State Consumer Disputes Redressal Commission
Dr.S.K. Shrma vs Prem Sagar on 8 January, 2024
Cause Title/Judgement-Entry STATE CONSUMER DISPUTES REDRESSAL COMMISSION, UP C-1 Vikrant Khand 1 (Near Shaheed Path), Gomti Nagar Lucknow-226010 First Appeal No. A/502/2015 ( Date of Filing : 18 Mar 2015 ) (Arisen out of Order Dated 16/02/2015 in Case No. C/95/2013 of District Basti) 1. Dr.S.K. Shrma Surya Orthopaedic & Spinal Centre Near District Hospital Distt. Basti ...........Appellant(s) Versus 1. Prem sagar Vill. Neurigara Kusraut P.O. Kothwa Tehsil Sadar Distt.Basti ...........Respondent(s) BEFORE: HON'BLE MR. Rajendra Singh PRESIDING MEMBER HON'BLE MR. Vikas Saxena JUDICIAL MEMBER PRESENT: Dated : 08 Jan 2024 Final Order / Judgement राज्य उपभोक्ता विवाद प्रतितोष आयोग , उ0प्र0 , लखनऊ। सुरक्षित अपील सं0- 502/2015 (जिला उपभोक्ता आयोग, बस्ती द्वारा परिवाद सं0-95/2013 में पारित प्रश्नगत निर्णय एवं आदेश दिनांक 16-02-2015 के विरूद्ध) डॉ0 एस0के0 शर्मा (एम.एस. आर्थोपेडिक), सूर्या आर्थोपेडिक एण्ड स्पाइनल सेण्टर, निकट जिला अस्पताल, जिला बस्ती। ...........अपीलार्थी/विपक्षी। बनाम प्रेम सागर पुत्र श्री रामजीत, निवासी ग्राम नेउरीगाड़ा कुसरौत, पोस्ट कोठवा, तहसील सदर, जिला बस्ती। ............ प्रत्यर्थी/परिवादी। समक्ष:- 1.
मा0 श्री राजेन्द्र सिंह, सदस्य।
2. मा0 श्री विकास सक्सेना सदस्य।
अपीलार्थी की ओर से उपस्थित: श्री एम0एच0 खान विद्वान अधिवक्ता।
प्रत्यर्थी की ओर से उपस्थित : कोई नहीं।
दिनांक : 14-02-2024.
मा0 श्री राजेन्द्र सिंह , सदस्य द्वारा उदघोषित निर्णय यह अपील उपभोक्ता संरक्षण अधिनियम, 1986 की धारा-15 के अन्तर्गत, जिला उपभोक्ता आयोग, बस्ती द्वारा परिवाद सं0-95/2013 में पारित प्रश्नगत निर्णय एवं आदेश दिनांक 16-02-2015 के विरूद्ध योजित की गयी है।
संक्षेप में अपीलार्थी का कथन है कि प्रश्नगत निर्णय एवं आदेश विधि विरूद्ध एवं तथ्यों की अनदेखी करते हुए दिया गया है। यह दोनों पक्षों को स्वीकार्य है कि दिनांक 02-01-2011 को परिवादी को वृक्ष से गिरने से दोनों पैरों की जॉंघों में चोट आयी और उसे उसी दिन अपीलार्थी के अस्पताल में लाया गया, जहॉं कम्पाउण्ड शाफ्ट फीमर फ्रैक्चर पाया गया, जिससे खून बह रहा था और हीमोग्लोबिन 07 प्रतिशत था, जिससे श्वास लेने में तकलीफ हो रही थी, जो उसके जीवन के लिए घातक था। ऐसी स्थिति में अपीलार्थी ने आवश्यक परीक्षण किया, एक्स-रे लिया और पाया कि दोनों पैरों की जांघों में कम्पाउण्ड शाफ्ट फीमर फ्रैक्चर है। इसके पश्चात् अपीलार्थी ने सभी आवश्यक टैस्ट करते हुए सावधानीपूर्वक आपरेशन किया और इसके पश्चात् आवश्यक स्पिलिण्टेज आवश्यक गति को रोकने के लिए किया गया। उसे आवश्यक दवा और एण्टीबायोटिक्स दिये गये और इस प्रकार रोगी को आपरेशन करने के लिए पूर्ण रूप से तैयार किया गया।
अपीलार्थी ने परिवादी की स्थिति से सन्तुष्ट होने के पश्चात् अगले दिन दिनांक 03-01-2011 को उसके दोनों पैरों की जांघों का आपरेशन विशेष सावधानी के साथ किया और खुली सर्जरी से बचा। इसके अन्तर्गत दोनों पैरों में नेल डाली गई, जिसको डिवाइस के माध्यम से देखते हुए किया गया। यह आपरेशन इस प्रकार सफल रहा। इसमें किसी भी प्रकार की कोई उपेक्षा नहीं की गयी। इसके पश्चात् रोगी को एक सप्ताह तक परीक्षणाधीन और उपचार हेतु रखा गया तथा यह पाते हुए कि कोई जटिलता उत्पन्न नहीं हुई, रोगी को वॉकर की सहायता से चलते हुए डिस्चार्ज किया गया। उसे सलाह दी गयी कि नियमित थेरेपी और एक्सरसाइज करता रहे, जो घुटने की स्टिफनेस से बचने के लिए आवश्यक है।
परिवादी इस मामले में डॉक्टर की सलाह मानने में नियमित नहीं रहा और फालोअप उपचार के लिए उसने काफी विलम्ब किया। जब-जब वह फालोअप उपचार के लिए आया तब-तब उसे सर्वोत्तम उपचार दिया गया और उसने इस दौरान् कभी भी कोई शिकायत नहीं की। दिनांक 18-03-2012 से एक वर्ष से अधिक होने पर उसे कोई शिकायत नहीं हुई, जिसका यह अर्थ हुआ कि उपचार भली-भांति चल रहा था। दिनांक 18-03-2012 को परिवादी, अपीलार्थी के यहॉं आया और उसके दाहिने पैर के घुटने में कड़ापन पाया गया। इसका तुरन्त उपचार किया गया और उसको तुरन्त आपरेशन थियेटर ले जाकर एनेस्थेसिया देकर दाहिने पैर के घुटने को चलायमान किया गया, जिसको परिवादी ने दूसरा आपरेशन समझ लिया। यह कोई सर्जिकल आपरेशन नहीं था। इसके बाद परिवादी को आवश्यक दवा देकर जाने दिया गया। उसे नियमित व्यायाम करने की सलाह दी गयी। दिनांक 18-03-2012 के पहले परिवादी स्वस्थ था और उसे किसी प्रकार की कोई शिकायत नहीं थी। अपने नियोक्ता के यहॉं वह अपनी सेवाऐं देने के लिए भी तैयार था। इसी आधार पर उसे एक स्वस्थता प्रमाण पत्र बनाकर दिया गया, जिसमें लिखा गया कि वह दिनांक 02-01-2011 से 18-09-2011 तक बिस्तर पर रहा और उसे इसके पश्चात् हल्का काम करने की अनुमति दी गयी।
परिवादी दिनांक 18-03-2012 से 03 महीने के उपरान्त अपीलार्थी के पास दिनांक 02-07-2012 को आया और परीक्षण में अपीलार्थी ने पाया कि दाहिने पैर की जांघ में हड्डीयों का जुड़ाव नहीं हुआ है, अत: उसे बोन ग्राफ्टिंग की सलाह दी गयी। रोगी को आपरेशन थियेटर में ले जाया गया। वहॉं पर सर्जिकल कट के समय यह देखने में आया कि उसकी दोनों हड्डीयों में काफी गहराई व संक्रमण है। इसलिए बोन ग्राफ्टिंग नहीं की गयी और संक्रमण की सफाई की गयी और उचित दवा दी गयी और फिर उससे आने के लिए कहा गया, लेकिन इसके बाद परिवादी इलाज कराने नहीं आया और वह दूसरे डॉक्टर के यहॉं उपचार के लिए चला गया। जहॉं पर वह डॉ0 सत्येन्द्र राय के उपचार में काफी दिन तक रहा, किन्तु वहॉं पर जब उसे कोई सुधार नहीं दिखायी दिया तब वह पुन: अपीलार्थी के यहॉं दिनांक 30-03-2013 को आया। इसके बाद उसे किंग जॉर्ज मेडिकल कालेज, लखनऊ के लिए सन्दर्भित किया गया, जहॉं पर परीक्षण के उपरान्त डॉक्टरों ने पाया कि उसके दाहिने पैर के फीमर शॉफ्ट में हड्डीयों का जुड़ाव नहीं हुआ है और उसे प्राथमिकता के आधार पर भर्ती करने के लिए निर्देश दिया गया, किन्तु वह ऋषि अस्पताल में अपना इलाज कराने चला गया, जहॉं उसे दिनांक 01-04-2013 को देख कर दिनांक 17-04-2013 को भर्ती किया गया और उसका आपरेशन दिनांक 18-04-2013 को करने के उपरान्त दिनांक 26-04-2013 को डिस्चार्ज किया गया। वहॉं पर ऋषि अस्पताल के डॉक्टरों ने आपरेशन किया और जंग लगे नेल को हटाया। साथ ही साथ संक्रमित कॉटन/कपड़े को भी हटाया।
