National Consumer Disputes Redressal
M. Aiyappan (Dr.) And Ors. vs Lakshmi on 10 December, 2007
Equivalent citations: I(2008)CPJ50(NC)
ORDER
Rajyalakshmi Rao, Member
1. This Revision Petition is filed against the order dated 17.1.2006 passed by the State Commission, Chennai in Appeal No. 190 of 2001 whereby the State Commission dismissed the appeal of the petitioners. In the Original Complaint No. 87 of 1999, District Forum, Tirunelveli allowed the complaint of Smt. Lakshmi against the petitioners by order dated 20th December, 2000 for deficiency in service and medical negligence. Brief facts of the case are:
The complainant (respondent herein), Smt. Lakshmi, resident of Tirunelveli, Tamil Nadu filed a complaint against the petitioners Dr. M. Aiyappan (petitioner No. 1) Assistant Civil Surgeon, Dr. G. Thangiah (petitioner No. 2), Civil Surgeon, Dr. R. Gopinath (petitioner No. 3), Civil Surgeon and the Dean (petitioner No. 4), who are working with Tirunelveli Medical College Hospital, Tirunelveli.
2. This Revision Petition requires to be decided mainly on two issues, (a) whether there is obstructive jaundice, and (b) if so, whether the petitioners are justified in delaying the surgery which is the remedy in this situation.
Complainant's version:
3. The case of the respondent is that on 2.2.1999 she approached petitioner No. 1, Dr. M. Aiyyapan at his clinic at Tirunelveli town for consultation with a complaint of continuous pain in her stomach and abdomen. After examining her, petitioner No. 1 suspected formation of stone in her gall baldder and advised to take USG (abdomen) scan. The scan report confirmed the formation of stone in her gall bladder. The respondent was advised for surgery at Tirunelveli Medical College Hospital. On 7.2.1999, she got admitted and the petitioner No. 2, Dr. G. Thangiah (the Civil Surgeon), performed the operation on 13.2.1999. She continued treatment as an in-patient in the post-operative ward under the care and supervision of petitioner No. 3, Dr. R. Gopinath, who was assisted by petitioner No. 1, Dr. Aiyappan.
4. The health of the respondent did not improve and she developed obstructive jaundice on 24.2.1999. She was also suffering from continuous pain in her stomach and abdomen even after the surgery. She was advised to take USG (abdomen) scan again which was taken on 27.2.1999. The scan report showed localized fluid accumulation in the gall bladder and it also disclosed compression of CBD biliary track measuring 7.35 x 4.3 cm and the presence of free fluid in the peritoneal cavity. The scan also showed suspected leakage in the biliary track.
5. It is contended that although she was suffering from continued pain, the level of jaundice increased day-by-day and there was also increase of fluid in the abdomen, the petitioners informed her relatives that she was recovering slowly but satisfactorily. No steps were taken to remove the fluid from her stomach and release the compression of CBD. She developed itching due to increase in the level of billirubin (jaundice) from 5.3.1999 and fluid accumulation in the stomach. It also resulted in flapping tremor which had been noted in the record on 10.3.1999, although the petitioners deny the same and struck it off from the record.
6. The petitioners had not started any treatment to cure these ailments. The fact that she had been undergoing all these symptoms, was known to the respondent. It was only on 10.3.1999, X-ray BMS was taken and the treatment for jaundice was started by administering Tablet Liver-52. The respondent's condition deteriorated further and her husband and relatives insisted for discharge from the hospital for better treatment in another hospital. She was discharged on 12.3.1999 and on the advice of Dr. Badrinath of Tirunelveli Junction.
7. She was admitted at Sri Ramachandra Medical College Hospital, Chennai on 15.3.1999 and on 16.3.1999 fluid collection was drawn from her abdomen. Ryles aspiration was done. ERCP scan was taken on 20.3.1999 and another surgery was done on 24.3.1999 to cure the complaint of her obstructive jaundice. She was discharged on 7.4.1999. She continued her treatment as an outpatient for another two weeks till 16.4.1999. The respondent contended that had the petitioners been given proper advice and started appropriate treatment she need not have gone through so much suffering of physical pain and mental agony. Due to apathy of the petitioners, she had incurred huge expenditure, which necessitated her going to another hospital and to undergo another surgery subsequently to rectify the damage done by the petitioners.
8. The respondent sent a notice on 17.5.1999 for which a reply was sent by the petitioners on 10.6.1999 and then the complaint was filed before the District Forum against the petitioners for a total claim of Rs. 5 lakh for the expenditure incurred, compensation for mental agony and suffering she has undergone. The District Forum accepted her contentions, after hearing both the parties, and held that there was negligence on part of the petitioners herein and directed them to pay a sum of Rs. 3,20,000 as compensation and Rs. 10,000 as costs. In the appeal by the petitioners, the State Commission affirmed the order of the District Forum and dismissed the same.
