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Beyond 2080 AD

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As you say, doctor...

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Consumer Protection

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"How many stitches?"

Hospital commerce

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The world of endoscopy

Too good is bad!

Why "Baap-Dada"?

Window Surgery

The Consumer Protection

“What are you saying doctor?”

“I cannot believe it!”

“Is she no more?”

“Are you sure, you are not talking of some one else?”

“My wife has not undergone any operation; she had a normal delivery, with nothing this sort expected!”

Mr Deshpande got panicky and went out of his senses. It became very difficult for the staff to hold him. He had been to his home to get some meals for them, after he was assured that every thing was fine. Mrs Deshpande had given him a contented look “see I have given you a male child. In the presence of his mother, he controlled his temptation to give her a kiss of thanks on her fore head. Her mother snatched the baby boy from the nurse with great eagerness. Sister gave her a smile; saying you are going to take him home, it is your ‘amanat’, but have some patience. The old lady’s eyes were full of tears of joy. She did not know at that time, what destiny is going to bring her just after 15 mts. That her lachrymal glands are going to then pour tears of grief, before they dry up. The small girl was thrilled to have a companion. Now she was promoted to become “Tai” (Elder sister – called in Marathi) she was busy working with her grand mother about, like whom does this cute one look? Mrs. Deshpande’s face showed signs of fatigue, which the old lady could read. She scolded the girl to leave both of them undisturbed so that she could take some rest. She gave order to Deshpande “She is alright. Now go home and get some sweets and afternoon meals.” And listen, she interrupted him as he was going out of the room, “Do not forget to bring the boiled water, which I have kept near the gas to cool down.”

The scene was different when he came back. He was singing his pet tune while climbing the stairs. The rush in front of his room disturbed him. He became uneasy. Why all of them were stealing eyes from him. As he made his way through the crowd, he was shocked to see his stunned mother in one corner of the room. She was holding his daughter in front. The child was simply confused. She could guess, something has gone wrong, but unable to analyze the situation. She was too small to know that her mother is no more, and the lying figure in front is the body of her mother. Mr Deshpande’s mother burst into tears, and collapsed into his arms, as he went near her. Doctors surrounded the body of Mrs. Deshpande. They had no courage left to turn around and face him.

He was told that his wife passed away due to penicillin hypersensitivity. Injecting penicillin after even normal labor, to prevent the post puerperal sepsis was routine those days. Then, we did not have these safer antibiotics. But the penicillin as such was not a new drug even then. It needs lot of precaution and careful testing before injecting it. The care starts from asking about the allergy first, even before the skin test, because rarely, people have succumbed to the skin test also. The negligence in this case was to the extent, that patient herself had told the sister about the allergy to some drug, and had requested her to hold the injection, till her husband returned. But because of the overload of the work, and haste to finish it off, the over confident sister injected it even without testing it. Mr Deshpande’s little daughter was the witness to this conversation.

So Mrs Deshpande passed away, leaving behind her young husband, a small daughter and an one day old baby! All of them became orphans instantaneously.

Imagine the future of that family?

Who is to be blamed?

The nurse who might have overheard and could not concentrate upon because of the exertion of the overnight duty, or the duty doctor, who did not take proper history, before prescribing the drug, or the hospital authorities, who have not compelled the junior doctors for methodical approach, treatment and documentation?

For the hospital it was one of the 2400 deliveries of this year, it was one of the only 12 deaths of this year, but for Mr Deshpande, she was his only wife, and he was a total looser.

Jan 1989.. Morning round ward 21...

We are ashamed to face a poor labour from Mandla. In his lap was a dark skinned, lean and thin child of 4 yr., sobbing with pain. This child was looking at us in frightened way. He was so scared of us, that he stopped crying immediately as we reached near him. We had put in a chest tube in his thorax last night. Nothing was coming out of it. Child’s father was standing with folded hands. His natural quarry was “ sahib the swelling over the scrotum has not reduced even after the operation. We glanced at each other. Could not face our teacher. It was a very difficult situation.

We had operated upon the wrong child!

We had our own satisfaction, but that could not have reduced the pains we had inflicted to the unfortunate poor child.

It was going to remain a black night for us, forever. We had come back to ward 21 after a sumptuous dinner at the hostel mess. I was accompanying my friend, who was on night duty. Ours was the O.T. day and I had come with him to take round of my post op patients. My friend said” DU, please come with me. I have to put in a chest tube in a child from Mandla.”