ऋषि अस्पताल में आपरेशन होने के उपरान्त परिवादी को उचित आराम नहीं मिला तब वह उपचार के लिए विवेकानन्द पालीक्लीनिक, लखनऊ गया और वहॉं भी वही जटिलता उत्पन्न हुई, जिसके लिए आपरेशन ऋषि अस्पताल में किया गया था। इसके बाद पुन: उसे ऋषि अस्पताल में दिनांक 12-10-2013 को भर्ती किया गया, जहॉं पर दिनांक 14-10-2013 को उसके दाहिने पैर के उसी शॉफ्ट का आपरेशन किया गया, जिसका पहले किया गया था। वहॉ से टूटे हुए एण्डर नेल को हटाया गया। ऋषि अस्पताल द्वारा प्रदत्त डिस्चार्ज समरी में दो आपरेशन दिनांक 18-04-2013 को और दिनांक 14-10-2013 को होना सन्दर्भित है, लेकिन कहीं भी यह नहीं कहा गया कि यह अपीलार्थी की उपेक्षा के कारण हुआ, जो आपरेशन दिनांक 03-01-2011 को किया गया था, जिससे स्पष्ट होता है कि परिवाद पत्र को मात्र अनुमानों पर अपीलार्थी की उपेक्षा मानते हुए निर्णीत किया गया है।
विद्वान जिला आयोग यह देखने में असफल रहे कि परिवादी को उसके परिवार के सदस्यगण दिनांक 02-01-2011 को गम्भीर चोट की हालत में लाये थे। तब दोनों पैरों की फीमर हड्डी के शॉफ्ट में कम्पाउण्ड फ्रैक्चर था और दाहिने पैर की टूटी हुई हड्डी खाल को चीरती हुई बाहर आ गयी थी। वहॉं से लगातार खून का बहाव हो रहा था, जिसके कारण श्वास लेने में तकलीफ भी हो रही थी। ऐसे कम्पाण्ड फ्रैक्चर गम्भीर प्रक्रति के होने हैं और घातक होते हैं। आकस्मिक मामला मानते हुए उसका तुरन्त उपचार किया गया और घाव को साफ किया गया तथा आवश्यक दवाऐं दी गयीं और जब परिवादी की हालत में कुछ सुधार हुआ तब अगले दिन दिनांक 03-01-2011 को उसका आपरेशन करते हुए उसकी हड्डीयों को क्रमानुसार व्यवस्थित किया गया और नेलिंग की गयी। इसके बाद मरीज को परीक्षणाधीन रखते हुए एक सप्ताह तक नियमित उपचार किया गया। वह वॉकर की सहायता से चलने लगा और कोई शिकायत न होने पर उसे डिस्चार्ज किया गया।
डिस्चार्ज के समय उसे सलाह दी गयी कि वह नियमित फालोअप लेता रहे और नियमित व्यायाम करता रहे तथा अपने को गिरने तथा किसी सख्त वस्तु से टकराने से बचाए रखे, लेकिन परिवादी ऐसा नियमित रूप से नहीं कर सका और उसने आवश्यक निर्देशों का पालन भी नहीं किया। उसकी हालत बिना किसी संक्रमण के लम्बे समय तक सुधर रही थी और इसी कारण उसे दिनांक 18-09-2011 को स्वस्थता प्रमाण पत्र दिया गया, जिसकी मांग परिवादी ने अपनी ड्यूटीपर जाने के लिए की थी। इसलिए यह सिद्ध होता है कि अपीलार्थी द्वारा किया गया आपरेशन सफल था और उसमें कोई उपेक्षा नहीं की गयी। विद्वान जिला आयोग इन महत्वपूर्ण बिन्दुओं पर विचार करने में असफल रहे।
हड्डीयों का न जुड़ना, उसमें कड़ापन आना और तत्पश्चात् संक्रमण होना यह प्रत्यर्थी/परिवादी की अपनी गलती और लापरवाही के कारण उत्पन्न हुआ। बोन का जुड़ना, कैलस के बनने और समुचित भोजन पर आधारित होता है। कम्पाउण्ड फ्रैक्चर में हड्डीयों का संयोजन फ्रैक्चर की गम्भीरता के साथ-साथ रोगी के स्वास्थ्य और उसकी आयु पर भी निर्भर करता है, जो 18 माह तक का समय ले सकता है। चिकित्सीय साहित्य में यह लिखा गया है कि कुछ टूटी हुई हड्डीयॉं सर्वोत्तम सर्जिकल तथा नॉन सर्जिकल उपचार के बाबजूद भी नहीं जुड़ती हैं। अत: यह स्पष्ट है कि हड्डीयों का संयोजन, घुटने में कड़ापन आना और संक्रमण होना, बाद की स्थिति है, जो आपरेशन के परिणामस्वरूप नहीं है। अपीलार्थी एम0एस0 (आर्थो) विशेष योग्यता वाला सर्जन है, जिसे 08 वर्ष का अनुभव आपरेशन के क्षेत्र में है। अपीलार्थी ने एक स्थापित नियमों और स्थापित डिवाइस के अन्तर्गत एण्डर नेल्स को टूटी हुई हड्डीयों में बिना किसी चिकित्सीय उपेक्षा के लगाया, जिसके सम्बन्ध में परिवादी ने काफी समय तक कोई शिकायत नहीं की।
अपीलार्थी/विपक्षी ने अपने लिखित कथन में कहा कि उसने दिनांक 03-01-2011 को आपरेशन किया और परिवादी के फीमर थाई शाफ्ट में कम्पाण्ड फ्रैक्चर गम्भीर प्रकृति का था और आकस्मिक मामला होने के कारण पूर्ण सावधानी के साथ आपरेशन किया जो सफल हुआ। किसी प्रकार की चिकित्सीय उपेक्षा नहीं की गयी। दिनांक 03-01-2011 को उसने रोगी का आपरेशन किया, जो ओपन सर्जरी नहीं थी, बल्कि एक डिवाइस के माध्यम से किया गया और इसके अन्तर्गत टूटी हुई हड्डी को ठीक करने के लिए नेल डाली गयी। दिनांक 18-03-2012 को जब दाहिने घुटने में कड़ापन आया तब उसे चलायमान करने की आवश्यकता थी और तब रोगी को एनेस्थेसिया देकर आपरेशन थिएटर ले जाया गया, जहॉं पर घुटने का कड़ापन दूर किया गया और घुटने को चलायमान किया गया। दिनांक 02-07-2012 को रोगी को बोन ग्राफ्टिंग की शिकायत हुई, अत: उसे आपरेशन थिएटर ले जायागया और बोन ग्राफ्टिंग नहीं की गयी, क्योंकि वहॉं गहरा संक्रमण पाया गया। फ्रैक्चर वाले हिस्से की सफाई की गयी और उपचार के लिए दवाईयॉं दी गयीं। यह सारा कार्य किया गया, जिसे परिवादी आपरेशन कहता है। परिवादी इसके पश्चात् अर्थात् दिनांक 02-07-2012 के बाद कभी लौट कर नहीं आया और वह बस्ती में डॉक्टर सत्येन्द्र राय के उपचार के अन्तर्गत चला गया और फिर काफी समय बाद वह दिनांक 30-03-2013 को विपक्षी के पास आया। तब विपक्षी ने पाया कि परिवादी अपने उपचार के प्रति गम्भीर नहीं है और प्रत्येक अवसर पर उसने विलम्ब किया है। इस मामले में दूसरे डॉक्टर को दिखाये जाने के कारण विपक्षी ने इसे नियन्त्रित करने में अपने को असफल पाते हुए उसे के0जी0 मेडिकल कालेज,लखनऊ को सन्दर्भित किया।
