravenous devices in hospitalisedpaediatric patients. They are primarily used for therapeutic purposes such as administration of medications, fluids, and blood products.
Illustration by The Royal Children's Hospital, Melbourne Aim The aim of this guideline is to provide an outline of the ongoing maintenance and management of the PIVC for patients in hospital, outpatient, and home healthcare settings. For information related to insertion of PIVC, please refer to intravenous access guideline (https://www.rch.org.au/clinicalguide/guideline_index/Intravenous_access_Peripheral/). Nurses who are deemed competent in IV insertion could continue to insert PIVC in consultation with NUM/CSN's.
Definition of terms A peripheral intravenous catheter (PIVC) is a thin plastic tube inserted into a vein using a needle. PIVCs allow for the administration of medications, fluids and/or blood products.
Aseptic technique - aims to prevent pathogenic microorganisms in sufficient quantity to cause infection, from being introduced to susceptible sites by hands, surfaces and equipment. Therefore, unlike sterile techniques, aseptic techniques are possible and can be achieved in typical hospital and community settings. It is a set of practices designed to reduce contamination and protect the patient from infection during invasive procedures such as PIVC insertion and maintenance. Maintaining asepsis is crucial for preventing microorganisms from entering the patient Decontaminate hands - Effective hand hygiene is an essential component of Aseptic Technique. Hand hygiene is performed to protect the patient from organisms which may enter their key sites or key parts during a procedure.
Key Parts are parts of the device/s that must remain aseptic throughout the clinical procedures. Examples of key parts include, the catheter hub, needleless connector, syringe hub and needle.
Double checking - refers to the practice of two clinicians (appropriately endorsed Enrolled nurses (EN), Registered Nurses (RN), Doctors or Pharmacists) independently checking the medications.
Key Parts are the equipment or solutions that must remain aseptic throughout the clinical procedures by ensuring that key parts only have contact with other aseptic key parts and sites to protect the patient from contamination or infection e.g. wound dressing, syringe hub, needle etc. These parts of the device/s that must remain aseptic throughout the clinical procedures. Examples of key parts include, the catheter hub, needleless connector, syringe hub and needle.
Key Sites the area on the patient such as a wound or intravenous (IV) insertion site that must be protected from microorganisms. Another example is any catheter insertion site.
Infiltration and extravasation injuries occur when the tip of the PIVC has slipped out of the vein and fluid, or medication unintentionally leaks into the surrounding tissue. An extravasation injury is distinguished from an infiltration injury when the type of infusate is a vesicant.
Infusion Pump refers to infusions pumps like large volume pumps (LVPs)/volumetric pumps (e.g. Plum 360™), Syringe drivers (e.g. Alaris GH+™), Patient Controlled Analgesia/PCA pumps (Alaris PCAM™) etc. Phlebitis is a sign of vessel damage. The cause can be chemical (due to the osmolarity of the solution), mechanical (from trauma at insertion or movement) or infective (microorganisms contaminating the device). Signs include swelling, redness, heat, induration, purulence, a palpable venous cord (hard vein) and pain related to local inflammation of the vein at or near the insertion site.
Scrub the hub refers to scrub access point vigorously with 2% chlorhexidine and 70% alcohol swab for 15 seconds and allow for it to completely air dry.
Assessment Patient and IV site assessments should be done on a regular basis.
PIVC assessment includes:
Assessment of PIVC insertion site: Assessment is to include the catheter position, patency/occlusion, limb symmetry, any signs of phlebitis (erythema, tenderness, swelling, pain etc.) pressure injuries, and for signs of infiltration/extravasation injuries. Paediatric patients are considered a vulnerable patient population therefore, the PIVC insertion site should be checked hourly when continuous infusions or medications are running. http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pressure_Injury_Prevention_and_Management/.
Assessment of PIVC dressing and splints: check securement of the PIVC dressing and securement devices and ensure they remain clean, dry, and intact. Ensure the splint tapes are not too tight or restrictive and that the insertion site remains visible for assessment Assessment of IV lines, equipment and IV fluid infusions:
If the patient is receiving continuous IV fluid infusion- observations of the IV site, type of fluid and volume infused, and accurate rate of infusion should be observed hourly and documented in the fluid balance flowsheet.
If the patient no longer requires IV access for infusions, remove the cannula at the earliest to avoid complications.
If the patient (inpatient setting) is having intermittent infusion, eight hourly assessments are a minimum. Unstable patients who have signs and symptoms of complications are to be assessed more frequently.
For Wallaby (Hospital-in-the-Home) patients, the nurse will assess the PIVC with each visit.
Caregiver and patient education will be provided on the signs of injuries and the process of contacting the nurse.
Management Administration of intravenous fluid, drug infusions or blood products
a) Continuous infusion of IV fluids Assessment and documentation of findings are to be completed hourly to determine effective delivery of prescribed medications and fluid.
Each bag of fluid is independently double checked, and a signed patient label is put on the bag. Check the solution is the prescribed one, the rate of infusion, and the amount infused is noted. Document the infused volume: Hourly on fluid balance flowsheet (it is advised to clear the infusion pump hourly) Check the infusion site for any signs of complications and document the assessment findings hourly in fluid balance flowsheet Review the cumulative volume infused and fluid output as required based on patient's clinical condition Infusion Pump Pressure Pressure limit defaults for intravascular infusion pumps are programmed by Biomedical Engineering, based on the manufacturer's recommendations.
Upper limit infusion pump pressure can be manually increased with clinical discretion to accommodate:
Increased viscosity of the fluid being administered High rate of the fluid being administered Reduced diameter of the intravascular catheter Increased length of the intravascular catheter Increased level of patient activity If pump pressure exceeds the recommended limits, check the patency of the PIVC.
Special consideration: Patients admitted to the Neonatal Unit should have line pressure documented within the Peripheral IV Cannula Lines, Drains, and Airway (LDA) tab.
b) Administration of bolus/loading doses:
Administering drugs:
Drugs administered via PIVC may be diluted into a bag of IV fluids added to the burette of an infusion set prepared for administration via a volumetric infusion pump in a syringe for use in a syringe driver administered directly as a bolus or push The most appropriate method should be selected depending on volume of diluent required, patient condition, fluid balance and intended rate of delivery.
Drugs administered via:
Burette of an infusion set: to dilute the drug in a smaller volume via burette giving system, hang the bag of infusion fluid and gradually open the roller camp to allow appropriate amount of diluent into the burette. Inject the prescribed drug into the burette via the additive port.
Line B (of the Plum 360™ pump): Certain medications can be infused as a secondary infusion through a syringe or infusion bag via line B. Syringe driver: is recommended for children weighing less than 10kg. Draw up required volume of diluent in appropriate size syringe and then pull back the syringe plunger to enable you to inject the drug into the syringe using principles of aseptic technique.
Infusion bag: Scrub the hub prior to access of additive port before injecting prepared drug into infusion fluid bag. Without contaminating the key part (spike)using a non-touch technique insert the spike of the administration set into the septum of the infusion bag.
Attach a completed drug label detailing the drug, dose, diluent, volume of diluent, date, time and signature of the nurse and the staff who double checked.
Access PIVC only after scrubbing the hub.
For intermittent infusions, IV lines which are disconnected are to be discarded between infusions.
Ensure the cannula is flushed with normal saline once the giving set is disconnected from the cannula.
For Opioid infusion bolus refer to the specific guidelines: Children's Pain Management Service (CPMS) (opioid infusion guideline) Flushing of PIVC's If the cannula is to be accessed intermittently for the administration of medications or fluids, the cannula should be flushed prior to infusion or at least once a shift.
Sterile 0.9% sodium chloride for injection should be used to flush a catheter. This must be prescribed as a medication.
The optimal volume used for intermittent injections or infusions is unclear. The literature suggests the volume of flush should equal at least twice the volume of the catheter and add on devices and a minimum of 2mL normal saline flush is recommended.
