National Consumer Disputes Redressal
Smt. Ushendra W/O. (L)Sh.Rajkumar& 2 ... vs Suprintendent, Christian Medical ... on 24 July, 2015
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI APPEAL NO. 445 OF 2007 (Against the Order dated 28/05/2007 in Complaint No. 24/2001 of the State Commission None) 1. SMT. USHENDRA W/O. (L)SH.RAJKUMAR& 2 OTRS ALL RES.NO.188,MALERI GALI LUDHIYANA PUNJAB 2. SMT.USHENDRA & ORS. W/O OF LATE SH. RAJ KUMAR JAISWAL RESIDENT OF 188, MALERI GALI, LUDHIYANA, PUNJAB 3. SMT.USHENDRA & ORS. W/O OF LATE SH. RAJ KUMAR JAISWAL RESIDENT OF 188, MALERI GALI, LUDHIYANA, PUNJAB 4. SMT.USHENDRA & ORS. W/O OF LATE SH. RAJ KUMAR JAISWAL RESIDENT OF 188, MALERI GALI, LUDHIYANA, PUNJAB ...........Appellant(s) Versus 1. SUPRINTENDENT, CHRISTIAN MEDICAL COLLEGE LUDHIANA & ORS. 410 R, MODEL TOWN, LUDHIYANA PUNJAB 2. SUPERINTENDENT & ORS. CHRISTIAN MEDICAL OFFICER, LUDHIYANA PUNJAB 3. THE DIRECTOR CHRISTIAN MEDICAL COLLEGE, LUDHIYANA, PUNJAB ...........Respondent(s)
BEFORE: HON'BLE MR. JUSTICE D.K. JAIN, PRESIDENT HON'BLE MRS. M. SHREESHA, MEMBER For the Appellant : Dr. Sushil Kumar Gupta, Amicus Curie For the Respondent : Mr. B.L. Saini, Advocate Mr. Ravison, Senior Law Officer Dr. Cinosh Mathew, OM Cardiology Dated : 24 Jul 2015 ORDER M. SHREESHA, MEMBER Challenge in this First Appeal under Section 19 of the Consumer Protection Act (for short the "Act") by the Complainant, is to order dated 28.05.2007, in Original Complaint No. 24 of 2001, passed by the State Consumer Disputes Redressal Commission, Punjab, Chandigarh (for short the "State Commission"). Vide its impugned order, the State Commission dismissed the Complaint on the ground that there was no expert evidence to substantiate that the treatment given to the deceased was negligent or against the standard medical norms.
2. The brief facts as set out in the Complaint are that late Shri Raj Kumar Jaiswal (hereinafter referred to as the "patient"), aged about 42 years, was admitted in the casualty department of Christian Medical College & Hospital, Ludhiana on 14.4.1998 at about 11.30 p.m. with a complaint of Chest Pain. The second Opposite Party, Dr. B.P. Singh, the Medical Officer on emergency duty, examined the patient and found him to be in a serious condition. It is pleaded by the Complainants herein, the legal heirs of the patient, that the second Opposite Party did not undertake any immediate steps or any emergency treatment despite the fact that the patient was in a serious condition. It is also pleaded that ECG was not done; oxygen was not administered; no injection namely Betnesol and Adrenaline were given; blood pressure was not controlled and it is only due to the negligence of the Opposite Parties that the patient developed Cardiac Respiratory Arrest and died at 12.40 A.M.