Our lungs are covered with a glistening smooth membrane called pleura. It also makes the inner lining of the chest wall. There is minimal fluid in between both these layers. The expansion of lungs is not due to positive pressure from outside. It is due to the negative pressure created by the expansion of the thoracic cage expands the lungs, which are stuck to it due to the fluid layer between both the layers of pleura. It is just like children expand the rubber film of the burst balloons by placing it in front of the mouth and drawing the air in. When this fluid increases, the negative pressure becomes less and patient has the difficulty to breath. This happens most commonly in tuberculosis, in our country. Then the only way out to relieve the patient is to drain that fluid. We do it by putting in the chest tube, through the gap between the ribs, and connecting it to the underwater drain, so that the atmospheric air doesn’t enter the pleural cavity. The drain is kept till it drains and then the tube is pulled out over a purse string suture. We had two similar looking kids, one of which was in distress with the extra pleural fluid, and needed drainage in emergency. My colleague received a scolding reminder at midnight about, why was it not done? He got the theatre ready and took the patient in. Put in the chest tube. Checked everything to be fine, shifted the case to the ward, and went to relax in the side room. He was tired of the hectic whole day schedule. The clock showed 1 AM. He again got a call from the consultant, after half an hour, whether he wants to continue with surgery postings or not? If he is not interested, why doesn’t he leave his seat for some one else, who wants to work? My friend could not understand, is he being scolded for? He had done every thing before retiring. Chief asked,” Why didn’t you still put in the chest tube? “The fellow said-“ I have already done that 2 hrs ago.” Now it was the time for our consultant to get shocked, because the patient’s relatives had gone to his house to tell him that the child is getting more and more serious. We were ashamed to find that the child whom we had put in the tube was a case of hernia. The reason why his father allowed us to take him at midnight, to the theatre, was, he became happy that his child’s surgery is being done before schedule. May it be by mistake, why unnecessarily interrupt the doctors and get more delayed? Hence getting consent was not difficult. Though we could judge retrospectively, that he was bit confused about the different site of surgery, and the necessity to put in the tube. As usual we did not bother to sit and doing a great favor by doing any job. At the same time, I remember, as we came out of the operation theatre, the serious child’s father had approached us, to request us again to save his child’s life. We just ignored him, because we knew that there was only one serious patient in the ward, upon whom, we have operated. He had no option left but to go to my teacher’s home. We forgot to apply tags to the child’s wrist of make proper inquiry for identification, mark the site of surgery, in ward itself, before shifting the patient to OT.

It was my ophthalmology posting. My teacher asked for an eye lotion. Sister gave carbolic acid instead. Sir could judge it by its smell. With anger he asked the nurse to spread her palm, and poured the whole bottle on it. She started screaming with pain. My teacher said “Dear, just imagine, you had given this to me to wash this patient’s eye.”

One of my ENT friends had the habit to always say – “Right Sir “. We had an old prof. of ENT. He was ready to operate upon one of his ear cases. The surgery proposed was of left ear. By mistake the nurse made the patient lie on his left lateral position, exposing the right ear for surgery. Prof asked “Are you sure of the side? Should we start?’’. My friend did not hear the first part of the question. He gave reply for the second part (should we start?). As usual instead of yes sir, he said “right sir.” Sir thought that this fellow approves the side i.e. Right ear. No need to write, what would have happened to the patient. We made total deaf, instead of cure.

These are, for example real blunders on our part, which cannot be excused.

Consumer protection act was necessary, but it becomes difficult to define, in which way it should be implemented.

Many questions arise, whether we were ready for it? When India got independence, the British people who had sympathy for this country, like Lord Mountbatten, and our leaders too had given a serious thought about, are we ready for independence?

You can expect a good yield of crop only after the soil is ready. I do not agree for the implication of this law so early.

To start with, when we say of Consumer Protection Act (CPA),

There has to be a Product, a Seller and a Consumer.

Seller in a surgeon, Product is the ultimate result of surgery and the Consumer is the patient.

A consumer lodges complaint in the court, if he is not satisfied with the product, i.e. the result of surgery.

Our product is quite different from a T.V or a Fridge. There the seller has all right to refuse to sell the product. If you do not have money and the shop keeper refuses to hand it over to you, I feel no body will mind. Are we permitted by the society to refuse a serious patient, if he does not have money, or, can we do that on moral grounds, even if permitted?

About the service – Any good you buy, there is a price tag on it. You assess it and make your decision about the purchase. A finished product is in front of him while deciding. Our finished product is the ultimate result of surgery. Surgery is not a mechanical job of dismantling, repairing and then again reassembling the body with screws and nut bolts. There are many hurdles and factors which modify the end result. We operate with the same technique and take equal care of every patient, then why do all wounds heal differently? Why do all scars look different?

The modifying factors other than surgery itself are :

Purity of the drugs, substitution of the medicines by chemists. Unfortunately the license laws to open a chemist shop are not so stringent. Govt officials are corrupt.

