National Consumer Disputes Redressal
Paulrajan (Mrs.) And Anr. vs Khm Hospital And Anr. on 15 February, 2007
Equivalent citations: 2(2007)CPJ135(NC)
ORDER
B.K. Taimni, Member
1. Appellants were the complainants before the State Commission, where they had filed a complaint alleging deficiency in service on the part of the respondents.
2. Very briefly the facts leading to filing the complaint were that the husband of the first complainant and the father of the second complainant/appellant approached the first respondent hospital with the complaint of stomach pain at about 12 in the mid night on 7.10.1997. He was given injection and after some time when he was about to go home, he vomited blood and immediately the deceased was admitted in I.C.U. He again vomited blood at about 4.30 p.m. on the next day, i.e., on 8.10.1997 and was transferred to Apollo Hospital at about 6.30 p.m., where he was declared brought dead. It was the case of the complainants/appellants before the State Commission that this was medical negligence on the part of the respondents for the following reasons:
1. There was no definitive treatment given to the patient;
2. The blood transfusion was not given immediately;
3. No specialists were called for;
4. Endoscopy was not done; and
5. Gastro Enterologist was not called in.
3. Upon admission of the complaint, the respondents were issued notices. Reply was filed; affidavits were also filed in support of their respective contentions; parties were cross-examined and State Commission after perusal of material on record and after hearing the parties, dismissed the complaint. Hence this appeal before us.
We heard the learned Counsel for the parties.
4. While it is the case of the appellants that the respondents should have carried out "blood transfusion' immediately, for which he relies upon the cross-examination of the second respondent wherein he states that, "blood transfusion is a foremost thing to be done in such cases to maintain loss volume" which was done after over twelve hours of the first episode of vomiting of blood. For this he also relies upon the examination of the expert witness brought in by the appellant/ complainant, namely, Dr. Mishra. In this case, the vomiting episode had happened at about 12 O'clock on the night of 7th and 8th October 1997 but the blood transfusion was done only at about 12.20 p.m. on 8.10.1997. It was also the case of the appellant that Endoscopy was not done at 9.00 a.m., 11.00 a.m. or at 1.30 p.m. on 8.10.1997 when the condition of the deceased was stable. The deceased was hamodynamically stable from 1.00 a.m. to 6.00 a.m. on 8.10.1997 and blood pressure was also stable. He also relies upon the medical literature appearing at page 184 of the paper book where it is stated "Where available Endoscopy interventions should be employed at first line treatment to control bleeding." He also relies upon literature, i.e., Gastrointestinal Bleeding : Initial Management, by Lawrence S. Freidman, MD, where he stated that "finally, I favour early Endoscopy in patient in whom variceal bleeding is suspected from a history of liver disease or prior variceal haemorrhage." He also relies upon the evidence given by the second opposite party where he himself states, "Endoscopy provides safe diagnosis and in most cases specific site of bleeding can be identified for normal individuals...." It was also the case of the respondent that no Gastro Enterologist was called. In fact, Dr. Rajnikanth was consulted after about 16 hours of the episode of blood vomiting. Thus, as we understand the case of the complainant is, that had the 'blood transfusion' been done in time which could have led to the stability of hamodynamic parameters of the deceased thus making fit for Endoscopy, which would have helped the respondent to treat the deceased in a more appropriate manner and secondly, no Gastro Enterologist was called who would be specialist in this field, in the absence of which the second respondent could not reach the correct cause of the internal bleeding, resulting in the death of the husband of the first complainant and father of the second appellant. In view of this, this is a clear case of medical negligence on the part of the second respondent.
5. We heard the learned Counsel for the parties on this issue and perused the material on record. After going through the evidence and literature on the subject of blood transfusion, there is no dispute that in the case of haemorrhage "blood transfusion' should be given the highest priority and should have been done immediately in normal circumstances. But what we see on record, is also the fact that as per blood report of the deceased the haemoglobin of the deceased read at 10.5gm%. There is also no dispute that medical literature and the evidence before the State Commission spoke of "replacement of blood loss to maintain intravascular volume take precedence over diagnostic studies and more specific intervention to stop bleeding". [Vol II Harrison's Textbook of Internal Medicine : Page No. 1864. This view is also supported by the evidence on record. But it needs to be appreciated that as to when the blood transfusion is required. We have a case before us, wherein while in ICU the deceased, as per material on record had a haemoglobin reading at 10.5 gm % on 8.10.97. In the affidavit as also in his cross-examination, complainant No. 2, the son of the deceased clearly states that he saw his father sleeping well at about past one O'clock on 8.10.1997. We have the literature before us on the subject 'Transfusion Therapy by Ronald D. Miller' (Chapter 46 page 1613):
Blood transfusions are given to increase oxygen-carrying capacity and intravascular volume. Theoretically, increasing vascular volume is not an indication for blood transfusions., because volume can be augmented. Therefore, in this author's opinion, the haemoglobin concentration should be the basis around which clinical judgment revolves in order to define transfusion requirements for an individual patient. No specific measure could consistently predict when a patient would benefit from a blood transfusion. That bulletin states, "adequate oxygen carrying capacity can be met by a haemoglobin of 7 al/dL or even less when the intravascular volume is adequate for perfusion. Transfusion is rarely indicated when the haemoglobin concentration is greater than 1oq/dL and is almost always indicated when it is less than 6 g/dh, especially when the anemia is acute. (All emphasis supplied)
6. In view of the medical literature and in view of the unrebutted facts that on 8.10.1997 the deceased had haemoglobin of 10.5 gm%, non transfusion of blood in the initial 12 hours or so would not amount to a case of medical negligence.