Use 10mL syringe for flushing to avoid excessive pressure and catheter rupture. Syringes with an internal diameter smaller than that of a 10mL syringe can produce higher pressure in the lumen and rupture the catheter. If resistance is felt during flushing and force is applied this may result in an infiltration or extravasation injury Use aseptic non touch techniques including cleaning the access port (scrub the hub) vigorously for at least 15 seconds and allowing to dry prior to accessing the system.
Flush the PIVC using a pulsatile flushing technique (push pause motion).
Flush catheters:
Immediately after placement Prior to and after fluid infusion (as an empty fluid container lacks infusion pressure and will allow blood reflux into the catheter lumen from normal venous pressure) or injection.
Prior to and after blood drawing.
Change of PIVC dressing and securement of cannula:
Dressings to PIVC sites are the first line of defence against infection and dislodgements. The dressing must be kept secure, clean dry and intact.
Indications for dressing change include when it becomes insecure or if there is blood or fluid leakage under the dressing.
Determine the need for an assistant considering patient age, developmental level and family participation prior to the procedure.
If patient is allergic to transparent film dressings, use sterile film dressing to be used and changed daily.
Carefully remove the old dressing, always holding the cannula in place. Loosen the edge of the dressing/tape and remove 'low and slow' in the direction of hair growth, keeping it close to the skin surface while pulling it back over itself, and supporting the newly exposed skin with your other hand.
Take the opportunity to thoroughly inspect the site of entry of the cannula for any sign of infection.
Skin preparation use 2% chlorhexidine and 70% alcohol swab or solution for dressings.
Cleanse the area around the catheter insertion site including under the hub using a pattern which will ensure entire area is covered.
Allow skin preparation to air dry prior to applying any dressing, this allows the disinfectant to work.
Consider placing a small piece of sterile cotton wool ball or gauze underneath the hub of the cannula to reduce pressure.
If desired, place sterile tape over the hub of the device before placing the transparent dressing.
Cover the cannula insertion site with sterile transparent semipermeable, occlusive dressing (e.g. Tegaderm™, IV 3000™) placed using an aseptic non touch technique over the catheter. This will allow continuous observation of the site and to help stabilise and secure the catheter.
IV board / splints are recommended to secure PIVC placed in or adjacent to areas of flexion. This will adequately immobilize the joint and minimise the risk of venous damage resulting from flexion.
When using Splints, ensure these are positioned and strapped with the limb and digits in a neutral position to prevent injury from restricting blood or nerve supply and to prevent pressure sores.
Inspect the splint at least daily and change if soiled by blood or fluid leakage.
Cover with non-compression tubular bandage. Ensure there is a clear window where the cannula enters the skin- insertion site, so the site can be regularly viewed.
In Summary, when dressing a peripheral IV cannula ensure:
it is secure the site is visible the child can't injure themselves, or be injured by the connections the child can't remove or dislodge the cannula tapes are not too tight or restrictive.
Refer to Intravenous access-Peripheral guideline for steps involved in accessing and securing the cannula http://www.rch.org.au/clinicalguide/guidelineindex/Intravenous_access_Peripheral/ Documentation shall contain information on the insertion site, gauge of the needle and date and time of insertion has been documented in the EMR- LDA properties.
Change of Extension sets Extension sets are to be changed when the access device is changed or immediately upon suspected contamination or when any break in integrity.
Extension sets are to be primed and attached to the cannula at the time of IV insertion using an aseptic non touch technique When exiting the flushing of extension set you must use a positive pressure clamping technique.
When not in use, extension sets must be clamped IV Fluid Considerations via Peripheral IV line Which Fluids and how much fluids to use Refer to the Intravenous Fluids Clinical Practice Guideline: Intravenous Fluids Administering fluids containing glucose concentration greater than 12.5% will require central venous line access due to the risk of vascular endothelial damage.
Labeling infusions:
Label the fluid bag/syringe with date, time, patient name and signature of two checking staff.
Label IV line if multiple lines are running: label close to the fluid bag or syringe or below the drip chamber.
If additives are added to infusion, please label the bag or syringe driver with additives added.
Approved label can be generated by the EMR.
Table 1.Changing IV bags and lines Task Minimum frequency of changes Aseptic technique method (based on risk assessment) Fluid bag/syringe with additive Every 24 hours Standard aseptic technique Fluid bag/syringe with no additive Every seven days Standard aseptic technique Giving set with lipid or blood products Every 24 hours Standard aseptic technique Giving set (with no TPN) Every seven days Standard aseptic technique Giving set with TPN and in-line filter With every new bag of nutrient Standard aseptic technique Giving set with in-line filter and no TPN Every 96 hours Standard aseptic technique Needleless connectors, extension sets or three-way taps Every seven days Surgical aseptic technique NOTE:
All components are to be changed earlier if the integrity of the dressing is compromised or if there is any visible debris in any of the add on devices or needleless connectors.
The outside tubing of the Primary PLUM™ giving sets are NOT sterile and are not to be placed on a surgical aseptic field.
Administration sets that have been disconnected (either accidentally or planned) are no longer sterile and are to be discarded and replaced.
Removal of PIVCs:
There is no evidence for routine replacement of PIVC unless clinically indicated. PIVC's should be maintained with regular assessment and documentation of complications.
The possible reasons for removal of PIVC's include a number of complications which range from infiltration, extravasation, phlebitis, occlusion, dislodgement and migration. Once the child's treatment is over, the PIVC should be removed to avoid any additional complications.
Perform hand hygiene Prepare patient and caregiver Perform hand hygiene and apply non-sterile gloves, carefully remove the adhesive dressing, holding the cannula in place at all times Hold a piece of sterile gauze or cotton wool over the exit site but do not apply pressure Slowly withdraw the cannula, maintaining a neutral angle with the child's skin Cover site with dressing e.g. pressure dot, cotton wool and tape or Band-Aid™ Advise the child and family that the cotton wool and tape or Band-Aid should remain in situ for up to 24 hours Remove gloves, perform hand hygiene Dispose of waste according to clinical practice, perform hand hygiene Document date and reason for removal. Ensure the device is also removed from the LDA in EMR.
Management of complications There are a range of complications that could occur with the presence of a PIVC in situ. Some of these complications can be prevented by the correct use of aseptic technique for insertion and maintenance as well as assessing the device as indicated.
Common complications are:
Infection:
Skin-based bacteria may enter through insertion site Local cellulitis or systemic bacteraemia are possible.
Phlebitis: Vein irritation Due to the presence of the catheter/fluids or medication Chronically ill patients requiring multiple and recurrent IV access.
Infiltration/Extravasation: delivery of fluids or medications into surrounding tissue If Infiltration/extravasation occurs refer to the extravasation injury management nursing guideline Abstract Background We studied the complications of peripheral intravenous (IV) catheters in the hand and forearm in a teaching hospital over a 3-year period.
Methods The records of 67 patients who developed IV catheter-related complications were reviewed.
Results The most common sites for developing complications in order of frequency were the forearm, hand, wrist, and antecubital fossa. There were 56 minor and 11 major complications. More than 50% of minor complications occurred in the hand and wrist, and more than 50% of major complications occurred in the hand. In 68% of minor complications, the patients were aged 50 years or older and 68% were women. Minor complications comprised 26 intravenous infiltrations, 23 cases of thrombophlebitis, and 7 cases of cellulitis. Ninety percent of major complication patients were aged 50 or older and 82% were women. Major complications included septic thrombophlebitis in three; hematomas resulting in skin necrosis in two; and infiltration related complications in six, resulting in skin necrosis in two, compressive nerve lesions in two, digital stiffness in one, and compartment syndrome in one. Ten patients with major complications were over the age of 50 years and nine were women. Two patients receiving anticoagulation developed large dorsal subcutaneous space hematomas. Chemotherapeutic agents contributed to two minor complications and one major complication.