परिवादी की दूसरी शिकायत मात्र कल्पनाओं पर आधारित है। परिवादी के अस्पताल से डिस्चार्ज होने पर विपक्षी ने सारे प्रेस्क्रिप्शन, डिस्चार्ज समरी और बैड हैड टिकट उसे प्रदान किये, जो उसने विद्वान जिला आयोग के समक्ष प्रस्तुत नहीं किये। इसलिए विद्वान जिला आयोग ने बिना किसी साक्षीय आधार के चिकित्सीय उपेक्षा का निष्कर्ष दिया।
इस मामले में परिवादी ने ही लापरवाही बरती है, जिसके लिए अपीलार्थी को उत्तरदायी नहीं ठहराया जा सकता है। परिवादी ने ऐसा कोई भी साक्ष्य नहीं दिया है कि उसको चिकित्सीय सहायता मेडिकल प्रोफेशन में स्थापित नियमों के अन्तर्गत नहीं दी गयी हो। माननीय सर्वोच्च न्यायालय ने जैकब मैथ्यू के केस में भी यही कहा है (इसका विवरण आगे दिया गया है)। किसी असामान्य निष्कर्ष के आने पर यह नहीं माना जायेगा कि डॉक्टर ने चिकित्सीय लापरवाही की है। विद्वान जिला आयोग ने कहा कि 03 सहमति पत्रों पर परिवादी के हस्ताक्षर नहीं है, लेकिन उसके परिवार के सदस्य के हस्ताक्षर हैं, जिससे उसे कोई क्षति नहीं पहुँचती है। अत: विद्वान जिला आयोग का यह निष्कर्ष तर्कसंगत नहीं है। विद्वान जिला आयोग ने प्रश्नगत निर्णय देने में अनियमितता की है और विधिक प्रावधान का उल्लंघन किया है।
अत: माननीय राज्य आयोग से निवेदन है कि विद्वान जिला आयोग का प्रश्नगत निर्णय अपास्त करते हुए अपील स्वीकार स्वीकार की जाये।
हमारे द्वारा अपीलार्थी के विद्वान अधिवक्ता श्री एम0एच0 खान की बहस विस्तार से सुनी गई तथा पत्रावली पर उपलब्ध अभिकथनों, साक्ष्यों एवं विद्वान जिला आयोग के प्रश्नगत निर्णय का सम्यक् रूप से परिशीलन किया गया।
विद्वान जिला आयोग ने निम्नलिखित आदेश पारित किया :-
'' परिवादी का परिवाद स्वीकार किया जाता है। विपक्षी को आदेशित किया जाता है कि वह परिवादी के इलाज में हुये खर्च एवं शारीरिक विकलांगता के लिये परिवादी को रू. 2,50,000-00 (दो लाख पचास हजार), शारीरिक एवं मानसिक कष्ट हेतु रू. 10,000-00(दस हजार) तथा वाद व्यय के रूप में रू. 5000-00 (पांच हजार) का भुगतान इस आदेश की तिथि से 30 दिन के अन्दर परिवादी को कर दे। '' परिवाद पत्र के अनुसार दिनांक 02.01.2011 को परिवादी दातून तोड़ते समय पेड़ से गिर गया जिससे उसे गम्भीर चोट लगने के कारण परिवादी के दोनों पैर की जांघ टूट गयी तब दिनांक 02.01.2011 को ही परिवादी के परिवार वाले उसे लेकर विपक्षी के अस्पताल आये और विपक्षी डाक्टर को दिखया तो उन्होनें एक्स-रे कराने के बाद स्पष्ट रूप से बताया कि परिवादी के दोनों पैर की जांघ टूटी हुयी है तथा आपरेशन में कुल 16,800/- रू0 का खर्च होगा। इस प्रकार परिवादी का प्रथम दिन ही जांच एक्स-रे आदि मिला कर लगभग रु. 20000/- खर्च हुआ। परिवादी के पैर का आपरेशन दिनांक 03.01.2011 को विपक्षी के द्वारा किया गया और एक सप्ताह तक अस्पताल में रखा गया जिसमें परिवादी का रु.10000/- खर्च हुआ एक सप्ताह के बाद परिवादी को डिस्चार्ज कर दिया गया और 10 दिन के अन्तराल पर परिवादी को बुला कर देखते रहे परन्तु परिवादी के दाहिने पैर की जांघ का घाव ठीक नहीं हुआ तब विपक्षी ने एक साल के बाद दिनांक 31.12.2011 को आठ हजार रूपये फीस लेकर पुनः आपरेशन किया। इस प्रकार परिवादी का इस बीच रूपये 50,000/- व्यय हुआ फिर भी परिवादी का पैर ठीक नहीं हुआ। विपक्षी ने इलाज के दौरान परिवादी के पैर का सात बार आपरेशन दिनांक 3.1.2011, 13.5.2011 31.12.2011, 17.3.2012, 02.7.2012 15.12.2012 व दिनांक 18.3.2012 को किया जिसमें कुल तीन लाख रुपये परिवादी का व्यय हुआ। परिवादी का पैर ठीक नहीं हुआ तब विपक्षी ने दिनांक 30.03.2013 को परिवादी को के.जी.एम.सी. लखनऊ के लिये रेफर कर दिया। वहां के डाक्टर ने बताया कि पुनः आपरेशन करना पड़ेगा और उनके पास बैड खाली नहीं है, तब परिवादी ने विवश होकर ऋषि हास्पिटल एण्ड डायग्नोस्टिक सेन्टर प्रा.लि. में डा. पी.के. सागर को दिखाया तो उन्होंने जांच करने के बाद बताया कि विपक्षी डाक्टर के द्वारा जो रॉड डाली गयी थी वह घटिया किस्म की थी इसलिये यह टूट गयी है तथा दाहिने पैर में दो हडिड्यों के बीच में कपड़ा और मिटट्टी फंसी हुई है, जिससे परिवादी की हडिड्यों में सड़न पैदा हो गयी है और फिर से आपरेशन करना पड़ेगा। उनकी सलाह पर परिवादी ने उनसे आपरेशन कराया, जिसमें लगभग एक लाख रूपये खर्च हुआ। डॉ0 पी0के0 सागर के द्वारा परिवादी को यह भी बताया गया कि विपक्षी डाक्टर की लापरवाही कारण वह 45 प्रतिशत विकलांग हो गया है। कार्यालय मुख्य चिकित्साधिकारी के द्वारा परिवादी को 35 प्रतिशत विकलांग का प्रमाण पत्र दिया गया है।
विपक्षी ने विद्वान जिला आयोग के समक्ष यह कहा कि परिवादी की दोनों जांघों के टूट जाने के कारण गम्भीर हालत थी और दाहिने पैर से खून का रिसाव हो रहा था। अत: उसे दिनांक 03-01-2011 को भर्ती किया गया था और उसके अटेण्डेण्ट ने आपरेशन की अनुमति प्रदान की, जिस पर उसका आपरेशन किया गया। दिनांक 03-01-2011 को किसी प्रकार का चीरा नहीं लगाया गया और वह आपरेशन अण्डर सीआरएएम के अन्तर्गत किया गया और यदि चीरे से आपरेशन किया गया होता तो मरीज का जीवन बचना सम्भव नहीं था। परिवादी का यह कथन गलत है कि 7 आपरेशन किये गये। प्रथम आपरेशन से दिनांक 03-01-2011 को दोनों पैरों में तार डाला गया और दूसरा आपरेशन में केवल घुटने को मोड़ने के लिए केवल 800/- रू0 लिये गये। विपक्षी ने यह भी कहा कि दिनांक 02-07-2012 को ग्राफ्टिंग के लिए 2,000/- रू0 लिए गये और परिवादी की पत्नी ने अपनी गरीबी का वास्ता देकर विपक्षी से 16,800/- रू0 के स्थान पर 20,000/- रू0 का बिल बनवा लिया। विपक्षी ने इलाज की संतुष्टि होने पर परिवादी को हल्का काम करने की सलाह दी और इसके बाद परिवादी ने विपक्षी से अपना इलाज कराना बन्द कर दिया। यह कहना गलत है कि विपक्षी ने घटिया किस्म की रॉड डाली और विपक्षी ने किसी प्रकार की कोई उपेक्षा नहीं बरती है।
इस मामले में सर्वप्रथम हम उस शपथ पर विचार करते हैं, जो प्रत्येक डॉक्टर, डॉक्टरी के पेशे में प्रवेश करने के पूर्व लेता है और उसे फ्रेम कराकर अपने नर्सिंग होम या चेम्बर में रखता है, जो निम्न प्रकार है :-
"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."