7. Coming to the second leg of the argument that the second respondent did not carry out the Endoscopy. There is no disputing the fact that as per material brought on record and literature brought on record Endoscopy can be done only when the patient is hamodynamically stable. It is the case of the appellant that he was hamodynamically stable at 1 a.m. to 6 a.m. We have seen the hospital record appearing at page 97 in which the readings of the blood pressure makes the following reading:
Tune B.P. 1.00 a.m. 120/80 1.30 a.m. 110/90 2.00 a.m. 90/70 2.30 a.m. 100/80 3.00 a.m. 100/70 3.30 a.m. 100/60 4.00 a.m. 100/not legible 5.00 a.m. 90/70 6.00 a.m. 100/60
8. We see that if the blood pressure was 120/80 at 1.00 a.m. and came down to 90/70 at 2 a.m. and was 100/70 at 3 a.m. and 90/70 at 5 a.m. It is worth noting that, even after blood transfusion at 12.20 p.m. on 8.10.1997, BP still hovered between 100/60 to 90/70 between 12.30 p.m. to 4.00 p.m. (Page 98 of the paper book) and much less after that even when the second blood transfusion took place at 4.30 p.m. This belies the contention of the appellant that blood transfusion, had it been done earlier, would have improved the B.P. of the deceased. The above figures show no such co-relationship between blood transfusion and maintenance of blood pressure (B.P.). Under no stretch of imagination this could be said to be a stable condition for carrying out Endoscopy which is an 'invasive' procedure. The cross-examination of the expert witness of the appellant firstly appears to be contradictory in this regard and secondly what he is expressing is his 'opinion'.
9. At page 141 of the paper book and page 5 of the cross-examination this is what he (Dr. Mishra) wants to say about the Endoscopy, "in my opinion the patient was hamodynamically stable on 8.10.97 from 1 a.m. to 6 a.m." and goes on to state, "A physician can assess whether to do a Endoscopy or not and the time to do it." and goes on to further state (contradiction in our view) later on, "I cannot say whether the OP was competent to decide whether it was necessary to be done or when it is to be done." He further states in his cross-examination that, "as blood-pressure was stable for 6 hours, may be I would have gone for Endoscopy though I could not be sure to say that he would have been saved".
10. The above would clearly show the words used are, "in my opinion,..., 'may be I would have gone for Endoscopy'. In view of these statements, firstly this cannot be said to be a definite opinion of a Gastro Enterologist and secondly under no stretch of imagination as reproduced earlier, the deceased could be said to be hamodynamically stable from 1 a.m. to 6 a.m. as admittedly the blood pressure was varying from 90/70 to 120/80. In these conditions, not resorting to Endoscopy by the second respondent would not fall in the category of medical negligence. There is another side to the deposition of the expert witness. Undisputedly Dr. Mishra, the expert witness was a student of one Dr. Bapat who was Director of Medical Education in Lucknow and is the father-in-law of the second complainant and had come all the way to Chennai to give evidence as an expert from the side of the complainants. In White House v. Jordan and Anr. (1981) 1 All ER P-276 and p-284, as per Lord Wilberforce and Lord Fraser, "while some degree of consultation and legal advisers is entirely proper, it is necessary that expert evidence presented to the Court should be, and should be seen to be, independent product of the expert, uninfluenced as to form or content by the exigencies of the litigation". In our view, evidence of Dr. Mishra does not foot the bill and we feel it difficult to accept him as an independent expert witness.
11. It is vehemently argued by the learned Counsel for the appellant that blood could have been transfused to make the deceased hamodynamically stable. It needs to be pointed out that the blood pressure and blood transfusion are different facets and cannot be equated. What blood transfusion does is to replace the volume of blood in the body but it cannot be said to mean that it will bring hamodynamic stability as each fall in a different category.