Conclusion The hand is a common site for minor and major IV catheter complications. Women and older patients are more susceptible to these complications. Peripheral IV line complications are not uncommon and can result in morbidity and increased health care costs from prolonged hospitalization, extended use of IV antibiotic therapy, and surgical intervention.
In the present case the patient aged about 40 years was suffering from fever and chest congestion the complainant to her son to the opposite parties hospital and admitted his son for proper treatment. The treatment started immediately after admission. For giving antibiotic injection a catheter (intravenous) was inserted by the opposite party - 3 on the left-hand of the son of the complainant. The complainant's son was admitted on 14 November 2013 and discharge on 16 November 2013. At that time of discharge catheter was not removable because the course of said antibiotic was to be continued up to 19 November 2013. After the last injection, the intravenous catheter was removed in the opposite parties hospital and then it was noticed a that there is swelling on the hand of his son near the place of catheter. The opposite party - 3 told that it is a normal phenomena and normal consequence of intravenous catheter and it will subside within two or three days. But it has not been subsided instead the size of the aforesaid blackening increased. The company immediately contacted opposite party - 3 who prescribed and ointment "T-Bact" .
T-Bact 2% Ointment is an antibiotic medicine used to treat certain skin infections such as impetigo (red sores), recurring boils, and others. It works by killing certain bacteria. This helps to improve your symptoms and cure the underlying infection.
T-Bact 2% Ointment is meant for external use only. It should be applied only to the affected area of the skin as per the dosage and schedule prescribed by your doctor. In order to get the most benefit, apply it regularly and preferably at the same time each day. Do not use larger amounts or apply it more often or for a longer duration than directed. This will only increase the risk of side effects. Do not use it for more than 10 days. Avoid any contact with your eyes, nose, or mouth. Rinse it off with water if you accidentally get the medicine in these areas.
Local side effects like minor burning or irritation may be seen after application. Consult your doctor if these persist or if your condition does not improve within 3-5 days. Before using this medicine, inform your doctor if you have any previous history of allergy with it or any other medicine. Pregnant or breastfeeding women should consult their doctor before using it.
Now the complainant administered at this ointment but did not get any relief instead the said blackening and selling further increased and condition became was on the same day, thereafter the complainant again contacted opposite party - 3 who after examined carefully told that it is a case of "Cellulitis". So on 20 November 2013 the doctor, a full party - 3 diagnosed it as cellulitis and then referred the patient to opposite party - 2 for the necessary treatment. The complainant took his son to the opposite party - 2 on the same day who after examining the son asked a doctor for dressing the affected area. The opposite party - 2 also told that it is not a case of Cellulitis and asked him to come on the next day. As opposite party - 2 is a senior surgeon, the complainant trusted on the advice. On the same day, the night the complainant contacted his brother-in-law who who is a senior government Dr in Madhya Pradesh told him that it is a clear case of gangrene and advised the complainant to rush immediately to KGMU or SGPGI . Thereafter the complainant came to KGMU Lucknow and admitted his son. The Doppler test revealed that flow of blood was almost absent in the middle finger of the son of the complainant and it is a case of "Thrombosis in Digital Arteries".
Any time a needle or catheter is put into a vein, the vein wall may become irritated or inflamed, which may lead to the development of small blood clots.
What are the signs of catheter-related thrombosis?
Symptoms of CRT include swelling, pain, redness, discoloration, and even cyanosis. Most patients with CRT are asymptomatic, even in the presence of an extensive, occlusive thrombus in the proximal veins. Some patients will complain of an ache in their shoulder or jaw without any other physical findings.
The doctors of KGMU , after Doppler test revealed that it is thrombosis in the Digital arteries and it was diagnosed by them as gangrene in left-hand. The doctors advised component to go to a higher centre for further management. Thereafter the complainant to thousand immediately to Medanta Hospital Gurgaon and got his son admitted there. The doctors of Medanta Hospital took this case as an emergency case and immediately started various desks and examination and thereafter the complainant was advised for immediate surgery of the affected area (palm and finger). In the opening of the doctors, the middle finger was completely dead and had to be amputated immediately to avoid the spread of the effect of gangrene. The doctors assured him that they will try their best to save the ring finger. After that as the Sugar level was very high, the operation could not be performed on 22 November 2013. After controlling the Sugar level, the option was performed on 23 November 2013 and middle finger of the patient was amputated. The debridement of the ring finger was done with the hope to save the ring finger but they could not save the ring finger and ultimately the doctors had to amputate the ring finger too, to save the life of the patient. An article about gangrene has been taken from the website which is as follow:
.Gangrene of hand due to faulty intravenous cannulation: Be cautious with hyperosmotic agents ( Desh Deepak Panwar, Rakesh Garg, S R Goel, Arindam Choudhary, M D Kaur, and Mridula Pawar ) Author information Copyright and License information Disclaimer Extravasation, non-intentional leakage of infused fluid into the surrounding tissue, is an iatrogenic complication. Extravasations of drugs should be suspected as a possible differential diagnosis of bullous, vesicular swelling in perioperative settings. The reported incidence of extravasations ranges from 10 to 30%.[1] The American Society of Anesthesiologists Closed Claims database revealed that intravenous catheters were an important source of liability for anesthesiologists, approximately half of which resulted from extravasation of drugs or fluid.[2] Extravasation injuries are caused by a variety of hyperosmotic, viscid, and alkaline solutions.
An 18-year-old patient was received at the intensive care unit (ICU) in the postoperative period, after undergoing frontotemporal meningioma excision, for planned elective ventilation. The patient had no other disease. General examination revealed bullous, fluid filled vesicles and swelling on the dorsal aspect of the left forearm, hand [Figure 1], and right hand. On enquiry, the attending anesthesiologists revealed that the patient had received 20% mannitol on the morning of the surgery, after intravenous cannulation, on the dorsum of left hand. Ten minutes after starting the mannitol infusion, the nurse noted a swelling in the hand. The infusion was stopped; fresh intravenous cannulation was secured on the dorsum of the other hand and the infusion restarted. This time, however, a swelling over the skin, near the tip of catheter, was noted immediately. Twenty milliliters of mannitol had already been infused. Both hands and the left forearm were covered by magnesium sulfate emulsion gel dressing. In the operating room, the anesthesiologist did not ask to uncover the dressed hands as a working 18G intravenous cannula in the left antecubital fossa was present. The right subclavian vein was cannulated using a triple lumen central venous catheter and all medications were given by a long extension line attached to this. The rest of the intraoperative period was uneventful. On the second day, the right hand showed signs of gangrenous changes. Bedside fasciotomy was done, as the radial pulse was not palpable and the pulse oximeter failed to show any waveform in the middle three fingers, indicative of compromised perfusion in the left hand [Figure 2]. Culture from the hand did not show any growth of organisms. After a written informed consent was obtained, hyaluronidase was infiltrated in the right hand and the magnesium sulfate emulsion gel dressing was continued. Supportive care with hand elevation and intermittent cold sponging was also done. The right hand recovered completely, while the left hand had residual gangrene after a few days.
