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11. PW-2 is a doctor, who was working in Care hospital since 1997. He was an M.D. in Anaesthesiology. He stated that Smt. Rupa Mutha was admitted in Care hospital and she was under his treatment. He identified the case sheet of Smt. Rupa Mutha. She was admitted in Care hospital on 19th of July 1999 at 12.30 p.m. and she was discharged on 16th of August 1999. When he saw the patient on admission, she was Comatose with coma scale of 7. According to this doctor, the patient was diagnosed as Comatose, which would mean; (a) she was not opening the eyes on verbal command, (b) movement of limbs on painful stimulous and (c) she was having tonic clonic contractions. She was on spontaneous respiration that means she was breathing on her own. He further stated that on the same day he got a phone from Laxmi Desai hospital, stating that a young lady underwent tubal patent test in the morning and sustained Cardiac arrest following tubal patent test and they wanted to shift the patient for Post-Cardiac-arrest management. He was asked about the availability of ventilator. As the ventilator was available in the hospital, he agreed for admission. When the patient came, she was accompanied by Dr. Sampath, Anesthesiologist i.e. A-2 and Dr. Jayasree Desai (A-1). He could identify A-1, who was present in the Court when the witness was examined. A-2 was not present. He was told by A-1 and A-2 that Mrs. Rupa Mutha was under their treatment before coming to Care hospital. A-1 and A-2 had given him the details of the treatment at the Laxmi Desai hospital. A-1 and A-2 had told him that Mrs.Rupa Mutha was tested for tubal patent for secondary infertility. They performed Rubins test. They also told him that they insufflated air to test the patency of the tubes. They told him that immediately after the test, Mrs. Rupa Mutha had suffered Cardiac arrest and resuscitation was done and her spontaneous respiration and pulse were restored after five minutes. She had Cardiac arrest for three minutes and later she restored to spontaneous respiration. She had two episodes of Cardiac arrest. The duration of 2nd episode was not informed to him. Following this, she had low blood pressure and she got fits. The fits were treated by injecting eptoin and diazopham. Low blood pressure was treated with dopamine which was being given when she reached Care hospital. Immediately after treatment in Care hospital, she was examined by Cardiologist Dr. Narasimhan and Aanesthesiologist Dr. Swamy. On admission, the diagnosis of all the doctors was Hypoxic Encephalopathy. This was also mentioned in the case record of the hospital. The meaning of Hypoxic Encephalopathy is lack of oxygen supply to the brain for a period of more than ten minutes. The signs of the condition which was observed by them were mentioned on the admission note. The said condition can occur on account of damage to the brain due to lack of blood supply. The condition of the patient with regard to brain damage did not improve till her discharge from the hospital. As soon as she was brought to the Care hospital, she was stabilized by connecting to life support system through ventilator. The team of doctors attending on her were of the view that the likely causes of her Cardiac arrest were; (1) Idio Synchrotic reaction to Thiopentone (2) Vaso Vagal reaction and (3) Air Embolism. The information was given by Dr.Sampath Kumar (A-2) with regard to use of Thiopentone inducing Anaesthesia. The Vaso Vagal reaction was because of cervical dilation done during the test. The third cause of Air Embolism was because of air insufflation. The doctor further was of the opinion that if the patient suffers from Cardiac arrest and the same is detected immediately and oxygen is administered, there would not be any damage to the brain, but however, if no oxygen is supplied for the initial ten minutes of suffering of Cardiac arrest, it would definitely lead to brain damage. During Anaesthesia, it is mandatory to monitor blood pressure, ECG and oxygenation through Pulse Oximeter. With these safeguards, the doctor can detect fall in oxygenation immediately if there is any fall. If 100% oxygen had been given soon after detection of Cardiac arrest along with proper Cardiac massage, even after three minutes of Cardiac arrest, the condition in which the patient was brought to the Care hospital would have not arisen. If Cardiac resusutation was given even within three minutes, the accident of brain damage (coma scale 7) could have been avoided. Resusutation means maintenance of air ways breathing through mask or tube with 100% oxygen. It is difficult to know the degree of oxygen desaturation without pulse oximetre. It is mandatory to record oxygen saturation levels when the patient is under anaesthesia. He can, as an expert, distinguish between sedation and coma scale 7. His opinion and the opinion of Neurologist was that the patient was in coma scale 7. when she was brought to the Care hospital. The reasons which the Care hospital documented in the case sheet for Cardiac arrest were discussed by him with the accused. The causes which they have documented are in conformity with the notes of A-1. A-1 had seen the patient in the Care hospital on 19.07.1999 at 7.45 a.m. which is born by the record and A-1 has signed the case sheet to that effect. Air embolism is a known complication of Rubins test. A-1 and A-2 informed him that air is pumped into the Fallopian tubes of the patient with the help of B.P. apparatus. Vaso Vagal reflex can be a cause of Cardiac arrest in the patient, if the patient was not deeply anaesthised. No analgesic was administered, Cervical dilatation was done. 6 mg of obopine does not prevent vaso vagal reflex. Nitrozen Oxide will not act as analgesic within few minutes. Thiopenton (anaesthetic agent) cause spasm. Laryn Thiopenton is avoided in Hypo Thyroid patient. If Thiopenton causes Cardiac arrest, it occurs during giving of anaesthesia and not during recovery from anaesthesia. Thyroid test was done in Care hospital, but thyroid was normal. The accused had informed him that the patient had Hypothyroid, but on performing