HINDI 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 statusand 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. Santha 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, in B. Krishna Rao Vs. Nikhil Super Speciality Hospital 2010 (V) SCC513 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.
1. DOCTRINE OF RES IPSA LOQUITAR The thing speaks for itselfis the gist of the maxim Res Ipsa Loquitur Maxim. What are the essentials of this 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 Achutrao Haribhau Khodwa 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.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 Chuen Tat, 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 Rs.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 ave 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 negligenceleads 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. Kunal Saha (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.KaushikNandy (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 Hon'ble 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 Hon'ble 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.KaushikNandy 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 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/- (rounded of to 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."
अब हमें यह देखना है कि इस मामले में लापरवाही और उपेक्षा अपीलार्थी द्वारा दिखायी गयी या नहीं, जो कि कम्पाउण्ड शाफ्ट फ्रैक्चर के दौरान थी। इस सम्बन्ध में सबसे पहले हम फीमर शाफ्ट फ्रैक्चर के बारे में जानकारी प्राप्त करते हैं :-
टूटी हुई जांघ की हड्डी मानव शरीर में फीमर (जांघ की हड्डी) सबसे मजबूत और सबसे लंबी हड्डी होती है। चूंकि फीमर मजबूत होता है, इसलिए इसे तोड़ने के लिए आम तौर पर मोटर वाहन की टक्कर जैसे उच्च बल की आवश्यकता होती है। तो, फीमर की लंबाई के साथ फ्रैक्चर फीमर शाफ्ट फ्रैक्चर हैं।
फीमर का सीधा और लंबा हिस्सा इसकी शाफ्ट (ऊरु शाफ्ट) है। यदि इस हड्डी की लंबाई के साथ कहीं भी फ्रैक्चर होता है, तो यह फीमर शाफ्ट फ्रैक्चर है। ऊरु शाफ्ट फ्रैक्चर के लिए आमतौर पर सर्जिकल उपचार की आवश्यकता होती है।
Femoral shaft fractures are a common orthopedic injury occurring in high energy trauma or low energy trauma in the elderly. Femoral shaft fractures are frequently associated with other comorbidities necessitating a thorough trauma life support assessment and interdisciplinary care. Among the various treatment modalities, Intramedullary nailing is the gold standard resulting in excellent outcomes. The goal of fixation is early healing and long-term functional recovery. This activity reviews the evaluation and treatment of abdominal abscesses and highlights the role of the interprofessional team in evaluating and treating patients with this condition.
Objectives:
Review the pathophysiology of femoral shaft fractures.
Describe the workup of femoral shaft fractures.
Outline the common complications of femoral shaft fracture treatment.
Explain the importance of improving care coordination among the interprofessional team to enhance the functional outcome for patients with femoral shaft fractures.
Introduction Fractures of the femoral shaft are one of the most common injuries treated by orthopedic surgeons. These fractures are often associated with polytrauma and can be life-threatening. They commonly result from high-energy mechanisms such as motor vehicle collisions (MVC) with sequelae of limb shortening and deformities if not treated appropriately. Femoral shaft fractures (FSF) typically occur in a bimodal distribution, high-energy trauma in the young population, and lower energy trauma in the elderly population. FSFs are also associated with other comorbidities necessitating a thorough advanced trauma life support (ATLS) assessment and interdisciplinary care. Intramedullary nailing (IMN) is the most common treatment for physiologically stable patients. The goal of fixation is early healing and long-term functional recovery. Treatment of modern-day femoral shaft fractures results in excellent outcomes.
Anatomy Proximally, the femur is composed of a specialized metaphyseal region consisting of the head, neck, and greater and lesser trochanters. Distally, the femur comprises the metaphyseal flare, which continues into the medial and lateral femoral condyles, separated by the intercondylar notch. The shaft, or diaphysis, is the segment inferior to the lesser and ending at the metaphyseal flair and condyles. Classically the first 5 cm distal to the lesser trochanter is termed the subtrochanteric region and is considered a separate fracture pattern. These fractures are challenging to manage secondary to the muscular deforming forces. They will not be discussed in this article.[1] According to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification of fractures, the femoral shaft begins at the inferior border of the lesser trochanter. It ends proximal to the condyles at a distance equal to the greatest width of the femoral condyles.[2] The diaphysis is a smooth cylinder with differences in cortical thickness throughout its length, which may help assess intraoperative femoral rotation. The femur is bowed anteriorly with an average radius of curvature 120 cm (+/- 36 cm); the shorter the radius, the greater the bow.[3] The linea aspera is the major cortical thickening along the posterior aspect of the femur and is an attachment site for muscles and the medial and lateral intermuscular septa and acts as a compressive cortical strut.[4] Three abundant muscular compartments envelop the femur. The anterior or extensor compartment is responsible for knee extension and houses the femoral nerve. The posterior or flexor compartment is responsible for knee flexion and houses the sciatic nerve. The medial compartment houses the adductor muscles. In FSF, the sciatic nerve and specifically the peroneal division are at the highest risk of injury because they lay close to the femoral shaft. The adductor compartment houses the obturator nerve. The gluteal muscles also surround and attach to the proximal femur and shaft; they include the gluteus maximus, medius, and minimus and cover the superior and inferior gluteal nerves. In FSF, the muscles are deforming forces on the fracture fragments depending on the location of the fracture. Generally, the proximal segment is flexed, abducted, and externally rotated by the iliopsoas and hip abductors. The distal segment is pulled proximally (shortened) by the quadriceps and hamstrings and adducted by the adductor muscles.