Figure 1 Bullous vesicular swelling in left hand and forearm Figure 2 Fasciotomy for gangrenous changes Extravasation injury is an important cause of morbidity in the perioperative period, especially with the use of mannitol, phenytoin, antiobiotics (erythromycin), and anesthetic agents (propofol, thiopentone).[3,4] Tissue injury can be caused by hyperosmolarity (mannitol, sodium bicarbonate), vasoconstriction (adrenergic drugs), cytotoxicity (phenytoin, chemotherapeutic drugs, potassium salts), infusion pressure, and altered regional anatomy.[5,6] Multiple risk factors like injection technique (automated syringe drivers, forceful injections), fragility of the patient's veins (as in infants and the elderly), number of venipuncture attempts prior to establishing an operational intravenous line, drug characteristics, and decreased vigilance during the administration of noxious agents, determine the likelihood occurrence of extravasation.[6] Patients who are comatose, anesthetized, or have a hypoaesthetic limb cannot indicate pain on injection and this may delay the detection of extravasation. Five phenomena involved in the evolution of tissue damage following drug extravasation are: (1) vasoconstriction and ischemic necrosis; (2) direct toxicity; (3) osmotic damage; (4) extrinsic mechanical compression by large volumes of extravasated solutions; and (5) superimposed infection.[6] The compartment syndrome develops when interstitial pressure of a given muscular compartment exceeds the capillary perfusion pressure. In the case reported, extravasation of 20% mannitol caused tissue injury and the compartment syndrome, leading to gangrene, due to its hyperosmotic nature. The osmolality of 20% mannitol is 1099 mosmol/kg. It is an acidic and irritating solution with a pH of 4.5 to 7.0.0.[7] Several treatment options, surgical and medical, have been proposed for extravasation injuries. These include debridement and skin grafting, warm or cold compresses, saline flush-out, multiple punctures, hyaluronidase, phentolamine, dapsone, magnesium sulfate gel dressing, liposuction, and hyperbaric oxygen (HBO) therapy.[6] We used hyaluronidase in our patient, as it degrades hyaluronic acid, which promotes an increase in tissue permeability and absorption of fluids through the tissues.[8] If a substance known to cause an extravasation injury is to be used, it is important to ensure that the vein cannula is appropriately placed and the area is monitored regularly. Multiple punctures of the same vein, a high infusion pressure, a tourniquet effect, and peripheral access sites in close proximity to tendons, nerves, or arterial vessels should be avoided. It will be prudent to infuse some crystalloid solution, like normal saline, prior to initiation of infusion of these agents.
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References
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8. Raszka WV, Jr, Kueser TK, Smith FR, Bass JW. The use of hyaluronidase in the treatment of intravenous extravasation injuries. J Perinatol. 1990:146-9. [PubMed] [Google Scholar] GANGRENE Gangrene is death of body tissue due to a lack of blood flow or a serious bacterial infection. Gangrene commonly affects the arms and legs, including the toes and fingers. It can also occur in the muscles and in organs inside the body, such as the gallbladder.
A condition that can damage the blood vessels and affect blood flow, such as diabetes or hardened arteries (atherosclerosis), increases the risk of gangrene.
Treatments for gangrene may include antibiotics, oxygen therapy, and surgery to restore blood flow and remove dead tissue. The earlier gangrene is identified and treated, the better the chances for recovery.
Symptoms When gangrene affects the skin, signs and symptoms may include:
Changes in skin color -- ranging from pale gray to blue, purple, black, bronze or red Swelling Blisters Sudden, severe pain followed by a feeling of numbness A foul-smelling discharge leaking from a sore Thin, shiny skin, or skin without hair Skin that feels cool or cold to the touch If gangrene affects tissues beneath the surface of your skin, such as gas gangrene or internal gangrene, you may also have a low-grade fever and generally feel unwell.
If the germs that caused the gangrene spread through the body, a condition called septic shock can occur. Signs and symptoms of septic shock include:
Low blood pressure Fever, although some people may have a body temperature lower than 98.6 F (37 C) Rapid heart rate Lightheadedness Shortness of breath Confusion When to see a doctor Gangrene is a serious condition and needs emergency treatment. Call your health care provider immediately if you have persistent, unexplained pain in any area of your body along with one or more of the following signs and symptoms:
Persistent fever Skin changes -- including discoloration, warmth, swelling, blisters or lesions -- that won't go away A foul-smelling discharge leaking from a sore Sudden pain at the site of a recent surgery or trauma Skin that's pale, hard, cold and numb Thereafter the complainant stayed at Medanta Hospital till 16 December 20 13. The estate at the rate was expensive therefore he was advised that things are under control and post-operative management can alternatively be done at SGPGI , Lucknow. Thereafter complainant returned to Lucknow and got his son admitted in SGPGI were he remained till 10 January 2014 and thereafter discharged. He came to Gorakhpur but regularly visited SGPGI , Lucknow for follow-up check up twice a month.
Now as we have seen all the pleadings and documents and also went through the facts of the case it is clear that the opposite parties totally failed to manage the patient.
Now let us see the oath taken be a doctor before entering the nobel profession of the Medical World . 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."
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 status and 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. SanthaIII(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.
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.
Essentials of Res Ipsa Loquitur 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 AchutraoHaribhauKhodwa 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.
Top of Form Bottom of Form 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 ChuenTat , 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 ₹ 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 have 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 negligence leads 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.KunalSaha ( 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.Kaushik Nandy (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 Honble 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 Honble 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 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/- ( roundedofto 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 have to see about the post-operative care. Every nursing home or hospital should have proper and efficient post-operative care unit so that the patient after operation should be kept under active supervision of the doctorS and paramedical staffS. In this case we not find any proper and efficient post-operative medical care. Regarding immediate post-operative care we have to produce the following article.
Immediate postoperative care:
Postoperative patients must be monitored and assessed closely for any deterioration in condition and the relevant postoperative care plan or pathway must be implemented.
The NCEPOD (2011) report found that patients whose condition was deteriorating were not always identified and referred for a higher level of care. Patients should be made as comfortable as possible before postoperative checks are performed.
Postoperative patients are at risk of clinical deterioration, and it is vital that this is minimised. Knowledge and understanding of the key areas of risk and local policies will help reduce potential problems (National Patient Safety Agency, 2007; National Institute for Health and Clinical Excellence, 2007).
Track and trigger or early warning systems are widely used in the UK to identify deteriorating patients. These have been adapted by trusts for adults and children and are based on the patient's pulse and respiratory rate, systolic blood pressure, temperature and level of consciousness. Additional monitoring may include pain assessment, capillary refill time, percentage of oxygen administered, oxygen saturation, central venous pressure, infusion rates and hourly urine output.
The National Early Warning Score (NEWS) was developed by a working party to provide a national standard for assessing, monitoring and tracking acutely and critically ill patients (not for use with children under 16 years or in pregnancy); the intention was that trusts would use it to replace their locally adapted early warning systems (Royal College of Physicians, 2012). Like other early warning systems, NEWS has six physiological parameters:
Respiratory rate;
Oxygen saturation;
Temperature;
Systolic blood pressure;
Pulse rate;
Level of consciousness (this will be impaired in patients who have had recent sedation or are receiving opioid analgesia, which should be taken into consideration in assessment).
The system also includes a weighting score of two, which is added if the patient is receiving supplemental oxygen via a mask or nasal cannulas.
When assessing the postoperative patient using NEWS, it is vital that the patient is observed for signs of haemorrhage, shock, sepsis and the effects of analgesia and anaesthetic. Patients receiving intravenous opiates are at risk of their vital signs and consciousness levels being compromised if the rate of the infusion is too high. It is therefore imperative that the patient's pain control is managed well, initially by the anaesthetist and then the ward staff and pain team or anaesthetist, to ensure that the patient has adequate analgesia but is alert enough to be able to communicate and cooperate with clinical staff in the postoperative period.
Many trusts have yet to implement NEWS, although it is beginning to be taught in pre-registration nursing programmes. Student nurses frequently perform postoperative observations under the supervision of a nurse; it is reassuring that they receive some insight and education as recommended by NCEPOD (2011).
Vital signs;
Vital signs should be performed in accordance with local policies or guidelines and compared with the baseline observations taken before surgery, during surgery and in the recovery area.