Aggrieved by the State Commission's order, petitioners filed this revision petition.
Petitioners' submission:
9. Learned Counsel for the petitioners contended that both the District Forum and the State Commission did not appreciate the evidence brought on record and that there was no negligence on the part of the petitioners. It is contended that proper treatment was given to the complainant. For this purpose, reliance is placed on the treatfnent given by them which is as under:
It is submitted that petitioner No. 1 saw the patient in his private clinic on 2.2.1999, and that she complained of suffering from continuous pain in stomach and abdomen.
10. On suspecting that the pain could be due to formation of stone in the gall bladder, USG scan of the abdomen was advised. The respondent was advised an operation as the scan confirmed stone in the gall bladder and she was admitted in Tirunelveli Medical College Hospital on 7.2.1999. USG scan of abdomen and pelvis was taken and the report showed normal size gall bladder with one stone measuring 1.4 cm impacted at the level of neck. The walls of gall bladder were thick and there was small right ovarian cyst measuring 4.4 x 3.2 cm. On 13.2.1999 Cholecystectomy was performed after general anaesthesia given by the petitioner No. 2. The case sheet reads as under:
Under GA by a right sub cortical incersion abdomen. Hepatic artery and cystic artery were well defined. The gall bladder was found very much distended much as there was a big size 2 1/2cm x 1 1/2cm x 1 1/2cm size in the...cystic duct was divided between ligat...cystic artery was divided between ligat...mous. G.B. was excised from gall bladder fossa and liver. Haemostaris was secured. Wound was closed in 4 layers....
11. It is submitted that after removing the stone, the Cystic Duct and the Cystic Artery, which connects the gall bladder, individually was ligated twice, as is required. It is further submitted from the operation notes of the Surgeon that the gall bladder with the stone was removed and nothing was left behind, as alleged by the respondent. A drain tube was kept from the gall bladder bed and was brought out through the right side of the abdomen. In this operation, non-absorbable material was used so that the sutures remain intact to prevent bleeding and leakage of bile. Her condition was regularly examined and she was recovering well. There was no complaint from 14.2.1999 to 22.2.1999.
12. It is contended that on 23.2.1999, she complained of nausea and vomiting. She was given the medicine to stop the same. On 24.2.1999, she was diagnosed suffering from jaundice which is the 11th day, after the operation. From the blood and urine test, jaundice was confirmed. USG scan of abdomen was advised by the petitioner No. 1 to ascertain whether jaundice was caused due to any residual stone in Common Bile Duct because of which there could be an obstruction which could be a reason for causing jaundice. The scan report of 27.2.1999 revealed that fluid collection in the gall bladder bed was compressing Common Bile Duct. Fluid was also seen in the peritoneal cavity. The Radiologist opined that the fluid collection in the gall bladder bed anterior to Common Bile Duct was causing compression of the Common Bile Duct. It is submitted that after the gall bladder surgery from the raw surface of the gall bladder Fossa there was some collection of fluid. The collection of fluid is normal which occurs after the surgery and hence in normal course a drain tube is kept to drain the fluid collection from the gall bladder bed.
13. It is submitted that the Medical Book on 'Essential Surgical Practice' supports the view of the petitioners wherein Chapter 10.6 explicitly deals with the post-operative jaundice. This text book further states that "Initially it warrants observation with repeated assessment of the patient's condition, sequential biochemical profiles, as the majority of cases with this syndryme subside within 3-4 weeks."
14. It is further submitted that in the book titled "Gastrointestinal Disease Pathophysiology, Diagnosis and Management" it has been stated "Jaundice is not evident until serum bilirubin concentration exceeds 3 mg/dl (deci liter)". "Either increase in bilirubin formation or decrease in hepatic clearance may lead to jaundice. It is reasonable to classify conditions that produce jaundice under the broad categories of isolated disorders".
15. On 2.3.1999 there was minimal soaking at the drainage site, which would mean that there was less fluid, collection. Third scan was taken which revealed that there was an echoic region measuring 2.75 x 5 x 8.3 cm resembling gall bladder, which means that there was little fluid collection. Pancreas, kidneys, urinal bladder, spleen were normal and there was free fluid in peritoneal cavity. Radiologist was of the opinion that jaundice could be due to duodenal ulcer infiltrating the Common Bile Duct.
16. The respondent was examined on 3rd and 4th March, 1999 and found that the abdomen was soft and this was indicative that there was no inflammation. Further, the fluid collection had considerably reduced, as noticed, through the drainpipe.