The main blood supply to the femur derives from the femoral artery, a continuation of the external iliac artery. The femoral artery passes under the mid-portion of the inguinal ligament and divides into the superficial femoral artery (SFA) and deep femoral artery (DFA), also known as the profunda femoris. The SFA supplies the tissues below the knee, and the DFA supplies the femoral shaft and the surrounding soft tissues. Multiple branches arise from the DFA, most notably the perforating arteries that encircle the femur. One or multiple nutrient arteries arise from the DFA or its branches to supply the inner 2/3 of the cortex and bone marrow. They anastomose with the metaphyseal-epiphyseal system. The periosteal blood supply supplies the outer one-third of the cortex.[5][6][7][8][9][4][10] Etiology Femoral shaft fractures can result from high or low energy mechanisms and are often associated with other serious injuries. The most common causes include automobile accidents, falls from heights, ground-level falls in individuals with osteoporosis, and gunshots. A study from Finland found that 75% of FSFs were caused by high energy mechanisms, 87% of which occurred in MVCs (65% of all fractures). Other less common causes of FSFs are atypical fractures from bisphosphonate use, pathologic fractures through a bone lesion, insufficiency fractures from osteoporosis, and stress fractures from overuse in athletes and military recruits.[11][12][13] Epidemiology The worldwide incidence of femoral shaft fractures ranges between 10 and 21 per 100,000 per year. Two percent of these fractures are open fractures.[13][14] The rate of atypical femur fractures as defined by the American Society for Bone and Mineral Research (ASBMR) Task Force 2013 ranges between 3.5% to 16%.[12] FSFs demonstrate a bimodal distribution. Men are more likely to sustain a fracture between the ages of 15 to 35, while women begin to show a steady increase starting at age 60. Men are more likely to sustain FSFs from automobile accidents or other high-energy mechanisms. Women are more likely to sustain an FSF from ground-level falls. Automobile accidents are more prevalent in the younger population, while ground-level falls are more common in the elderly population, which is attributed to osteoporosis.[13][11] Interestingly, the age of presentation with a femoral shaft fracture has increased with time. According to the Edinburgh Orthopedic Trauma unit in the UK, the average age of presentation in 1990 was 44 years with a steady increase to 65 years in 2000, likely due to more rigorous traffic laws and improved automobile safety.[15] Pathophysiology Trauma is the most common mechanism of femoral shaft fractures, typically involving a direct hit to the thigh or an indirect force transmitted through the knee. Younger individuals generally are engaged in high energy mechanisms such as automobile accidents, frequently resulting in other associated injuries. Gunshots can also cause significant isolated injuries. Individuals with osteoporosis are at an increased risk of fracture, even with low-energy trauma. Irrespective of the mechanism, the deforming forces of a fracture depend on the fracture characteristics. The proximal segment is most commonly pulled into flexion and external rotation by the psoas and abduction by the abductors. The distal fragment is drawn into varus by the adductors, into extension by the two heads of the gastrocnemius, and shortening by the extensor mechanism and hamstrings.
Associated orthopedic injuries of the femur that must be ruled out include fractures of the proximal femur (femoral head and neck, intertrochanteric fractures), and bilateral femoral fractures. A study demonstrated that simultaneous injuries to the proximal femur occur in 1% to 9% of patients, and 20% to 50% were not identified during the initial evaluation. The presence of associated injuries is clinically relevant because it will determine the order of fixation and implant selection.[16] Bilateral femur fractures account for 2% to 7% of all femur fractures and are associated with increased risk of systemic complications, resuscitation requirements, and mortality. 80% of individuals with bilateral femoral shaft fractures have other associated injuries; therefore, the treating physician should be suspicious of additional injuries.
Fat emboli syndrome is a systemic disorder prevalent in the polytraumatized patient with shaft fractures. It classically presents as respiratory compromise, altered mental status, fever, and rash. Manifestations can span the spectrum from subclinical symptoms to acute respiratory distress syndrome (ARDS). Up to 36% of patients with long bone fractures will require some form of ventilatory support.[17] History and Physical The life support protocols must be initiated for every traumatized patient, even those sustaining a ground-level fall, to rule out associated morbidities that may preclude early definitive care. Clinically, shaft fractures manifest as pain, bruising, swelling, deformity, shortening, and instability around the thigh. In the polytraumatized individual, injuries are frequently masked by more severe or painful injuries; therefore, a complete examination is imperative.
Open fractures of the femoral shaft are exceptionally severe injuries and occur in about 2% of all femoral shaft fractures.[18] A thorough exam is essential to rule out open fractures, and if present, prompt administration of antibiotics and tetanus is imperative to reduce the risk of infection. Any gross debris should be removed in the acute setting, and the wound and bone covered in sterile saline-soaked dressing. Formal irrigation and debridement should follow in the operating room. Open fractures are classified according to the Gustillo-Anderson (GA) or the Oestern and Tscherne classification. Communication with the outside world can lead to significant uncontained bleeding and an increased risk of infection.[19] A study demonstrated an infection rate of 2.3% for GA type I and II vs. 17.6% for GA type III.[20] Open fractures do not preclude compartment syndrome that can develop due to blunt trauma and the violent motion of the femur moving through the surrounding tissues. A retrospective study of thigh compartment syndrome identified FSF in 48% of patients; of these, 5 were open.[21] Documentation of neurovascular status is imperative. Although rare, a vascular injury may occur with femoral shaft fractures up to 2% of the time, particularly with gunshots and penetrating trauma.[17] Damage to the deep femoral artery (DFA) and its branches is the most common and typically results in significant hemorrhage rather than ischemia due to abundant collateral flow. Because the thigh can hold around 1.5 L of blood, vascular injuries can significantly contribute to a polytraumatized patient's shock state.[19] On the other hand, injury to the SFA causes ischemia to the leg and foot as its first branches arise in the popliteal fossa. The superficial femoral artery (SFA) is a conduit throughout the thigh. If vascular compromise is suspected, characterized by pulselessness, enlarging pulsatile hematoma, bruit, thrill, hemorrhage, and acute ischemia, the extremity should be placed in traction and ABIs obtained. If the ankle-brachial index is <0.9, a computed tomography (CT) angiogram and vascular surgery consultation are merited.[22][17] Evaluation Typically, femoral shaft fractures are readily identified injuries due to thigh deformity and instability; however, occasionally, these injuries are not evident, and further assessment and imaging are required, such as radiographs and computed tomography (CT) scanning. Obtunded patients may necessitate more imaging to identify their injuries.
Imaging X-rays of the chest and pelvis are obtained as part of the ATLS protocol. When the patient is stabilized, orthogonal radiographs of the suspected injured extremity, including the ipsilateral joints proximal and distal to the injury, should be obtained to characterize the fracture. These images help identify potential fractures to the acetabulum, proximal femur, proximal tibia, and patella and help identify a possible floating knee injury.
CT is typically not the initial imaging modality of the femur, but it is often the first form of imaging obtained in a polytraumatized individual. It has utility in identifying occult injuries and characterizing the fracture for operative planning. Thin cut imaging can help identify occult femoral neck fractures not seen on standard radiographs. Combined with contrast, vascular lesions can be identified and expeditiously treated.
Classification Classification of femoral shaft fractures may be descriptive in which the location, type, angulation, shortening, comminution, rotation, and displacement is described.
The most commonly used fracture classification system used is the AO/Orthopaedic Trauma Association classification because of its high interobserver reliability and accuracy. The system utilizes a coding system to identify the fracture type resulting in 27 different patterns. 3= femur, 2 = diaphysis.[2][23] 32A - Simple A1 - Spiral A2 - Oblique, angle > 30 deg A3 - Transverse, angle < 30 deg 32B - Wedge B1 - Spiral wedge B2 - Bending wedge B3 - Fragmented wedge 32C - Complex C1 - Spiral C2 - Segmental C3 - Irregular The Winquist classification system is mostly of historical significance. It described the cortical comminution and served as a guide on whether to lock the nail and determined weight-bearing status. With the advancement in nailing techniques and nail design, most intramedullary nails are locked, and full weight-bearing is permitted postoperatively.[24] Treatment / Management Treatment of femoral shaft fractures can be operative or non-operative. Operative fixation with intramedullary nailing is the gold standard of treatment in high-income countries. Other operative techniques include plate osteosynthesis and external fixation. Closed treatment with traction, splinting, and casting may be temporary treatment or definitive treatment in some third-world countries.