Nurses should also be aware of the parameters for these observations and what is normal for the patient under observation. When assessing patients' recovery from anaesthesia and surgery, these observations should not be considered in isolation; the nurse should look at and feel the patient. This also applies to children and should include observation of other signs and symptoms, for example abdominal tenderness or poor urine output, which could indicate deterioration (Royal College of Nursing, 2011). The RCN (2011) provides guidance on vital signs performed post-operatively on children. Many trusts now insist that vital signs are performed manually to provide more accurate recording and assessment.
All vital signs and assessments should be recorded clearly in accordance with guidelines for record keeping (Nursing and Midwifery Council, 2009). Handheld personal digital assistants (PDAs) are used at some trusts to store track and trigger data and calculate early warning scores, which can be accessed by the clinical and outreach teams.
When a patient's condition is identified as deteriorating, this information can be passed verbally to appropriate health professionals using the Situation, Background, Assessment and Recommendation (SBAR) tool advocated by the NHS Institute for Innovation and Improvement (2008).
Airway and respirations Respiratory rate and function is often the first vital sign to be affected if there is a change in cardiac or neurological state. It is therefore imperative that this observation is performed accurately; however, studies show it is often omitted or poorly assessed (NPSA, 2007; NCEPOD, 2005).
Nurses should observe and record the following:
Airway;
Respiratory rate (regular and effortless), rhythm and depth (chest movements symmetrical);
Respiratory depression: indicated by hypoventilation or bradypnoea, and whether opiate-induced or due to anaesthetic gases.
Oxygen therapy Oxygen is administered to enable the anaesthetic gases to be transported out of the body, and is prescribed when patients have an epidural, patient-controlled analgesia or morphine infusion. Nurses should ensure and record the following:
Oxygen therapy is prescribed;
Oxygen is administered at correct rate;
Continuous oxygen therapy is humidified to prevent mucous membranes from drying out;
The skin above the ears is protected from elastic on the mask.
Pulse oximetry Oxygen saturation should be above 95% on air, unless the patient has lung disease, and maintained above 95% if oxygen therapy is prescribed to prevent hypoxia or hypoxaemia. An abnormal recording may be due to shivering, peripheral vasoconstriction or dried blood on the finger.
Nurses should ensure that:
The finger probe is clean;
The position of the probe is changed regularly to prevent fingers becoming sore.
Heart rate, blood pressure and capillary refill time The following should be checked and recorded:
Rate, rhythm and volume of pulse;
Blood pressure;
Capillary refill time to assess circulatory status, along with the colour and temperature of limbs, also identifying reduced peripheral perfusion.
Particular attention should be paid to the systolic blood pressure as a lowered systolic reading and tachycardia may indicate haemorrhage and/or shock, although initially the blood pressure may not drop and will remain within normal limits as the body compensates. Tachycardia may also indicate that the patient is in pain, has a fluid overload or is anxious. Hypertension can be due to the anaesthetic or inadequate pain control.
Body temperature Children, older adults and patients who have been in theatre for a long period are at risk of hypothermia. Shivering can be due to anaesthesia or a high temperature indicative of an infection, while a drop in temperature might indicate a bacterial infection or sepsis.
Patients' temperature should be monitored closely and action taken to return it to within normal parameters.
Use a Bair Hugger (forced-air blanket) and blankets to warm the patient if their temperature is too low;
Choose an appropriate method to cool the patient if their temperature is too high (antipyretics/fanning/ tepid sponging).
Level of consciousness Postoperative patients should respond to verbal stimulation, be able to answer questions and be aware of their surroundings before being transferred to the ward and throughout the postoperative period.
A change in the level of consciousness can be a sign that the patient is in shock. The AVPU scale (Box 2) is appropriate for assessing consciousness in adults, children and young people unless they have had neurosurgery (RCN, 2011).
Fluid balance The NCEPOD (2011) found, in 30% of patient data reviewed, there was insufficient recording of postoperative fluid balance. Nurses should observe/undertake and record on the fluid balance chart the following:
IV fluids (colloids and crystalloids used to replace fluid loss postoperatively) and infusions;
Oral intake;
Urine output: catheter urine measurements should not be less than 0.5ml/kg/hour. Oliguria can be a sign of hypovolaemia and should be reported to medical staff immediately. Check that the catheter is not kinked or that the patient is not lying on the tubing if urine output is reduced;
Colour of stoma (where appropriate) and whether there is any bleeding;
Nausea and vomiting: if necessary, administration of antiemetics should be checked and vomit bowls and tissues should be within easy reach of the patient;
Oral care;
Nasogastric tube drainage (aspirate if patient feels nauseous unless otherwise indicated);
Colour and amount of wound drainage: large amounts of fresh blood could be an indication of haemorrhage; if there is no wound drainage, it is advisable to check that the drain has not fallen out.
Intravenous infusions The RCN (2010) and Health Protection Scotland (2012) recommend that peripheral venous catheters (PVC) are checked daily as a minimum, and consideration given to removing any PVC that has been in situ longer than 72 hours (Health Protection Scotland, 2012) or 72-96 hours (Department of Health, 2011).
A phlebitis scale can be used to help assess the PVC site; the Visual Infusion Phlebitis Scale (Jackson, 1998) is frequently used and recommended by the RCN (2010). These national guidelines should be used as resources in caring for PVCs. The following should be checked and recorded:
The PVC site when changing IV fluids, before administering IV medication;
Signs of phlebitis (redness, heat and swelling).
Conclusion The postoperative healthcare team is under constant pressure to discharge patients quickly. This can lead to vital signs being missed and result in a delay in recovery.
Patients can be discharged quickly only when they do not experience any post-operative complications, many of which can be avoided or identified with correct and thorough monitoring of signs and symptoms.
All health professionals must continually update their theoretical knowledge and clinical skills; those working in post-operative care can do this by relying less on electronic equipment and developing their ability to combine the use of assessment tools with good observational skills; feeling, listening for abnormal sounds and closely observing their patients.
There are guidelines issued by World Health Organisation for Post Operative Care - these are Postoperative care Post operative note and orders The patient should be discharged to the ward with comprehensive orders for the following:
• Vital signs • Pain control • Rate and type of intravenous fluid • Urine and gastrointestinal fluid output • Other medications • Laboratory investigations The patient's progress should be monitored and should include at least:
• A comment on medical and nursing observations • A specific comment on the wound or operation site • Any complications • Any changes made in treatment Aftercare: Prevention of complications • Encourage early mobilization:
o Deep breathing and coughing o Active daily exercise o Joint range of motion o Muscular strengthening o Make walking aids such as canes, crutches and walkers available and provide instructions for their use • Ensure adequate nutrition • Prevent skin breakdown and pressure sores:
o Turn the patient frequently o Keep urine and faeces off skin • Provide adequate pain control Discharge note On discharging the patient from the ward, record in the notes:
• Diagnosis on admission and discharge • Summary of course in hospital • Instructions about further management, including drugs prescribed.
Ensure that a copy of this information is given to the patient, together with details of any follow-up appointment .
(WHO/EHT/CPR: WHO Surgical Care at the District Hospital 2003 Postoperative Management) If the patient is restless, something is wrong.
Look out for the following in recovery:
• Airway obstruction • Hypoxia • Haemorrhage: internal or external • Hypotension and/or hypertension • Postoperative pain • Shivering, hypothermia • Vomiting, aspiration • Falling on the floor • Residual narcosis The recovering patient is fit for the ward when:
• Awake, opens eyes • Extubated • Blood pressure and pulse are satisfactory • Can lift head on command • Not hypoxic • Breathing quietly and comfortably • Appropriate analgesia has been prescribed and is safely established (WHO/EHT/CPR: WHO Surgical Care at the District Hospital 2003 ) Post operative pain relief • Pain is often the patient's presenting symptom. It can provide useful clinical information and it is your responsibility to use this information to help the patient and alleviate suffering.
• Manage pain wherever you see patients (emergency, operating room and on the ward) and anticipate their needs for pain management after surgery and discharge.