12. As far as the third allegation of medical negligence relating to calling of Gastro Enterologist is concerned, the second respondent himself is a qualified doctor with long standing. There is no dispute that Dr. Rajnikanth the Gastro Enterologist, was consulted and advised Endoscopy the next day and it was on his advice that tablet Sumatostatin was given. There is no disputing the fact that the patient was suffering from variceal bleeding resulting in haemorrhage. There is also no dispute that one of the tests carried out on 8.10.1997 by Dr. Kailash Ultrasound Clinic that the patient was having Cirrhosis of liver. Earlier hospital reports also indicated the deceased having enlarged heart. In the medical literature brought on record by the respondent, the principle of management of Hypertensive bleeding is reported to be "(1) prevention of the initial bleeding episode, (2) control of acute haemorrhage, and (3) prevention of recurrent variceal bleeding, all with minimal morbidity and without hampering the performance of future liver transplantation in potential candidates." Relying upon the literature titled, "Hypertensive and Gastro intestinal bleeding", the following is also recorded:
There often is great temptation to perform immediate Endoscopy on a patient with massive bleeding. However, the need for adequate and careful resuscitation cannot be overemphasised.
13. In the literature, "The Portal Venous System and Portal Hypertension" it is mentioned that the "patient with alcoholic cirrhosis may be at most risk" and goes on to add that, "probability of death is significantly greater, particularly in those more than 50 years old". The State Commission has relied upon the literature produced by the parties before the State Commission and have, in our view, rightly held this not being a case of medical negligence.
14. The degree of skill and care required from a medical practitioner is that he must bring to his task a reasonable degree of skill and must exercise the reasonable degree of care. Neither very highest nor a very low degree of care and competence judged in the light of particular circumstances of each case, is what the law requires. In this case, the patient came with a complaint of stomach pain, injection was administered. He was feeling relieved and was ready to go back home when he vomited blood. He was immediately shifted to ICU and was given treatment. Ryles tube was inserted for cold water lavage and IV fluids were given. It showed no bleeding after the first episode. When the position improved, blood transfusion was done at about 12.20 a.m. There was another episode of vomiting at about 4.30 p.m. The patient was administered Stomastatin and Vasopressin and then after that he was shifted to Apollo Hospital. This line of treatment is also supported by PW-3, Dr. Mishra in his cross-examination, except that his case is that it should have been done earlier.
15. It has been shown that in the case of people with liver and heart problems, the first episode of haemorrhage could be disastrous. "SHELIA SHERLOCK" Page No. 170 (Chapter 10) appearing at P-151 of the Paper Book notices this in following terms:
6.5% of Cirrhosis patients with varices will not bleed within 2 years of diagnosis. 50% will die of the first haemorrhage (This indicates the disease is severe and dangerous.)
16. In the aforementioned circumstances, we are not shown as to what else was expected from a medical practitioner. We have already held, based on medical literature, that the transfusion was not required as the patient already have a haemoglobin of 10.5gm%. 'Endoscopy' could not have been done till the time patient was hamodynamically stable. In these circumstances, State Commission cannot be faulted for not having found the respondents negligent in view of the treatment given as per record of the patient maintained by the Hospital.
17. An attempt is also made by the learned Counsel for the appellant by relying upon a news item appearing in Newspaper "Anna Nagar Times" where a victim suffered profuse loss of blood when his right forearm got chopped off, and was in state of deep shock. Fortunately he was brought to the hospital in the nick of time, or otherwise it would have been difficult to save him. His colleagues also had the presence of mind to bring the chopped off arm kept in a polythene bag. According to this Newspaper what saved him was administration of blood within period of 15 minutes and it was the 2nd respondent who did this. Since blood transfusion was not done in the instant case as was done in this case in the quoted Newspaper, the appellants wish to hold the 2nd respondent negligent. We are afraid that this material brought on record does not show at all as to what was the 'blood loss' in the person who met with an accident and also what was the haemoglobin of the person, in question, relied upon by the appellant as appearing in the above quoted Newspaper? It should be an admitted proposition that unless the whole facts are brought before us, we are in no position to co-relate one case with another.
18. In the aforementioned circumstances, based on material on record as also the medical literature as also the examination of witnesses, we are of the view that the State Commission has correctly inferred that no case of medical negligence has been made out by the appellants/complainants against the respondentsespecially the second respondent. We have also examined the material ourselves, as discussed above and find that the appellants have failed to make out a case of medical negligence against the respondents before us.
19. In the light of above discussion, we see no merit in this appeal hence dismissed.
No order as to costs.