Genuineness of investigations, Patients age, his general condition, his healing power, and his body reaction towards the drug, how careful is he towards taking the medicine properly and following the post operative instructions?

With poor status of the Govt health care structure, the patients are bound to seek for the treatment in private hospitals. With the implication of CPA, the private surgeons became reluctant to take the critical cases. They write investigations very liberally due to the fear of CPA. The ultimate increase of the cost has to be beared by the patient. Just imagine a CT scan costing about 2000/- for a simple headache! I do agree, headache is one of the symptoms of a brain tumor, but how frequently a headache is associated with brain tumor? Treating doctor enjoys two benefits, one safety and the other commission money that comes from the investigation center.

Paper work has become more important than the treatment. If given choice, let the patient die but complete your file first, because they can snatch your file immediate after the patient’s death, so that we cannot make any changes in it.

Any way, since now the law is implemented, what should be our reaction?

There is no need to be panicky. If you are a good doctor, no law will harm you.

The law has been implemented just to make the doctors realize that they are accountable to the patients and the society! It was a bad practice to say since ages that – Don’t argue, you are not doctor. Just do as I say. Don’t say any thing”.

Gone are those days. With increasing literacy, awareness and media in action, the patient knows quite a lot about his problem before he comes to you.

Recently I had a patient of Gall stones with possibility of a stone in her bile duct. She never developed jaundice. The Sonography made the entire picture confusing. Her husband took my interview before surgery, in a very logical way, from what is the normal size of common bile duct, to how are you going to rule out the possibility of CBD stone per operatively? About is there not any sort of injection or dye, which could show you the obstruction? Then why not arrange for the same? I was surprised to see his crystal clear understanding and logical thinking. I was allowed to operate only when I got through the viva. My examination did not stop here. We had to open her bile duct, because the stones were palpable and then had to put in a “T tube”. I had to face the questionnaire on T tube also.

The patient has all rights to know about, what you are going to do with his body. Now you will have to limit the number of consultations in your OPD to ensure that you satisfy all the patients, tell them in detail about the procedure you are going to perform, about the possible complications, and also the financial aspect, so that he prepares himself and comes accordingly.

Do proper investigations, make a methodical file and do good documentation, so that you can retrieve it later on whenever needed.

Surgery is like a war, to be faught collectively by the surgeon, the patient and the relatives. Every body has to try hard on his front. All have to come together . Tell them all that happened in Operation Theater. Do not hide any thing. Better admit that it was an open and close laparotomy. We could not see any positive finding. I feel sorry for the same, but let us satisfy ourselves that it was a good exploration and that has relieved us, there is nothing serious inside. Any way even if you hide, he is going to know all over a simple cup of tea with OT worker.

If there is any problem after operation, let the relatives know every thing in detail. Give them freedom to call any surgeon of their choice for second opinion, if they wish. We have a wrong habbit to assure them through out and saying that don’t worry, every thing will be all right. When the situation goes out of your control, then you suddenly declare the patient to be serious. Now, if the relatives abuse you, what is their mistake? They think (according to your version), everything was going on well till you have done some negligience, making their patient serious. Had they known in details about shy the patient was sinking gradually, it would have made up their mind for the mishap. If they know the reasons, they will also accept even the death. They should feel you are one of them, and trying your best, without hiding anything.

In many situations, relatives are provoked to take benefit from CPA, by the lawyers and relatives. Only one thing will save you, the “Rapport”. It is absurd to take a thumb mark on consent form, which is printed in English, without explaining anything about surgery and it’s complications.

In nut shell, let us be happy for the implementation of this law, try to give better services to the society. I am happy because it is now that we good doctors will be valued for our genuine practice.

I feel exhilarated when my dear patients say to me – all this is not for you doctor. Why are you taking our signatures on consent form? Do you feel we can ever sue you?

How did this law emerge in India, where the surgeons are worshipped like God?

This is outcome of negligence of the surgeons, realized by the educated class.

I have heard Dr.Lele R.D in many meets, talking about this act. He is the authority in this. I would be happy to quote what he says about this-

Sir William Osler described medicine “ as a science of uncertainty and the art of probability “ Due to wide ramifications in living organisms’ responses, doctors frequently make only probability statements which must be constructed in the proper light in the courts, There are several grey areas in medicine which are difficult to understand and are the major cause of litigations.

From legal point of view, doctors are subject to two types of liabilities:

Criminal: When an act of omission or commission has caused a patient’s death. The punishment is imprisonment for 2 yrs and fine, or both.

Civil: When doctor fails to exercise ordinary, or reasonable care. Civil liabilities can arise irrespective of whether doctors are paid a fee for the service, or not. Therefore Government and charitable hospitals also come under the ambit of this act. It must be proved that doctor has behaved like a quake. It is expected fom a doctor to have at least an average skill. When there are two schools of thought for the treatment of any disease, doctor is free to choose any one.