• Do not unnecessarily delay the treatment of pain; for example, do not transport a patient without analgesia simply so that the next practitioner can appreciate how much pain the person is experiencing.
Pain management is our job.
Pain Management and Techniques • Effective analgesia is an essential part of postoperative management.
• Important injectable drugs for pain are the opiate analgesics. Nonsteroidal antiinflammatory drugs (NSAIDs), such as diclofenac (1 mg/kg) and ibuprofen can also be given orally and rectally, as can paracetamol (15 mg/kg).
• There are three situations where an opiate might be given: o Preoperatively o Intraoperatively o Postoperatively • Opiate premedication is rarely indicated, although an injured patient in pain may have been given an opiate before coming to the operating room.
• Opiates given pre- or intraoperatively have important effects in the postoperative period since there may be delayed recovery and respiratory depression, even necessitating mechanical ventilation.
• Short acting opiate fentanyl is used intra-operatively to avoid this prolonged effect.
• Naloxone antagonizes (reverses) all opiates, but its effect quickly wears off.
• Commonly available inexpensive opiates are pethidine and morphine.
• Morphine has about ten times the potency and a longer duration of action than pethidine.
(continued next page) WHO/EHT/CPR: WHO Surgical Care at the District Hospital 2003) Post operative pain relief (continued) • Ideal way to give analgesia postoperatively is to:
o Give a small intravenous bolus of about a quarter or a third of the maximum dose (e.g. 25 mg pethidine or 2.5 mg morphine for an average adult) o Wait for 5-10 minutes to observe the effect: the desired effect is analgesia, but retained consciousness o Estimate the correct total dose (e.g. 75 mg pethidine or 7.5 mg morphine) and give the balance intramuscularly.
o With this method, the patient receives analgesia quickly and the correct dose is given • If opiate analgesia is needed on the ward, it is most usual to give an intramuscular regimen:
¾ Morphine: - Age 1 year to adult: 0.1-0.2 mg/kg - Age 3 months to 1 year: 0.05-0.1 mg/kg ¾ Pethidine: give 7-10 times the above doses if using pethidine • Opiate analgesics should be given cautiously if the age is less than 1 year. They are not recommended for babies aged less than 3 months unless very close monitoring in a neonatal intensive care unit is available.
Anaesthesia& Pain Control in Children • Ketamine anaesthesia is widely used for children in rural centres (see pages 14-14 to 14-21), but is also good for pain control. • Children suffer from pain as much as adults, but may show it in different ways.
• Make surgical procedures as painless as possible:
o Oral paracetamol can be given several hours prior to operation o Local anaesthetics (bupivacaine 0.25%, not to exceed 1 ml/kg) administered in the operating room can decrease incisional pain o Paracetamol (10-15 mg/kg every 4-6 hours) administered by mouth or rectally is a safe and effective method for controlling postoperative pain o For more severe pain, use intravenous narcotics (morphine sulfate 0.05-0.1 mg/kg IV) every 2-4 hours o Ibuprofen 10 mg/kg can be administered by mouth every 6-8 hours o Codeine suspension 0.5-1 mg/kg can be administered by mouth every 6 hours, as needed.
(WHO/EHT/CPR: WHO Surgical Care at the District Hospital 2003) Therefore it is clear that post-operative careis most important in a case of Surgery. If you have no infra or paraphernalia, you are not supposed to proceed further regarding operation.
Introduction Gangrene is a condition characterized by the death of body tissues due to the loss of blood. It can be caused by illnessA, injury, or infection and usually happens in extremities like fingers, toes, and limbs. Gangrene can also occur in organs and muscles [1].
Symptoms Signs and symptoms of gangrene may include the following: [2] Skin discoloration which can be from pale to blue, purple, black, bronze, or red, depending on the type of gangrene you have Swelling Blisters Sudden, severe pain followed by a feeling of numbness A foul-smelling discharge leaking from a sore Thin, shiny skin, or skin without hair Fever and feeling unwell depending on the type of gangrene A few symptoms can be red flags and begin before gangrene starts:
Rest pain Pallor of extremities on elevation Poor capillary filling Thickening or scaling of the skin Types of Gangrene There are two main types of Gangrene:
1. Dry Gangrene Dry gangrene is frequently observed among patients who have vascular disease, diabetes, and autoimmune diseases. It usually affects the hands and feet and happens when there is poor blood circulation to a certain area. Therefore, the tissue that dries up changes color and can either turn brown, purplish-blue, or black before the tissue can fall off. There is no infection associated with dry gangrene, but it can lead to wet gangrene if infected. Dry gangrene has a slow progression.
2. Wet Gangrene Wet gangrene is a condition that involves infection and affects moist tissues such as respiratory tissues, oral tissues, cervix, and vulva. Swelling and blistering of the tissue are observed. An infection from wet gangrene can rapidly spread swift around the body[1]. For a patient with a history of foot ulcer or tissue injury post diabetes or ischemia, the presence of drainage and edema should be a red flag for a wet gangrene diagnosis. Moreover, a thorough evaluation of the foot is needed to rule out any presence of deep foot abscess that comes with a plantar tenderness [3]. Wet gangrene can progress from dry gangrene as the necrotic tissue becomes infected. In this case, it is therefore accompanied by an edematous and erythematous tissue surrounding the necrotic area [4].
The different types of Wet gangrene include:
Internal gangrene affects internal organs such as the appendix or colon most of the time.
Gas gangrene is a rare, dangerous, and life-threatening infection and is characterized by the presence of gas. If left untreated, gas gangrene can cause death within 48hrs [2].
Fournier's gangrene is also a rare condition caused by an infection of the genital area. When the infection gets into the bloodstream, it is referred to as sepsis and is life-threatening. This type of gangrene affects more often men than women.
Meleney's gangrene usually causes painful lesions on the skin one or two weeks post-surgery or minor trauma.
Risk Factors There are conditions that affect the blood flow supply and therefore increase the risk of getting gangrene. They include: [2], [5] Diabetes Arteriosclerosis Severe injury or surgery High cholesterol Smoking Obesity Weakened immune system Injected medications or drugs Raynaud's Phenomenon Complications of COVID-19 Diagnosis The diagnosis of gangrene is primarily clinical symptoms, with the medical history of the patient taken and physical examination done. Moreover, further tests can be done to confirm the diagnosis. These are:[5], [6] Blood Tests to look for bacteria or signs of infection.
Imaging Tests such as MRI to specify the range of infection and CT scan offers a greater specificity for evaluating the extent of the disease to rule out any gas build up in the tissues.
Angiography is a radiological test done to see the extent of ongoing or potential blood loss to tissue.
Cultures to look for signs of bacteria or tissue death through a sample of fluid, blood or tissue. They help determine the appropriate antibiotic therapy to be given.
Treatment Although the treatment of gangrene depends on its type, they all share the same general treatment goals which involve removal and treatment of dead tissue while focusing also on stopping the spread of infection and treating its cause.
The treatment of gangrene include: [1] Antibiotics to treat or prevent infection Hyperbaric Oxygen Therapy is used to treat Wet gangrene but can also be used to slow the growth of bacteria Surgery or debridement to remove dead tissue and avoid the spreading of the infection Physiotherapy Management The general goal here is to improve the functional status of the affected limb/limbs with:
Exercises such as walking to improve circulation.
Exercises to increase the range of motion (muscle flexibility and joint mobility).
Buerger-Allen Exercises to increase proprioception and balance.
Thermotherapy for wound healing.
Massage Therapy.
More about the physiotherapy management of Diabetic Neuropathy can be found here.
Complications If not well diagnosed and immediately treated, gangrene can lead to serious complications such as: [1], [2] Low blood pressure Rapid heartbeat Shortness of breath Body temperature change Body pain and rash Confusion Cold, clammy and pale skin Blood infection leading to sepsis then Septic shock. This needs immediate treatment.