Intramedullary Nailing Intramedullary nailing (IMN) is the gold standard of treatment for femoral shaft fractures. Early definitive treatment in systemically stable patients within 24 to 48 hours reduces the incidence of pulmonary complications, infection rates, and mortality. Hemodynamically stable patients with multiple injuries received the most benefit from early fixation. Delayed treatment increases pulmonary complications in up to 56% of patients compared to only 16% of patients treated early.[25][26][27] The insertion site of an IMN is outside the zone of injury, preserving the surrounding blood flow and retains the hematoma that contains beneficial bone growth factors. Intramedullary nailing also has the benefits of early weight-bearing that helps maintain muscle mass, function, strength, and mobility.
Antegrade Nailing In the 1940s, Dr. Gerhard Küntscher developed the first intramedullary nail. With improved designs, nailing techniques, and locking screws, more complex injuries have been treated with intramedullary nailing. Approaches to nail fixation depend on the patient's age, body habitus, comorbidities, nail design, and physician preferences.
Antegrade nailing is the gold standard treatment of femoral shaft fractures with excellent outcomes if patients are treated within the first 24 hours. Early fixation decreases pulmonary complications, improved rehabilitation, reduced length of stay, and lower healthcare costs.[17] There is debate about the benefits of early fixation in patients with closed head injuries. Some studies demonstrate an increased incidence of pulmonary complications and CNS function with early treatment secondary to a second hit phenomenon of hypoxia and hypotension. Other studies have shown that early fixation does not increase CNS complications; rather, it is the head injury that increased the risk of both CNS and pulmonary complications. However, it is advised to avoid hypoxia and hypotension in these individuals and to consider less invasive treatments in the acute phase of treatment.[28][29][17] Approaches include the piriformis, trochanteric, and lateral entry. In the piriformis entry approach, the nail trajectory is along the long axis of the femur, and a straight design nail is used. Disadvantages of this approach include injury to the abductor muscles with resultant Trendelenburg gait and damage to the blood supply to the femoral head. The trochanteric entry technique spares the abductors to a greater degree, and it is easier to establish the starting point. The anterior and lateral bow of the nail accommodates the curvature of the femur. Using a straight nail in this approach risks perforation of the anterior cortex or when the starting point on the greater trochanter is too posterior. The trochanteric entry technique has a reduced operative and fluoroscopic time compared to the piriformis entry technique. Long term functional outcomes are equivalent between the approaches.[30][31] Retrograde Nailing Retrograde nailing has recently become more popular. Indications for this technique include the ipsilateral femoral neck, acetabular, tibia fractures (floating knee injuries), bilateral femur fractures, pregnancy, and morbidly obese individuals. Studies have demonstrated comparable outcomes for antegrade nailing. Union (100% vs 99%), malunion (11% vs 13%), and nonunion rates (6% vs 6%) are similar for retrograde and antegrade approaches. A common complaint of retrograde nailing is knee pain, while for anterograde nailing, it is hip pain and stiffness.[32][33] The starting point in this approach is in the middle of the intercondylar notch and 2 to 4 mm anterior to the distal tip of Blumensaat's line. Despite entering the knee joint, there is no increase in septic knees. Long term, patients may report anterior knee pain or screw irritation distally. Iatrogenic injury to the cartilage and ligaments of the knee is possible.[32][34] Reaming Reaming techniques of the medullary canal provide both mechanical as well as biological benefits to intramedullary nailing. In rat models, reaming did affect the endosteal blood supply, which regenerated in about 12 weeks.[35] Reamings deposited at the fracture site acted as a bone graft containing osteoprogenitor cells and inductive molecules.[36] Reaming decreases the nonunion rate by more than 4-fold, and reamed and locked IMNs have a reported union rate between 97% to 100%, while non-reamed techniques have union rates of 84%.[37] Reaming was once thought to increase the rate of pulmonary complications such as fat emboli syndrome or inflammatory reactions resulting in respiratory compromise. This was considered secondary to the increased pressure that occurs in the femoral canal when instruments or implants are inserted, causing venous embolization of fat. Increased fat in the blood was demonstrated in humans during the procedure, with no increase in pulmonary compromise. Reaming does increase intraosseous bleeding, although there is no increase in postoperative transfusion requirements in patients.[38][39][40] Plate Osteosynthesis Open reduction internal fixation (ORIF) techniques developed in the 1960s were the first operative techniques utilized for fracture fixation. Over time, a better understanding of biological and mechanical processes in fracture fixation was established. ORIF is typically not the primary treatment of femoral shaft fractures unless there is extension to the proximal or distal femur, which may be a contraindication to intramedullary nail fixation. Plates are used in recalcitrant nonunions, periprosthetic and peri-implant fractures, narrow femoral canals, and open fractures with vascular injury. Open plating techniques require fracture site visualization and significant soft tissue stripping around the fracture site, resulting in interruption of blood flow to the bone, especially the periosteum.[41] Extensive soft tissue dissection may also increase an individual's inflammatory response to surgery, further complicating care and tissue healing. Minimally invasive techniques such as minimally invasive plate osteosynthesis (MIPO) avoid exposure of the fracture site. The plate is introduced away from the fracture site, positioned submuscularly but above the periosteum, and fixed percutaneously. Bridge plating is a technique that spans an area of comminution with fixation proximal and distal to the affected area.[8] External Fixation External fixation is indicated for patients with open fractures, vascular injuries, polytrauma, stabilization for transfer, and those unstable for early definitive care. External fixators can be applied with minimal effect on the trauma patient's disease burden. Fixator constructs can vary from surgeon to surgeon, but the governing principles are stable fixation with the relative restoration of length, alignment, and rotation. Neurovascular structures can be avoided by placing pins laterally into the femur rather than from anterior to posterior. Proximal pins can be placed into the femoral neck and head, while distal pins may be placed in the distal femur or proximal tibia. Infrequently external fixators can be used as definitive treatment if conversion to internal fixation is contraindicated because of medical or other orthopedic problems. Definitive treatment with external fixation has a relatively high complication rate, such as loss of reduction, malunion, pin site infections, osteomyelitis, nonunion, and joint stiffness.[42][43] Treatment with an external fixator is rare because of the successful early treatment with intramedullary nailing.
Traction First responders at the scene of an accident must quickly assess for any potentially life-threatening injuries. Special attention must be placed on the lower extremities where significant pooling of blood is possible, as discussed earlier. Temporary traction devices such as the Thomas, Hare, Sager, Kendrick, CT-6, Donway, and Slishman splints may be utilized to stabilize apparent femoral injuries. Longitudinal traction applied to the extremity stabilizes the fracture site, restoring the gross length, alignment, and rotation. Traction may also relieve pressure on neurovascular structures and tamponade bleeding by stabilizing the surrounding clot. These devices should be promptly exchanged for fiberglass vs. plaster splint or skin vs. skeletal traction in the hospital because prolonged use may cause pressure sores or compress neurovascular structures distally.[44] More tolerable and effective traction systems include skin and skeletal traction that provide better distraction of the affected extremity. Skin traction, also called Bucks traction, is applied through a boot attached to the distal extremity with a counterweight. The problem specific to this technique is a shear injury to the underlying dermal tissue.
In skeletal traction, a pin is placed through the bone distal to the injury preventing the soft tissues from bearing the traction forces. Common sites of pin placement include the distal femur, proximal tibia, and calcaneus, with the distal femur as the preferred placement because of the superior force vector, better control, and ability to range the knee. In rare cases, skeletal traction may serve as a prolonged treatment in medically unstable patients or as definitive treatment in certain parts of the world. Complications of skeletal traction include pin site infections, iatrogenic neurovascular injury, muscle wasting, immobility, malunion, deep vein thrombosis, and pulmonary embolism.[45] In high-income countries, the preferred treatment is operative fixation resulting in superior outcomes and less morbidity and mortality compared to traction.[46] Other Considerations An aging population that aspires to stay active for longer will continue to seek hip and knee replacements, and a growing elderly population will undergo hemi or total hip arthroplasty for femoral neck fractures and cephalomedullary nailing for other proximal femoral fractures. It is projected that by 2040 there will be 1.4 million THA (284% increase) and 3.4 million TKA (401% increase) replacements performed each year.[47] There will be more periprosthetic femoral shaft fractures that will pose new treatment dilemmas and require specialized care. The fracture characteristics and prosthesis design will determine the fixation modality. More invasive open reduction internal fixation may be necessary, placing increased physiologic strain on the patient.