17. On 5.3.1999, USG scan was repeated and it was found that the intrahepatic biliary radicals and Common Bile Duct were not dilated. It is submitted that when the fact that intrahepatic biliary radicals and the Common Bile Duct were not dilated, it means that there was no obstruction in the Common Bile Duct. Hence, the allegation of the respondent that there was an obstruction in the Common Bile Duct/retro duodenal part of Common Bile Duct due to stone or sutures are absolutely false and baseless.
18. As regards the complainant's argument that the entry dated 10.3.1999 "flapping tremor" was wrongly detected from the record, it is admitted then on 10.3.1999, the case sheet was entered by the House Surgeon, who had made wrong entries in the case sheet and that his diagnosis was wrong. Petitioner contended that the respondent was not having these symptoms and hence, the entries 'Conscious' and 'Oriented' and 'Flapping tremor' had been scored out. It is averred that petitioner No. 1 examined the condition of the respondent and thereafter made fresh entry on the next page of the case sheet. It is further averred that flapping tremor would not occur in this case. For this, reliance was placed on the textbook "Gastrointestinal Disease" Pathophysiology/Diagnosis/Management" Table 87.2, which states that 'Flapping tremor' also known as 'Asterixis' would not occur in obstructive jaundice.
19. As regards complainant's argument that though the Radiologist suggested Barium meal test on 2.3.1999, which was taken only on 10.3.1999 it is stated that Barium meal test requires minimum 24 hours preparation of the patient. In the test result, it was found that the stomach was normal and smooth indentation was seen in the first part of duodenum. It only suggested that there was compression due to the collection, of fluid in the gall bladder bed.
20. On 12.3.1999, the petitioner No. 1 found that serum bilirubin was 5 mg, then he referred the patient to higher centre for management because ERCP procedure was required to be done to find out actual cause for jaundice. Although she was referred to Stanley Medical College Hospital for higher management but the respondent preferred Sri Ramchandra Medical College Hospital (hereinafter referred as SRMCH). Hence, the respondent was admitted at SRMCH.
21. It is submitted that approximately one month after the surgery at Tirunelveli Medical College Hospital, the investigations at SRMCH revealed that the total bilirubin level of 10.1 mg/dl and Alkaline Phosphatase levels decreased from 828 u/1 to 328 u/1 between 15.3.1999 to 23.3.1999. At SRMCH, ERCP was done and the report revealed that Pancreatic Duct was visualized and the Common Bile Duct was found to be transected in its retroduedonal portion. It is argued that during the intervening period of 8 days from 15.3.1999 to 28.3.1999 no therapeutic intervention was done at SRMCH to relieve the so-called bile duct obstruction, if any.
22. From the fact that the levels of Alkaline Phosphate decreased during this period even without any therapeutic intervention, it can be inferred that the patient was recovering gradually without any intervention. Jaundice is self-limiting which reduces itself within 3 to 4 weeks as soon as the fluids are absorbed into circulation and jaundice will reduce automatically. It is submitted that the allegation that four sutures were made in and around Common Bile Duct and that as a result biliary tract was tied up which resulted in leakage of bile into duodenum is not sustainable. When Cystic Artery and Cystic Duct cut individually petitioner No. 1 had done double ligation so that there was no bleeding or bile leak during the operation.
23. It is submitted that Dr. Surendran, who appeared as an Expert Witness before the District Forum deposed that if Common Bile Duct is tied accidentally during operation, the jaundice would appear within a week and serum bilirubin would increase to about 15 to 20 mg. He further deposed that "flapping tremor" would not occur in postoperative jaundice.
24. Dr. R. Surendran, Professor of Surgical Castro Enterology, Stanley Medical College Hospital, Chennai deposed as under:
In case of obstructive jaundice the only treatment is either surgery or endoscopy.
In TVMC Hospital endoscopy treatment was not given. ERCP treatment was not given.
In this case sutures are not the cause for collection of fluid.
In TVMC Hospital no treatment was given specifically for obstructive jaundice.
In Sree Ramachandra Medical College Hospital, the fluid was drained before surgery. Flapping tremor is definitely a serious condition of liver failure.
Findings:
25. In our view, the main deficiency in service by the petitioners is not promptly treating the complainant for obstructive jaundice, after the surgery. On this point we find that the District Forum and the State Commission have properly appreciated evidence and allowed the complaint. SRMC Hospital record showed that there was stone left behind and the same was removed by them at the time of operation and we accept this evidence on the basis of medical record placed by the Surgeon at SRMC Hospital and reject the argument of the petitioners that USG scan is inferior to MRCP and ERCP.