Amputation Prevention Gangrene can be prevented by :
Taking proper care of diabetes and diabetic foot Not smoking Keeping a healthy weight Preventing any infection Staying warm Low Resources Health Settings It is difficult to know the prevalence and incidence of gangrene in some countries since some patients especially in poor rural areas in Uganda, don't visit healthcare facilities and therefore die from gangrene and its complications. For those who manage to visit health centres, there are sometimes cases of misdiagnosis or diagnosis not properly recorded [7]. Published data from a study done in Tanzania reported late surgical intervention after the onset of gangrene to prevent death [8]. In their study, Richard et al., 2020, suggested that there are no estimates of the number of skin and soft tissue infections in Low and Middle-Income Countries (LMICs). Furthermore, they also suggested that Fournier's gangrene may occur as a result of untreated soft tissue infections [9].
The treatment and management of gangrene in LMICs may also differ from the one in the High-Income Countries (HICs) for the following reasons:
There are few existing countries- or regional-level studies assessing the burden of necrotizing soft tissue infections in LMICs, with most studies retrospective, descriptive, hospital-level assessments or compilations of case reports.
Shortage of trained personnel and material resources Here are the recommendations from these studies :
Early detection of gangrene for patients with risk factors for developing it.
Early presentation of patients and prompt surgical intervention.
Proper and adequate documentation of findings seen during surgical operations to reduce the under-reporting syndrome in developing countries. It includes patients' diagnoses and health records.
AMPUTATION Definition Amputation is defined as surgical removal or loss of body part such as arms or limbs in part or full.[1][2][3] Prevalence One million limb amputations are reported globally each year. And as of 2017, 57.7 million people across the globe have been living with traumatic amputation. Approximately 185,000 amputations occur in United States each year according to the amputee coalition. And also, as of April 2021, United states has over 2 million Americans living with amputation, and another 28 million at a risk of surgical amputation due to underlying causes.[3][4][5][6] Data from Stanford Healthcare shows 49% rise in total number of amputations during the time of COVID-19 pandemic, during March 2020 to February 2021.[7][8] Causes of Amputations There are several conditions that can lead to amputation.[1] [2][3] Severe infection with extensive tissue damage Gangrene Trauma resulting from accident or injury, such as crush or blast wound Congenital/ Paediatric limb deficiency undergoing conversion amputation Congenital deformities of digits or limbs Congenital extra digits or limbs Necrosis or Necrotizing Fasciitis Cellulitis Peripheral Arterial Disease Frostbite Malignant/ cancerous tumor in bone or muscle of the limb e.g. Osteosarcoma Conditions that affect blood flow for example Diabetes Levels of Amputation Upper Limb [9][10] Forequarter Shoulder Disarticulation (SD) Transhumeral (Above Elbow AE) Elbow Disarticulation (ED) Transradial (Below Elbow BE) Hand/ Wrist Disarticulation Transcarpal (Partial Hand PH) Transmetacarpal Lower Limb[9][10] Hemicorporectomy Hemipelvectomy/ Hindquarter amputation Hip Disarticulation Short transfemoral(above knee) Transfemoral (above Knee) Long transfemoral (above knee) Knee Disarticulation Short transtibial (below knee) Transtibial (below knee) Long transtibial (below knee) Ankle Disarticulation (Symes) Tansmetatarsal Partial Foot/ray resection Toe disarticulation Partial Toe Pre-Surgical Evaluation General system review- Cardiovascular & Respiratory[1] Nutritional status[1] Diabetes Control if appropriate Bowel & Bladder Function Past medical history Social history[1] Pre-morbid mobility[1] Strength & Condition of Healthy limb Psychological assessment to access emotion impact of amputation Home & work place assessment to make sure, everything is in accordance for patients maximal self reliance Explanation of post-operative regimen.[1] Surgery for Amputation Anesthesia is the first step to any surgery. During amputation, choice of anesthesia depends on the type of amputation, described above on levels of amputation. Two option of anesthesia for amputation are general anesthesia or epidural anesthesia.
While performing amputation, special care is to be taken to make sure the procedure does not hamper the functioning of remaining limb. It is vital to condition, shorten & smoothen the remaining bone, so there is a healthy stump that in future can take the load of a prosthetic limb and reduce complication risk.
Muscle is sutured to the bone at the distal residual bone so maximal strength of the remaining limb can be retained. This procedure is known as myodesis.
Distal stabilization of the muscles is always recommended, allowing for effective muscle contraction and reduced atrophy. This in turn allows for a greater functional use of the stump and maintains soft tissue coverage of the remnant bone. As the procedure for amputation is completed, the wound us sealed by performing myoplasty: suture to opposite muscle in the residual limb to to each other and to the periosteum or to the distal end of the cut bone for weight bearing purposes; and is covered with a bandage. A drainage tube might be placed to drain all excess fluid. Hence, every possible measure is taken to reduce risk of infection.[1] Ideal Stump Skin flaps: skin should be mobile, sensation intact, no scars Muscles are divided 3 to 5 cm distal to the level of bone resection Nerves are gently pulled and cut cleanly, so that they retract well proximal to the bone level to reduce the complication of neuroma Stump care [11] For hygiene and skin care see handout on amputations A hip flexion contracture may develop because of elevation to reduce swelling Stump bandaging is done to 'cone' the stump, thereby preventing oedema, which occurs because there is no muscle pump and the stump hangs Swelling must be prevented to allow proper attachment of the prosthesis, and the prevention of pressure sores The stump sock is put on first, then the prosthesis The prosthesis must be cleaned and maintained (children who are still growing, grow out of their prostheses) Complications of Amputation Edema & Swelling Wounds Infection Pain (phantom limb) Muscle weakness Muscle Tightness & contractures Joint Instability Autonomic dysfunction See here, for more detailed information on post-operative complications following an amputation.
Post Surgical Evaluation General system review- Cardiovascular & Respiratory[10] Nutritional status Diabetes Control if appropriate Bowel & Bladder Function Strength & Condition of Healthy limb Psychological assessment to access emotion impact of amputation Signs of Infection Type of pain(Incisional, phantom, other)[10] Level of Pain(VAS 1 - 10) Functional status (Bed mobility, transfers, sitting, standing, walking, balance)[10] Strength and/or pain of the un-amputated limb Post-operative Care Maintain function in the remaining leg and stump to maintain peripheral circulation Maintain respiratory function (important with smokers and those patients under general anaesthesia) Prepare for mobility rehabilitation Pain in Amputation Residual Limb pain and phantom limb pain are the two essential types of pain, post amputation.[9] Residual Limb Pain Residual limb pain has three main cause:
Very likely post operative pain Peripheral nerve neuroma formation at the end of cut peripheral nerve Prosthetic pain caused by ill fitting prosthesis Phantom Limb Pain Phantom limb pain is defined as "pain that is localized in the region of the removed body part." Cause of Phantom limb pain is not fully understood , but it is distressing and has a significant impact on patients life.
Psychological Implications of Amputation Loss of limb has a huge psychological impact on ones mental health, as if the person has lost a loved one. It is difficult to cope with loss of sensation and function from the amputated limb. It also changes your (patients) and other peoples perception of your (patients) body image, which can lead to depression and anxiety as negative thoughts are very common.
Psychological well being of the patient is vital to a good rehabilitation process. Hence, it is the duty of a physiotherapist/ physical therapist to acknowledge patients concerns with good knowledge of natural grieving process.[1][2] Fall Risk Post Amputation Patient undergone amputation is at a higher risk of fall especially when they try to get up from the bed or chair and they have forgotten about the absence of the limb. These falls can cause injury to the surgical site, leading to prolonged healing.[1] To deal with the risk of fall, it is mandatory to place a walker besides the patient. This reminds the patient to use assistance for transfers.
Goals of Post-operative Physiotherapy Management Patient education on amputation and rehabilitation post amputation.