Differential Diagnosis Injuries to the femoral shaft are typically quite obvious and quickly diagnosed with imaging. It is essential to identify associated bony fractures of the pelvis, proximal or distal femur, and tibia as this will change the treatment. In the context of bisphosphonate use, it is vital to look for hypertrophied lateral cortices bilaterally and identify signs of impending fracture. Patients may present altered or unresponsive and unable to provide an accurate history and physical, resulting in a delay in diagnosis.
Prognosis Reamed nailing has demonstrated excellent union rates, 100% retrograde, and 99% antegrade, with excellent functional results.[32][33] Patients that undergo early definitive fixation have improved outcomes, fewer complications, and reduced mortality. After intramedullary nailing, patients are allowed to weight bear as tolerated, accelerating their rehab, and return to baseline mobility. Recovery in the elderly population may be slower and often hampered by multiple comorbidities. Patients with bilateral femoral fractures are at an increased risk of mortality in the presence of other injuries and physiologic instability. Isolated bilateral femur fracture (no other injuries) vs. bilateral fractures with associated injuries had a mortality of 9.8% and 31.6%, respectively.[48] Patients with unilateral shaft fractures had an overall in-hospital mortality rate of 1.4%. If treatment is delayed greater than 48 hours, the risk of mortality increased five times.[49] Complications Intraoperative complications include neurovascular injury, iatrogenic fractures, compartment syndrome, thermal necrosis, and malalignment. Postoperative complications include fat emboli syndrome, pulmonary embolism, infection, osteomyelitis, malunion, nonunion, and hip and knee pain. Reaming can cause increased temperatures of up to 57 degrees C resulting in thermal necrosis secondary to enzyme denaturation, potentially leading to delayed fracture healing.[50] In-vivo animal studies have shown that bone necrosis can occur at temperatures of 47 degrees C with prolonged reaming.[51] Nerve injuries are common and can be due to positioning as well as iatrogenic injury. Pudendal nerve injuries occur from positioning patients with a perineal post and have an incidence of 15%.[52] The sciatic nerve can suffer injury in retrograde nailing with excessive traction of the lower extremity or surgical instruments.
Vascular injury to the DFA or SFA can occur after penetration with instruments or implants. Despite the use of safe zones for implant insertion, aberrant anatomy can predispose the patient to iatrogenic injury.
Intraoperative fractures may occur, especially of the greater trochanter, the knee, and perforation of the anterior cortex by the implant. Patients with an abnormally low radius of curvature (increased anterior femoral bow) are at increased risk for anterior perforation.[53][54] Postoperative fractures are most common in areas of stress risers at the ends of an intramedullary nail or plate.
Malrotation is one of the most significant complications of long bone fractures, with an incidence of up to 25%. Malrotation of greater than 14 degrees from neutral can alter gait mechanics and efficiency. Patients cope better with internal than with external malalignment.[50] There are several landmarks for assessing rotation, including cortical overlap and comparing the rotation of the lesser trochanter fluoroscopically. Computed tomography of both extremities is the most reliable method to assess rotation.[55] Comminuted fractures can present a significant challenge in determining leg length that can manifest as pelvic tilt leading to hip pain and back pain. In a study of comminuted femur fractures, six patients had a leg length discrepancy greater than 1.25 cm, with only 4 of these patients requiring revision surgery.[56] Nonunion is a failure of the fracture to heal or lack of signs of healing for six months. Nonsurgical treatments may include supplementation or vitamin D and calcium and external bone stimulation. Work up would include evaluation for infection as a cause of nonunion. Surgical treatment may include revision fixation with or without bone graft, depending on the cause of nonunion.[57] Postoperative and Rehabilitation Care Postoperatively patients may experience local and systemic complications. Laboratory tests can help diagnose anemia, renal insufficiency, and other metabolic disturbances. Patients are evaluated for compartment syndrome, wound issues, and neurovascular compromise. Systemic complications include DVT, PE, and fat emboli syndrome. Shortly after surgery, patients will start physical and occupational therapy in the hospital to regain mobility and function in daily activities with continuation in the outpatient setting. Patients are typically allowed to bear weight as tolerated and return to full or near full capacity before radiographic healing, described as callus formation on three of the four sides of the bone on imaging. Patients are advised to restrain from smoking and taking nonsteroidal anti-inflammatory drugs (NSAIDs), although the evidence against NSAIDs is inconclusive.[58] Patients may return to driving a car when they can weight bear without assistance and can safely use the right leg to break. Implants are retained until there is a reason to remove them. Partial implant removal is accepted in cases of local irritation from prominent screws.
Deterrence and Patient Education There is no way to prevent trauma that results in femoral shaft fractures altogether, but social initiatives aim to reduce the incidence of these events. Every year there are about 40,000 fatalities from motor vehicle accidents.[59] and up to 87% of FSF occur as a result of MVC. Governments have and will continue to implement regulations to make automobile transport safer for passengers as well as pedestrians, penalizing impaired driving, and mandating improved car safety equipment and design. All physicians should screen their at-risk patients for the possibility of osteoporosis and guide them in the appropriate medical treatment.[1] Enhancing Healthcare Team Outcomes The complexity of patients with femoral shaft fractures varies and can range from isolated injuries to a polytraumatized individual. Interprofessional collaboration between emergency services, surgical teams, critical care providers, internists, nurses, therapists, social workers, and case managers is necessary at various stages of treatment and recovery. Dedicated geriatric units have been shown to manage older patients with multiple comorbidities better. This specialized care has resulted in shorter times to surgery, fewer postoperative infections, fewer complications, and shorter length of stay despite treating an older and sicker population.[60] After surgery, patients need specialized nursing familiar with the care of orthopedic injuries and rehabilitation protocols. Case management and social work should provide a safe transition from hospital to home or an extended care facility. Case managers outside the hospital can be an invaluable resource for patients, helping them navigate the complex social, legal, and administrative hurdles associated with their injury. Multilevel interprofessional team care can improve patient outcomes. [Level 5] :