thyroid function test, it was found to be normal. Ex.P-20 was the case sheet of the patient Mrs. Rupa Mutha, maintained at Care hospital. They also gave a discharge summary while discharging the patient. Ex.D-1 was issued by him. Patient did not suffer with brain damage during her stay in Care hospital for one month. Whatever damage the patient had suffered, it had been suffered by her before admission in the Care hospital. It was mentioned in Ex.P-9 that Pentothal was given at about 8.30 a.m. for inducing anaesthesia. The name of the drug in Pentothal is Thiopentona Sodium. The duration of action of Pentothal is eight minutes for standard dose. The test lasted from 8.30 a.m. to 8.55 a.m. The drug was given only once as per the record. The effect of Pentothal could have not last for whole of the procedure which was carried for 25 minutes, according to the record. In anaesthesia charts, the routine parameters that are documented are; pulse rate, blood pressure, respiratory rate and oxygen saturation. Said parameters are necessary to know hemodynamic stability of the patient throughout. The above parameters were mentioned in Ex. P-9. Occurring of fits is a common name of seizures. According to the discharge summary, the patient suffered with fits. It was mentioned in Ex. P-12 that Phenytoin injection was given to prevent and control seizures. The reason for fits is secondary to Cardiac arrest and Cerebral Hypoxia. Hypoxia, independent of Cardiac arrest, can cause fits. When the patient was taken to Care hospital, the history of the patient was taken from the treating gynaecologist. It was stated that air was injected to know the tubal patency. Injecting air can cause embolism if it is in large quantity. The amount of air that is injected to know the patency of tubes is sufficient to cause air embolism. The air embolism is treated if it is detected early. The case sheet and discharge summary did not disclose the treatment given for air embolism. Injecting Corbandioxide can also lead to air embolism. Air and Corbandioxide are both risky if administered in large doses. Out of the two, Corbandioxide is less risky. According to Ex. P-12, Cervix was dilated. Cervical dilatation can cause vagal reflex, which can lead to bradycardia and hypotension. If Vaso Vagal reflex is undetected, it would lead to Cardiac arrest. Harrison's Principles of Internal Medicine is a standard text on the subject. He agreed with the opinion expressed in passage at page No. 2050 of the text book relating to the topic Anoxic-ischemic Encephalopathy and it is marked as Ex. P-21. 'Brain Diseases of Nervous System, is the standard text of Neurology. He also agreed with the opinion expressed in a passage at page No. 166 of the text book that, "Cessation of oxygenated blood flow to the brain for more than 3-5 minutes is likely to cause long term cerebral anoxic injury". It is marked as Ex. P-22. 'Desk reference for Critical Care Nursing' is the standard text for critical care for nursing. He agreed with a passage at pages 170 and 171. The relevant passage was marked as Ex. P-23. He also agreed with opinions expressed by various authors relating to the subject and they were marked as Exs. P-21 to P-23.

73. The very admitted facts of the case are that Smt. Rupa Mutha went to the hospital of A-1 to know whether she can give birth to another child and therefore, the accused have insufflated Carbon dioxide into the fallopian tubes and while conducting the said test, she developed gasping which was of a sudden onset followed by cardiac pulmonary arrest according to Ex.P-9 and as soon as gasping was observed, during recovery from anaesthesia, the patient developed difficulty in breathing, she was incubated immediately, placed in head low position, bradicardia ensued and despite injection Atropine, she developed cardiac asystole, and the accused also found myoclonic jerks of the fore fingers of both hands and she was given Diazepam 10 mg and injection Phnytoin was also given to control and prevent seizures. Thereafter, she was shifted to Care Hospital with AMBU ventilation with Oxygen on pulse oximeter on Dopamine under supervision of A-2 according to Ex. P-2. As seen from the said Ex. P-9 and P-12 and also from the evidence of. PW-2 it is proved that the patient Smt. Rupa Mutha had cardiac arrest in the hospital of A-1 while conducting Rubins Test. It is also proved that the patient was never regained consciousness after inducting anaesthesia at 8.30 a.m., till shifting to Care Hospital or till today i.e. as on this day. It is also discussed that bradicardia is reduction in heart rate less than 50 beats per minute and it led to cardiac asystole as documented in Ex.P-12 and it is caused by prolonged hypoxia (non-supply of oxygen for more than 10 minutes to brain). It is also discussed that the patient was developed gasping at 8.55 a.m., and it was developed before cardiac arrest and it reflects brain stem damage. The another factor is that the patient was found myoclonic seizures in her fore fingers of both hands before shifting to Care hospital. It is also discussed that myoclonic seizures are on account of brain damage. All these things were happened in the hospital of A-1, before shifting to Care hospital. The evidence of PW-2 and Ex. P-20 clearly established that on admission, the patient was found that she was comatose with Coma scale of 7, not opening eyes on verbal command, movements of limbs on painful stimulus, was having tonic clonic contractions and on spontaneous respiration. It is also seen that immediately on admission, the patient was seen by cardiologist and neurologist and diagnosed as Hypoxia encephalopathy (lack of oxygen to the brain more than 10 minutes) and all these conditions are noted on admission in Care hospital which are on account of brain damage. According to the evidence and documents, it is proved that the said condition was not improved till her discharge from Care hospital. Therefore, the question of brain damage occurred in Care hospital does not arise particularly due to the negligence of PW-2 as stated by the accused. Whatever brain damage was caused was happened in the hospital of A-1.