Maintenance of respiratory & cardiovascular status both pre- & post- surgery Proper positioning of amputated limb to maintain the limb in right anatomical position.[10] Maintaining/improving strength of unamputated limb Residual Limb care Balance training Transfer Training Mobility Training Prosthetic training Post-operative Physiotherapy Management Start with respiratory maintenance with pain control for amputated limb. Also start strengthening the unamputated limb to maintain its strength.[9] Teach the patient to wrap the residual limb correctly.
Prevent hip flexion contracture by avoiding prolonged sitting & guiding patient to spend more time in prone position.[10] For proper positioning avoid side lying position, maintain the residual limb in extension at hip & knee.
Start balance training Procced to mobility training initially with a walker followed by crutches.
Start strengthening of the residual limb before proceeding to prosthetic training[9] Pre- Prosthetic Evaluation Social History of patient Financial status Cause of amputation Cardiopulmonary status examination[10] Scar healing assessment Sensory assessment Residual limb length & shape Emotional status of patient for acceptance of amputation and body image Vascularity (pulse, color of limb, temperature, edema/swelling, pain & tropic changes[10] Range of motion Muscle strength Pain (residual & phantom) Functional status ( transfers, mobility, activities of daily living) Please find below links to more detailed pages on the management of amputees Pain Management Pre-Fitting Management of the Patient with a Lower Limb Amputation Post-fitting Management Prosthetic Rehab High level Rehab Clinical Guidelines: Mental Health Amputees More to do with patients with amputation Buerger's Exercises [12] Stimulates collateral blood flow in the patient's leg It is performed for 20 min.
The leg is elevated until the toes go white, then lowered, then level Repeat 2-3 times to improve collateral circulation
2. Connective Tissue Massage
3. Dynamic Stump Exercises
4. Balance and Gait Retraining Improve static and dynamic balance Use parallel bars, walking frame then Crutches (in that order) Therapist stands on the amputation side, using a belt around the patient's waist to support Rest if the patient feels tired [13]
5. Short Wave Diathermy (SWD) Through the pelvis to warm the arteries (contraindicated in patients with arterial insufficiency because the warmth leads to increased metabolism, causing a greater demand for nutrients, which are not available) Walking Again Post Amputation/ Mobility Aids The choice of mobility aids depends on the level of fitness, strength, balance skills of the individual:
Walking frame Axillary crutches Elbow crutches Walking stick For bilateral lower limb amputees a wheelchair is often indicated (high energy expenditure during gait with prostheses) Prosthetic Training Prosthetic training is vital for smooth and energy efficient living, while performing all of daily living activities.
Below is step by step guidance to prosthetic training:[10] Accepting weight of the body on each leg is vital to prosthetic training work on strengthening unamputated limb along with residual limb Teach the patient to balance on both legs and than on one leg Teach walking with prosthetic first with use of walker followed by crutches and stick Further proceed to independent prosthetic training.
Teach the patient to adapt to environmental demands while walking Now in this case when a catheter has been inserted on the left-hand of the son of the complainant, and he complained about selling and blackning of nearby area, the opposite parties should have known that it is not a natural phenomena and immediate steps for proper treatment should have been taken but they have taken it very likely prescribe indictment for local administration. From 14 November 2013 till 19 Number two and 13, the catheter was there and it was removed on 19th November 2013 . When the blackening and swelling was very much visible, we are unable to understand that why did the opposite parties not go for any type of test even x-ray, CT scan or any other which may help to diagnose the real problem.
T-Bact 2% Ointment is an antibiotic medicine used to treat certain skin infections such as impetigo (red sores), recurring boils, and others. It works by killing certain bacteria. This helps to improve your symptoms and cure the underlying infection.
T-Bact 2% Ointment is meant for external use only. It should be applied only to the affected area of the skin as per the dosage and schedule prescribed by your doctor. In order to get the most benefit, apply it regularly and preferably at the same time each day. Do not use larger amounts or apply it more often or for a longer duration than directed. This will only increase the risk of side effects. Do not use it for more than 10 days. Avoid any contact with your eyes, nose, or mouth. Rinse it off with water if you accidentally get the medicine in these areas.
Local side effects like minor burning or irritation may be seen after application. Consult your doctor if these persist or if your condition does not improve within 3-5 days. Before using this medicine, inform your doctor if you have any previous history of allergy with it or any other medicine. Pregnant or breastfeeding women should consult their doctor before using it.T-Bact 2% Ointment is an antibiotic that works by stopping the growth of infection-causing bacteria on your skin. In this case whether it was better infection or any fungus infection, cannot be made clear by the doctor. When the complainant contacted the doctors of KGMU and got Dr test of his son then it was revealed that it is a case of thrombosis in the digital arteries and diagnose as gangrene in left-hand. The Medanta Hospital Gurgaon could not do anything except amputation. What was the result of negligence shown by the opposite parties in this case is loss of middle finger and ring finger. Who is responsible for it? Clearly due to lack of post-operative care and carelessness and negligence of the opposite parties the complainant's son lost his two fingers. Can these laws the compensated in terms of money? No! The son of the complainants will bear it throughout his life.
In the above-mentioned circumstances it is a clear case of res ipsa loquitur showing the total negligence of opposite parties for which they are totally responsible. We have discussed a number of medical articles, case laws and facts of the case which establishes that the opposite parties are not in and there is clear that on the part of the opposite parties.
What will be the amount of compensation in this case? The complainant has prayed ₹ 7,225,000/- in different heads. In our opinion this amount is a meagre amount as for as the loss is concerned. For relief 'D' we are of the opinion that a special cost of ₹ 20 lakhs to be paid to master Adwitiya and it shall be kept in a monthly income scheme for six years on which the interest shall be paid every month to master Adwitiya. The complainant is decided accordingly.
ORDER The opposite parties are directed jointly and severally to pay ₹ 7 lakhs to the complainant towards cost/expenditure incurred in the treatment of the patient to the complainant within 45 days from the date of the judgement of this complaint case with interest at a rate of 10% per annum from 14.11.2013 and if not paid within 45 days, the rate of interest shall be 15% per annum payable from14.11.2013 till the date of actual payment.
The opposite parties are directed jointly and severally to pay ₹ 5 lakhs to the complainant towards cost/expenditure incurred in the transportation within 45 days from the date of the judgement of this complaint case with interest at a rate of 10% per annum from 14.11.2013 and if not paid within 45 days, the rate of interest shall be 15% per annum payable from14.11.2013 till the date of actual payment.
The opposite parties are directed jointly and severally to pay ₹ 10 lakhs to the complainant towards physical and mental agony, torture, depression within 45 days from the date of the judgement of this complaint case with interest at a rate of 10% per annum from 14.11.2013 and if not paid within 45 days, the rate of interest shall be 15% per annum payable from14.11.2013 till the date of actual payment.
The opposite parties are directed jointly and severally to pay ₹ 50 lakhs to the complainant as the damages within 45 days from the date of the judgement of this complaint case with interest at a rate of 10% per annum from 14.11.2013 and if not paid within 45 days, the rate of interest shall be 15% per annum payable from14.11.2013 till the date of actual payment.
The opposite parties are directed jointly and severally to pay ₹ 20 lakhs to be paid to master Adwitiya and it shall be kept in a monthly income scheme of any Nationalised Bank for six years on which the interest shall be paid every month to master Adwitiya.
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.
(Sushil Kumar) (Rajendra Singh) Member Presiding Member Judgment dated/typed signed by us and pronounced in the open court. Consign to record. (Sushil Kumar) (Rajendra Singh) Member Presiding Member Dated 28 February 2023 Jafri, PA II Court 2 [HON'BLE MR. Rajendra Singh] PRESIDING MEMBER [HON'BLE MR. SUSHIL KUMAR] JUDICIAL MEMBER