26. Although it is contended by the petitioners that the statement of Dr. Suraj Balaji that the condition of the respondent was poor at the time of admission at SRMCH is untenable, we rely on the deposition made by Dr. Suraj Balaji, who is an Assistant Civil Surgeon in Surgical Castro Enterology Department, SRMCH, who assisted Dr. B. Krishna Rao, Head of the Department, SRMCH given as under:
At the time of admission the complainant having deeply jaundiced and general condition was poor.
Subsequently on coming to know the history of the complainant, she had already undergone Cholecystectomy operation one month back at Tirunelveli Medical College Hospital and was suffering from obstructive jaundice and was referred for further treatment.
On admission blood investigation was done and ultrasound scan of abdomen was taken. It was found that there were three large collections of fluid in the abdomen for which two drainage tubes were put under ultrasound guidance.
Further MRCP was done which showed collection in the gall bladder fossa. Further ERCP was done showed complete obstruction just above the retroduodenal portion of the common bile duct. She was planned for surgery after getting required fitness for surgery. During surgery there were four silk sutures found on the CBD which were removed.
Syringe aspiration in that region was used to identify the biliary duct. A Roux-n Y loop Hepatico jejunostomy was done. There was dense fibrosis adhesion in that area.
Post operatively the patient recovered well and subsequently discharged on 7.4.99. I cannot say now after the lapse of one and a half months from surgery what is the real cause for the collection of fluid in the gall bladder area.
The four sutures in and around the gall bladder area may be one of the causes for the collection of fluid in that area.
If there is mild jaundice in the post operative period it will subside spontaneously within a week or two.
When the complainant came to us she had obstructive jaundice.
Itching is a sign of increasing jaundice and obstructive jaundice.
Flapping tremor may occur in increasing level of Serum bilirubin and deposition in brain.
The following investigations namely ultrasound scan abdomen and CT or MRI scan followed by ERCP are required to diagnose obstructive jaundice.
In the case of obstructive jaundice. Hepatico jejunostomy is to be done.
27. In our view, instead of taking immediate steps to drain the fluid collection, the petitioners delayed to correct the problem and did not take proactive steps to do the necessary surgery. Once the petitioners knew on 26.2.1999 itself that it could be a case of obstructive jaundice, then there was no need for them to wait. If obstructive jaundice is something that requires surgery, they should have acted promptly and sent the patient to Chennai or to any speciality hospital for further treatment immediately which eventually they sent for better care but rather late.
28. With regard to the sutures, these were not removed by the petitioners and because they were not removed the biliary track was also tied up. The question is not of whether the sutures are retained or removed but the question is of biliary track being obstructed due to this. Due to obstruction in the biliary track and as a result, there was leakage in the biliary track, which resulted in jaundice. Although the petitioners have referred to some medical text references which emphasize that surgery was the only cure for obstructive jaundice, they continued to wait and watch and have not justified their delay in not apprising the family of the patient to rush to Chennai for better care and treatment. This casual attitude of the petitioners is not acceptable as the respondent suffered for this delay and she had to undergo further treatment in SRMC Hospital from 15.3.1999 to 7.4.1999 for nearly three weeks. Subsequently, on two occasions, i.e. on 12.4.1999 and 16.4.1999, she had undergone medical check ups in the said hospital. She had to go through a risky surgery for this suffering because of initial negligence by the petitioners.
29. Petitioners have acted maliciously by scoring out the words "flapping tremor and drowsiness" in the case sheet of the complainant. The contention and feeble explanation of the petitioners that they had to rewrite the case after scoring these words explaining that the House Surgeon had wrongly written those words cannot be accepted, as they are all bald statements made as an afterthought to protect themselves and to cover up the mischief. It is strange that Dr. Surendran stated "Flapping tremor" does not occur in post-operative jaundice, which is being relied upon by the petitioners, without any satisfactory explanation as to why the House Surgeon wrote those words. It is stated by the petitioners that it was a mild jaundice, which was subsiding day-by-day, but in reality it was increasing day-by-day. The condition of the patient worsened. The practice of covering up their act and scoring off the medical notes should be discouraged by the hospitals and medical profession. It does not speak well when it is happening in the field of a noble profession, i.e. medical profession. The confidence and trust, which the patients have towards Doctors and Hospitals, will completely be shaken if this is allowed.
30. We find that there is deficiency in service and negligence on the part of the petitioners due to which the respondent had to suffer which was not at all necessary in the present case. After taking into consideration the facts, the District Forum and State Commission have directed the petitioners to pay Rs. 3,20,000 jointly and severally along with costs of Rs. 10,000. The State Commission has dealt with the entire case at length and dismissed the appeal of the petitioners. In this Revision Petition the matter was argued at length in this Commission but we find there is no justifiable reason for us to interfere with the well reasoned orders of the lower Fora.
In the result, in view of the aforesaid discussion, we dismiss the Revision Petition. There shall be no order as to costs.