3. The first Complainant is the widow of the deceased and is dependent on him and the second, third and fourth Complainants, the young children of the deceased, are students and dependents. It was pleaded that the patient was a Cloth Merchant, earning about ₹10,000/- per month. The Complainants prayed for compensation of ₹19.71 lakhs, as detailed below:
Loss of Consortium Rs. 4,50,000/- Funeral Expenses Rs. 20,000/- Loss of Estate & Income Rs. 8,00,000/- Mental agony and pain Rs. 7,00,000/- Medical Expenses Rs. 1,000/-
4. The Opposite Parties filed their written version in which they denied that the patient was admitted in the Hospital. It is stated that he was brought into Casualty at around 11.30 p.m. with High BP and Chest pain. The patient was examined by the second Opposite Party who found that the patient had accelerated hypertension with angina or acute myocardial infarction and that the patient's condition was very serious. They pleaded that the pulse rate of the patient was 110 per minute and blood pressure was 150/110 and to control the blood pressure the patient was given 5 mg. of S/L Nifedipine; was started on oxygen, E.C.G. was ordered; and I.V. line was established. The patient developed cardiorespiratory arrest and thereafter his B.P. and Pulse were not recordable. The patient was immediately intubated and started on AMBU ventilation and Cardiac Massage. He was put on a cardiac monitor which showed ventricular fibrillation. The patient was given injections Adrenaline and Atropine and was given synchronized cardioversion, but the patient could not be revived. The resuscitative measures were stopped and the patient was declared dead at 12.40 a.m.
5. It is averred by the Opposite Parties that injection Betnesol is not required to be prescribed, or given in such a situation, when the patient was suffering from High Blood pressure. It is specifically pleaded by the Opposite Parties that necessary treatment was given to the patient and he was only brought into Casualty on the intervening night on 14.4.1998 at 11.30 p.m. and he expired at 12.40 a.m. despite all efforts.
6. The State Commission after going through the evidence on record held as follows:
"After hearing the counsel for the parties and going through the records, we are of the opinion that the complaint deserves dismissal. There is no material evidence on record to prove medical negligence on the part of the opposite parties. The burden of proving medical negligence is on the complainant. Mere allegations are not sufficient to come to a conclusion. There is no specific allegation as to what was required of a doctor which he has not done. Further, no medical expert evidence has been produced on record to contradict the stand taken by the opposite parties. In the absence of any expert evidence, it cannot be said that the treatment given to the deceased was against the medical norms especially when the opposite parties have given detailed reply to the allegations made by the complainant to prove their stand that the treatment given to the deceased was strictly as per medical literature.
In view of discussion made above, the complaint is dismissed. However, there will be no order as to costs".
7. Aggrieved by the said order, the Complainant preferred this Appeal.
8. Dr. Sushil Kumar Gupta was appointed as Amicus Curie, who assisted the Court in this case.
9. The learned Amicus Curie submitted that the 'time of examination' is very important and drew our attention to the 'Out-Patient Record' dated 15.4.1998, in which the time is noted as 12.15 A.M. The learned counsel for the Respondents stated that as per the 'Treatment Sheet' dated 14.4.1998, the time is noted as 11.35 p.m. and submitted that it takes a few minutes to administer I.V. and immediately conduct the necessary investigations. The Treatment Sheet filed before this Commission reads as follows:
"Form No. 39CHRISTIAN MEDICAL COLLEGE Raj Kumar LUDHIANA, PUNJAB TREATMENT SHEET Casualty DATE TIME MEDICINES & TREATMENT REMARKS ON CONDITION INITIALS 14.4.98 11:35 PM 42 years old conscious male patient came with H/o chest pain since evening 11:40 PM Cap. Nifedipine 5 mg. S/D 11:50 PM Inj. Adrenaline (1) ETT B.P. 150/110 mmHg (EMO) 11:50 PM Inj. Atropine (1)I/V Pulse 110/min 12:00 MN Inj. Adrenaline (1) I/V Resp 24/min 12:00 MN Inj. Atropine (1) I/V Temp 980 6 only 12:05 AM Inj. Adrenaline (1) IV 02 started 12:10 AM Inj. NaHCO3 25 ml (1)
Patient had sudden seizure & B.P. & Pulse taken but not recordable. IVF started. CPR done. On positive pressure. Patient put on cardiac monitor. But patient not revived. Patient declared dead at 12:40 AM.
ATTESTED Sd/-
Medical Superintendent CMC Hospital, Ludhiana, Punjab, India
10. The out-patient record states as follows:
"FORM 16-B OUT PATIENT RECORD DATE NAME UNIT NO. C EMO 15/04/98 12:15 AM 42 years old male with h/o Chest Pain (L) precordial region, radiating to both arms and assoc. with ghabrahat.