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वर्तमान मामले में परिवादी का आपरेशन दिनांक 03-01-2011 को विशेष सावधानी और खुले आपरेशन से बचते हुए किया गया। अपीलार्थी ने कहा कि उसने दोनों पैरों में नेलिंग की। इसके पश्चात् रोगी को परीक्षणाधीन एक सप्ताह के लिए रखा गया और फिर उसे यह सलाह देते हुए डिस्चार्ज किया गया कि वह नित्य एक्सरसाइज करेगा। इसके पश्चात् प्रत्यर्थी दिनांक 18 मार्च 2012 को अपीलार्थी के पास आया और शिकायत की कि घुटने में कड़ापन आ गया है। इसका उपचार एनेस्थेसिया देते हुए किया गया। इसके बाद पुन: प्रत्यर्थी दिनांक 02-07-2012 को उसके पास आया और तब यह पाया गया कि दाहिने पैर की हड्डी में जुड़ाव नहीं हुआ है। इस पर आपरेशन थिएटर में उसे ले जाया गया। जहॉं पर यह पाया गया कि उसकी दोनों हड्डीयों में काफी गहराई तक संक्रमण है। बाद में उसे मेडिकल कालेज, लखनऊ को सन्दर्भित किया गया, जहॉं पर यह पाया गया कि उसके दाहिने पैर की फीमर हड्डी में कोई जुड़ाव नहीं हुआ है।
अब हमें यह देखना है कि पैरों में हड्डी न जुड़ने का क्या कारण है ? इसका स्पष्ट कारण अपीलार्थी की लापरवाही है, क्योंकि हड्डीयों में जुड़ाव का होना प्रथम दिन से ही शुरू हो जाता है और कैलस बनना शुरू हो जाता है। दो से तीन सप्ताह में ही यह स्पष्ट हो जाता है कि कैलस का निर्माण हो रहा है अथवा नहीं और हड्डीयों में जुड़ाव सन्तोषजनक है अथवा नहीं। इस मामले में डॉक्टर ने रोगी के पैरों में नेलिंग की है। नेलिंग कई प्रकार की होती है और यह नहीं बताया गया कि यह एण्टीग्रेड नेलिंग या इण्ट्रामेडुलरी नेलिंग है या रेट्रोग्रेड नेलिंग है। अपीलार्थी के विद्वान अधिवक्ता यह नहीं दिखा सके कि नेलिंग के लिए कौनसी प्रक्रिया का अनुसरण किया गया और वह हड्डी के जुड़ाव के बारे में भी कुछ नहीं बता सके। हड्डी में गहराई तक संक्रमण होना इस बात का द्योतक है कि इस मामले में अपीलार्थी ने आपरेशन के बाद की सुविधाऐं भलीभांति प्रदान नहीं कीं। यद्यपि उसने अपील में यह कहा है कि इस मामले में चिकित्सीय नियमों और प्रोटोकॉल का पालन किया गया है। यदि ऐसा होता तो हड्डीयों में संक्रमण नहीं होता।
प्रत्येक आपरेशन के पश्चात् रोगी का अत्यधिक ध्यान रखना होता है, जिससे आपरेशन स्थल पर किसी प्रकार का संक्रमण या सेप्सिस न हो पाये क्योंकि सेप्टीसीमिया होने पर वह पूरे शरीर में फैल जाता है और फिर रोगी को बचाना मुश्किल हो जाता है।
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 care is most important in a case of Surgery. If you have no infra or paraphernalia, you are not supposed to proceed further regarding operation. In this case when you go to peruse the total cases history of the patient, it was crystal clear that the opposite parties failed to provide the required post-operative care and has shown carelessness right from the first operation, second operation and asking the patient to go to some other hospital . No doubt that the doctor performed his duty with utmost care and caution but they also showed negligence in some cases. The circumstances shows that after operation, the opposite party left the patient on the operation table ,and directed the staff and junior doctors to do further dressing and stitching. No documents, discharge summary and all the notes regarding both the above mentioned operation which have been performed in the nursing home of the opposite parties has been filed for perusal. No evidence has been shown for taking the patient for two round of operation. In the operation of appendix what complications develop after the operation which made it compulsory for second operation. In spite of second operation the opposite party failed to manage the post-operative management and miserably failed to provide life-support system to the patient. It shows that the opposite parties have no paraphernalia for the operation. This itself shows the carelessness of the opposite party and also establishes the negligence played in this case with the complainant.
What is septicaemia?
Septicemia, or sepsis, is the clinical name for blood poisoning by bacteria. It is the body's most extreme response to an infection. Sepsis that progresses to septic shock has a death rate as high as 50%, depending on the type of organism involved. Sepsis is a medical emergency and needs urgent medical treatment. Without treatment, sepsis can quickly lead to tissue damage, organ failure, and death.
अत: यह स्पष्ट होता है कि रोगी अपीलार्थी के हास्पिटल में भर्ती हुआ, जिस दिन उसे चोट पहुँची। उसके दाहिने पैर की हड्डीयॉं टूट गयीं, जिनका आपरेशन किया गया और यह कार्य अपीलार्थी द्वारा किया गया। जब आपरेशन के पश्चात् वाली उचित और समुचित सुविधाऐं रोगी को प्रदान नहीं की गयीं, तब उसके दाहिना पैर काटना पड़ा और मुख्य चिकित्सा अधिकारी के प्रमाण पत्र के अनुसार वह 35 प्रतिशत अयोग्य हो गया। यह अपीलार्थी की लापरवाही और उपेक्षा के कारण हुआ, जिसके परिणामस्वरूप रोगी को अत्यधिक कष्ट उठाना पड़ा और अन्तत: वह 35 प्रतिशत विकलांग हो गया।
हमने विद्वान जिला आयोग के निर्णय का अवलोकन किया, जिन्होंने कई तथ्यों का समावेश करते हुए अपना निर्णय दिया है और कई न्यायिक दृष्टान्तों को भी प्रदर्शित किया है। रोगी का उपचार अपीलार्थी के अस्पताल में किया गया, इसलिए अपीलार्थी का अस्पताल अपने डॉक्टर द्वारा किये गये कृत्य के लिए भी उत्तरदायी है। फलस्वरूप इस मामले में अपीलार्थी क्षतिपूर्ति देने के लिए उत्तरदायी है, जैसा कि विद्वान जिला आयोग ने अपने निर्णय में कहा है, जो नीचे उद्धरित किया जा रहा है :-
'' परिवादी का परिवाद स्वीकार किया जाता है। विपक्षी को आदेशित किया जाता है कि वह परिवादी के इलाज में हुये खर्च एवं शारीरिक विकलांगता के लिये परिवादी को रू. 2,50,000-00 (दो लाख पचास हजार), शारीरिक एवं मानसिक कष्ट हेतु रू. 10,000-00(दस हजार) तथा वाद व्यय के रूप में रू. 5000-00 (पांच हजार) का भुगतान इस आदेश की तिथि से 30 दिन के अन्दर परिवादी को कर दे। '' मामले के समस्त तथ्यों एवं परिस्थितियों को देखते हुए हम इस निष्कर्ष पर पहुँचते हैं कि विद्वान जिला आयोग द्वारा पारित प्रश्नगत निर्णय एवं आदेश विधि सम्मत है और इसमें किसी प्रकार के हस्तक्षेप की आवश्यकता नहीं है। तदनुसार वर्तमान अपील सव्यय निरस्त किए जाने योग्य है।
आदेश वर्तमान अपील सव्यय निरस्त की जाती है। जिला उपभोक्ता आयोग, बस्ती द्वारा परिवाद सं0-95/2013 में पारित प्रश्नगत निर्णय एवं आदेश दिनांक 16-02-2015 की पुष्टि की जाती है।
अपील व्यय उभय पक्ष पर।
राज्य उपभोक्ता आयोग के निबन्धक से अपेक्षा की जाती है कि अपीलार्थी द्वारा उपभोक्ता संरक्षण अधिनियम की धारा-15 के अन्तर्गत यदि कोई धनराशि जमा की गई हो तो उस धनराशि को अर्जित ब्याज सहित विधि अनुसार एक माह में सम्बन्धित जिला आयोग को प्रेषित किया जाए ताकि विद्वान जिला आयोग द्वारा उक्त धनराशि का विधि अनुसार प्रश्नगत निर्णय के अनुपालन के सन्दर्भ में निस्तारण किया जा सके।
उभय पक्ष को इस निर्णय की प्रमाणित प्रति नियमानुसार उपलब्ध करायी जाय।
वैयक्तिक सहायक से अपेक्षा की जाती है कि वह इस निर्णय को आयोग की वेबसाइट पर नियमानुसार यथाशीघ्र अपलोड कर दें।
(विकास सक्सेना) (राजेन्द्र सिंह) सदस्य सदस्य
निर्णय आज खुले न्यायालय में हस्ताक्षरित, दिनांकित होकर उद्घोषित किया गया।
(विकास सक्सेना) (राजेन्द्र सिंह) सदस्य सदस्य दिनांक : 14-02-2024. प्रमोद कुमार, वैय0सहा0ग्रेड-1, कोर्ट नं.-2. [HON'BLE MR. Rajendra Singh] PRESIDING MEMBER [HON'BLE MR. Vikas Saxena] JUDICIAL MEMBER