Certain acts of negligence are:

1. Failure to attend the patient when he complains of chest & abdominal pain.

2. Failure to elicit symptoms or signs properly or perfunctory examination.

3. Inability to reach a diagnosis or employ appropriate diagnostic tests.

4. Not obtaining appropriate consent.

5. Failure to administer proper treatment or take proper precautions when giving penicillin etc.

6. Failure to leave proper written instructions with attendant doctors, nurses.

7. Anaphylaxis or other doctor induced problems.

Contributory negligence: is established when certain acts committed by the patient have contributed towards whatever is the outcome on the patient’s health, besides negligence by the doctor.

Damages: Monitory compensation, are of two kinds –

Pecuniary – For financial loss, past, or future.

Non-Pecuniary – A patient can claim for pain, and mental anguish and loss of enjoyment with respect to married life, physical activities etc.

A patient can claim damages on the following counts of negligence :

1. Failure to attend or examine the patient.

2. Give a wrong diagnosis.

3. Failure to prevent an illness (HIV through blood transfusion)

4. Failure to warn of inherent risks.

Vicarious liabilities: is the liability to which a doctor is subject owing to the acts committed by the persons he employs, either ward boys, nurses, other doctors working under him. It includes injury sustained by the patient owing to fall from cot etc.

The consumer protection act 1986

The CPA came into being in the year 1986. At that time, the tenth Union Health Minister Mr. Bharadwaj had clearly stated that it was not applicable to the medical profession.

In 1989 Mrs. V.P. Shantha filed a complaint against a private hospital before the Kerala state commission. The hospital put forth the argument that the complaint was invalid since the medical profession was exempt from the act. The state and National commission rejected this. The Indian Medical Association had appealed to the supreme court requesting exemption of the medical profession under the terms of the Act. (The National commission ruled in 1989 that the medical profession is covered under the CPA).

The medical profession must understand the eagerness of the lay persons to see, applications of the CPA for doctors since legal redressal in this country is painfully slow. In order to foster a healthy doctor-patient relationship strenuous effort has to be made by the medical profession to relate themselves to the patients and seek to understand their economic and social compulsions. Equally, dissemination of information to the patient is important, because, poor communication is frequently the reason for breakdown of trust between patients and doctors.

Healthy doctor-patient relationship falls into anyone of the categories :

The paternal relationship : is where the doctor acts as a guardian and presents information selectively to the patient.

The informative relationship : is where the patient is given all the inputs in order to take the decisions he considers optimum which are duly carried out.

The interpretative relationship : here the doctor seeks to interpret the patient’s needs and helps him in choosing the best possible medical intervention suitable for him.

The deliberative relationship : is where doctor interprets the patient’s needs, provides him with information regarding available alternatives and helps him select the best possible alternative.

While ideal relationship would be that based on the deliberative model, all the above relationships change with the circumstances, depending on the doctor and the patient. The bane of medical practitioners are also so called “Difficult patients” who fall into the following categories:

1. Oppositional: who are averse to obeying any advice from doctors.

2. Manipulative: who seek to manipulate doctors in order to obtain certain benefits like leave etc.

3. Hostile patients: who chronically change the doctors and complain whatever be the treatment given.

4. Malingering patient: who in order to satisfy some secret desires adopt certain symptomatology, that mimics diseases.

To a large extent the medical profession’s indifference may have contributed to the production of first three categories of patients. In understanding the doctor patient relationship and in straining to achieve the ideal relationship, it would be important to follow certain guidelines on both sides

For the patient:

To provide adequate and truthful information to the doctors, to take medications as advised, and report duly for follow up.

For the doctors:

To keep abreast of the advances in diagnosis and “At least do no harm to the patient”, to remain available for the care of the patient once he has accepted the responsibility and to know his own short comings and be honest with the patient when the case requires the skills that are beyond him.

While litigations against doctors are justified when they have committed acts of negligence, undue harassment should be avoided. In United States, where litigations against doctors have reached paramount proportions, medical insurance is very expensive and the ultimate cosrt is passed down to the patient in the form of fees or expensive test, so as “to be on the safe side”. Certain doctors have also started employing counter litigations to the patients. This is indeed a sad state of affairs and we should learn our lesson from this and prevent such detiorition in our communities.

I came across another wonderful article by courtesy Dr P.M.Bhujang. He describes how to safeguard your interests in the form of 10 c’s

Competence / Consent / Communication / Confidentiality / Correst medical records / Continued update of knowledge, technology / Consult colleagues / Co operation / Cover – Prof indemnity / Confidence.