O/E no pallor, icterus, cyanosis, edema CVS JVP S1 S2 normal P 110/min S.P. 150/110mmHg Chest clear Abd/CNS NAD Impression - Ac MI/accelerated HTN with angina EKG stat
Patient had a sudden cardioresp arrest, B.P. & pulse not recordable. Inj. Adr. /Atropine given Patient intubated started CPR. Put on cardiac monitor. Monitor V. Fibrillation Patient cardioverted; given atropine/adrenaline But could not be revived.
O/E Pupils B/L fixed & dilated.
Patient declared dead at 12:40 AM Barendra Pal Singh Attested Sd/-
Medical Superintendent CMC Hospital"
11. The learned Amicus Curie drew our attention to the opinion given by Dr. B.K. Chaurasia, MBBS, DV & DHB (Cardiologist) which reads as follows:
"(1) How did the diagnosis of Acute myocardial infarction was made as S1 S2, were normal.
There was no S3, S4 no gallop Rhythum.
No crapitation in lungs were heard.
E.C.G. was not done.
Emzymes were not done.
(2) When patient was put on Cardiac monitor which should ventricular fibration - at that period. You had given J/V Inj. adrenaline - which accilirate the ventricular fibrillation.
It seems that this faulty administration of adrenaline injection has remarked in the death of Shree R.K. Jaiswal.
Ideally, in ventricular fibrillation J/V Xylocamia is given and not J/V adrenaline.
Their contonition may be that J/V adrenaline was given to the B.P. as B.P. was not recordable that in such cases where patient has developed ventricular fibrillation. One should give J/V Dopsmina Drip and not adrenaline.
Sd/-
Dr. B.K. Chaurasia M.B.B.S. D.V. & D.H.S. (Cardiologist)
12. The Appellants also relied on the report of Dr. G.K. Agarwal, Heart Specialist, District Hospital, Banda which reads as follows:
"Date...........
For Late Raj Kumar Age 42 years Jaisawal R/o 188, Mallari Gali, Ludhiana (Punjab) In this condition of the patient must be done E.C.G. earliest moment not the 5 mg. nefidipine cap. is given wrongly on Examination, can not be confirmed S1, S2, S3, S4, even CVS J-V extra without E.C.G. Injection adrenaline should not be given as it is wrong, also in such condition. Only cardiologist can do better.
Date: 13.9.2007 Dr. G.K. Agarwal Heart Specialist Distt. Hospital, Banda Through:- Case summary Dated 12.5.98 of C.M.C. & Hospital, Ludhiana (Punjab)"
13. As against this Report, the Respondents filed the opinion of Dr. (Prof.) Rakesh Kumar Aggarwal, Department of Cardiology, Christian Medical College & Hospital, Ludhiana, which reads as follows:
"The line of management of this patient is universally accepted world over. I have also seen the alleged opinion dated nil given by Dr. G.K. Aggarwal. In the alleged opinion Dr. G.K. Aggarwal has claimed himself to be Heart Specialist but has failed to mention any medical qualification what to say of cardiology. The opinion given by Dr. G.K. Aggarwal makes no sense and it is difficult to comprehend what he intends to convey. His assertion that injection Adrarenaline should not be given is wrong and is not based by any accepted medical texture. In fact the treatment given to the patient by the C.M.C. Hospital, Ludhiana is supported by the Medical Text Book, copies of which are Annexure - A and Annexure-B. In such like situation injection Betnesol is not to be given.
After going through the medical record file of the patient Raj Kumar and the opinion of Dr. G.K. Aggarwal, I am of the considered opinion that the treatment given to the patient Raj Kumar is the universally accepted line of treatment throughout the world".
14. A reading of PACA (Placebo versus Adrenaline versus Cardiac Arrest) a study by Jacobs and colleagues, published in Resuscitation, the official journal of the European Resuscitation Council, provides the best evidence to date supporting the use of Adrenaline to treat cardiac arrest. In this single-centre double blind study, 601 out-of-hospital cardiac arrest victims were randomized to receive either placebo (0.9% sodium chloride) or Adrenaline during advanced life support. Data available from 534 patients (262 placebo vs. 272 adrenaline) showed no difference in the primary end study point, survival to hospital discharge, but did show that a spontaneous circulation was restored (in other words the heart was 'restarted') three times more commonly with Adrenaline (23.5%).
15. In the Data Sheet : (http://www.medsafe.govt.nz/profs/datasheet/a/ Adrenaline1in1000injMax.pdf):
"Presentation of Adrenaline:
Adrenaline injection contains no antimicrobial agent. It should be used only once and any residue discarded. It is a clear, colourless solution and should not be used if it is coloured.
Actions Adrenaline acts on both alpha and beta adrenergic receptors of tissues innervated by sympathetic nerves, except the sweat glands and arteries of the face. It is the most potent alpha receptor activator. Adrenaline stimulates the heart to increased output; raises the systolic blood pressure; lowers diastolic blood pressure; relaxes bronchial spasm and mobilises liver glycogen, resulting in hyperglycaemia and possibly glycosuria.
Cardiac Arrest Adults The recommended dose is 1 mg intravenously, using 10 mL of the 1:10,000 solution. This may be repeated every 3-5 minutes. If given through a peripheral line, each dose should be followed by a flush of 20 mL of IV fluid to ensure delivery of the drug to the central compartment.
16. As seen from the Data Sheet, Adrenaline is used for improving relative coronary and cereal perfection. In this case, the patient admittedly suffered Cardiac Arrest within a few minutes of his being taken to the hospital. In this condition, administering of Adrenaline, as can be seen from the Medical Literature, seems to be the standard line of treatment as per medical parlance. Therefore, the contention of the Appellant/Complainants that Adrenaline was wrongly used, is unsustainable.
17. The Appellants alleges that the basic protocol of Cardiac Arrest Management has not been followed and in support of their case relied on the Medical Literature on Treatment of Acute Myocardial Infarction - Bibliographic Source(s) - Institute for Clinical Systems Improvement (ICSI), Treatment of acute myocardial infarction, Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2002 Nov.,68 p., which in brief reads as follows:
"A chest pain protocol should be in place to ensure the following occur within 30 minutes of presentation:
Obtain 12 lead electrocardiogram (ECG).
Begin cardiac monitoring.
Administer supplemental oxygen.
Establish intravenous (IV) access at two or three sites (especially if thrombolytics are to be administered). Rapid volume expansion with normal saline solution may be indicated.
Routine laboratory studies:
Electrolytes, blood urea nitrogen (BUN), creatinine, complete blood count and marker(s) for myocardial injury (creatine kinase [CK]/creatine kinase isoenzyme-myocardial [CK-MB] or troponin).
"6. Administer IV or sublingual nitrates to lower blood pressure if needed and potentially relieve pain.
Administer analgesics and/or anxiolytics; morphine sulphate, 2 to 5 mg IV every 5 to 10 minutes as needed. Benzodiazepines may be of benefit in selected patients.
Check vital signs often. An automatic recording blood pressure cuff is helpful".
Beta-blockers, *such as metoprolol (Lopressor ®, 5 mg IV every 5 minutes for three doses, followed by 25 to 50 mg orally every 6 hours for 48 hours, then 50 to 100 mg orally twice a day. Relative contraindications include systolic blood pressure <100mm Hg, heart rate <60 beats/min, reactive airway disease, and heart block greater than first degree."
18. From the material placed on record, we observe that the 'Treatment Sheet' read with the afore-mentioned 'Out Patient record' shows that the ECG was ordered immediately-(EKG Stat). The impression recorded was - Myocardio infarction/accelerated Hypertension with angina. The case summary shows that the patient was given 5 mg of S/L nifedipine for high blood pressure; started on Oxygen; an ECG was ordered; and an IV line was established. But after five minutes, the patient suddenly suffered a cardiorespiratory arrest; BP and pulse were not recordable; heart sounds were not heard; and there was no spontaneous respiration. It is submitted that the patient was immediately intubated endotracheally and started on AMBU ventilation and Cardiac Massage, but the patient could not be revived and the cardiac monitor showed no electrical activity. The patient's brainstem reflexes were absent and there was no heart beat or peripheral pulses. Resuscitative measures were stopped and the patient was declared dead at 12.40 A.M.
19. It is the Appellant's case that the patient was not immediately treated at 11.30 AM, the time he was brought to the hospital, which in the instant case, has not been established. The Medical records clearly show that the patient was immediately treated with Nifedipine - 11.40 P.M.; Inj. Adrenaline - 11.50 P.M.; Inj. Atropine -11.50 P.M.; Inj. Adrenaline- 12.00 MN; Inj. Atropine-12.00 MN; Inj. Adrenaline-12.05 A.M. ; Inj. NaHCO3-12.10 A.M. It is the main contention of the Appellant that ECG was not done immediately when the patient was brought into Casualty before starting the treatment. In compliance of the Order dated 11.5.2015 passed by this Commission, Dr. Cinosh Mathew, Department of Cardiology, CMC & Hospital, Ludhiana stated in his report that the patient was immediately connected to a Cardiac Monitor which shows continuous ECG tracing. As the patient had a cardiac arrest within five minutes of arrival to the Casualty and needed resuscitation, ECG was monitored continuously on cardiac monitor. Once patient has a cardiac arrest, it is not technically possible to take an ECG tracing on paper without interrupting the cardiac resuscitation procedure. Therefore, the ECG was monitored continuously on cardiac monitor. ECG on monitor showed ventricular fibrillation, for which the appropriate management was given. With respect to use of Injection Betnesol, the Doctor stated that it shows no benefit and may be hazardous in acute myocardial infarction.
20. It is pertinent to note that the patient developed Cardiac Arrest within a few months of starting of the treatment. It is apparent that despite all efforts made by the Respondent/Opposite Party from 11.40 PM to 12.40 A.M., the patient had expired. In the light of the aforementioned treatment rendered to the patient as per the medical records, establishes that the contention of the Appellants that the protocol of Cardiac Arrest has not been followed, cannot be sustained.
21. What constitutes medical negligence is well settled through a catena of decisions of the Hon'ble Supreme Court, including in Jacob Mathew Vs. State of Punjab & Anr. (2005) 6 SCC 1, a three Judge Bench decision; Indian Medical Association Vs. V.P. Shantha and Ors. (1995) 6 SCC 651. Noted from these judgments, the broad principles to determine what constitutes medical negligence, inter alia, are: (i) Whether the doctor in question possessed the medical skills expected of an ordinary skilled practitioner in the field at that point of time; and (ii) Whether the doctor adopted the practice (of clinical observation diagnosis - including diagnostic tests and treatment) in the case that is accepted as proper by a responsible body of professional practitioners in the field. In this connection, in Jacob Mathew (supra) the three Judge Bench, elaborating on the degree of skill and care required of a medical practitioner quoted Halsbury's Laws of England (4th Edn., Vol.30, para35), as follows:
"35. The practitioner must bring to his task a reasonable degree of skill and knowledge, and must exercise a reasonable degree of care. Neither the very highest nor a very low degree of care and competence, judged in the light of the particular circumstances of each case, is what the law requires, and a person is not liable in negligence because someone else of greater skill and knowledge would have prescribed different treatment or operation in a different way; ..."
22. Keeping in view the afore-mentioned Judgments of the Apex Court, wherein the Hon'ble Supreme Court has repeatedly laid down the law that if the treating Doctor has administered a reasonable degree of skill and has followed standard norms of medical parlance, it cannot be construed as negligence, we are of the considered opinion that even in the instant case, there is no material on record to establish that the Respondent Doctors/Hospital have been negligent in the treatment of the patient.
23. Hence, this Appeal must fail and is dismissed accordingly. No order as to costs.
24. Before parting with the case, we place on record our appreciation for the valuable assistance rendered by Dr. Sushil Kumar Gupta, the learned Amicus Curiae.
......................J D.K. JAIN PRESIDENT ...................... M. SHREESHA MEMBER