Case Study

The vital “Shifting of patient to higher centre”

Kannaya Chettiar v. Nair Service Society, FIRST APPEAL NO. 380 OF 2009 decided by the Hon’ble NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION  NEW DELHI on 26.04.2018

FACTS: On 09-08-2000 the complainants’ son, Jayaprakash had severe abdominal pain and vomiting, immediately he was rushed to OP2-NSS Medical Mission Hospital. The OP3, the General Surgeon, Dr. Moorthy examined the patient at about 4:30 P.M. and diagnosed the ailment as acute appendicitis with peritonitis and, accordingly, advised for immediate admission and surgery. On the same day, the patient was operated at 08:30 P.M., under spinal anesthesia, administered by OP4-Anesthetist (Dr. Santha Raju). After surgery, the patient was brought to the ward at 09:45 P.M.. He was unconscious, shivering and white froth was flowing from his mouth. The complainants informed OP-3 about the serious condition of the patient, but he did not see the patient. None attended the patient despite his worsening condition. At last at 0030 hours (10-08-2000), the patient was shifted to ICU in the critical stage; but the doctor and staff in ICU failed to take care of the patient. At 11:45 A.M., when the patient was in sinking stage, OP3 with the help of his subordinates shifted the patient hurriedly to Kottayam Medical College Hospital (KMCH), Kottayam. The patient was in a comatose state. It was alleged that, OPs 3 & 4 were aware of the cause of coma. It was alleged that, there was overdose of anesthesia, wrong sedative injection and lack of proper post-operative care. The patient breathed his last on 20-08-2000 in KMCH, Kottayam. The post mortem findings revealed death was due to septicemia.

DEFENSE: The patient was brought to their hospital at 4:15 P.M. on 09-08-2000 with severe abdominal pain and vomiting from two days. The Casualty Medical Officer, Dr. Sharmila, referred the patient for surgical consultation to OP3, who diagnosed it as Acute Appendicitis with Peritonitis and advised immediate investigations. It was revealed that, the blood count was high, WBC 19100/per cmm and the neutrophils were 80%. Therefore, for emergency operation, patient was admitted in OP-2. At 6.00 P.M., surgeon reviewed the case again and after informed consent from the patient and his mother for anesthesia and surgery; emergency appendectomy was performed at 08:30 P.M.. As per the assessment of OP 4, the Anesthesist, the patient was ASA Gr.II (E), indicating that the patient had mild systemic disease. The pre-medication for anaesthesia were given. Lignocaine Hydrochloride (5%) was used for Spinal anesthesia. Surgery was concluded within 25 minutes and the patient was shifted to recovery room for observation till 09:35 P.M.. The patient was conscious and coherent. OP4 was in the hospital till 09:35 P.M. as he was attending another emergency Gynec case. OP4 left the hospital around 10 P.M. but, within five minutes he received a telephonic call from a casualty sister informing that the patient had no respiration and had feeble pulse.

Immediately, instructions were passed to shift the patient to the recovery room and OP4 rushed there at 10:10 P.M.. At that time, the patient had no cardiac/respiratory activity. Therefore, Cardio Pulmonary Resuscitation (CPR) was started with cardiac massage, DC shocks and drugs. The patient was intubated and was connected to a ventilator at 10:35 P.M.. The OP3 reached in the recovery room within 10 minutes, also the cardiologist reached the recovery room by 10:35 P.M.. Patient had regained spontaneous cardiac and respiratory activity. Thereafter, at 12:30 A.M. the patient was shifted to ICU. Thereafter, the patient developed recurrent episodes of convulsions in spite of anti convulsant drugs. As there was no neurology department and CT scan facility in OP2-hospital, it was decided to shift the patient to KMCH, Kottayam. Therefore, the patient was shifted in an ambulance on 10-08-2000 at 11:30 A.M. to Kottayam. During shifting, OPs 3 & 4 along with two other nurses accompanied the patient. The insurance company-OP5 in their written statement admitted that OP-2 is having Professional Indemnity Policy and maximum limit in respect of one instance was Rs.2,50,000/-. The OP-5 supported the contention of OPs 1 to 4.    On the basis of the pleadings and evidence, the State Commission dismissed the complaint.

EXPERT OPINION: As per the evidence on record, the Associate Professor from the Department of Medicine at Medical College, Kottayam was testified as PW2 before the State Commission. He had stated that, at the time of admission on 10-08-2000 at 1:15 P.M., the patient was unconscious and prior to it the patient developed the Status Epilepticus. The final diagnosis made at KMCH was Ischemic Encephalopathy and the treatment was started accordingly. PW2 also stated that, after surgery, if patient had spoken, then it would not be a case of overdose of anesthesia. The Professor & Head of Department of Medicine was examined as PW-3, who also stated that the patient undergoing surgery falls into coma on account of allergy to medicine administered for spinal anesthesia and it depends on the quantity of the medicine administered. Similarly, possibility of cardio respiratory arrest was also there. The convulsions are usually so on account of allergy of the medicine administered for anesthesia. According to the anesthetist, the Lignocaine Hydrochloride 1.8 cc was administered. Lignocaine is most widely used for anesthesia.

OBSERVATIONS: It is an admitted fact that, the patient was admitted in emergency and OP-3 operated for emergency appendectomy under spinal anesthesia. The spinal anesthesia was given by OP4, and as per anesthetic notes, patient was assessed as ASA, Grade II (E) indicating thereby that patient had mild systemic disease. The patient was, accordingly, taken for anesthesia and pre-medication drugs were administered. The spinal anesthesia was given with 5% Lignocaine Hydrochloride. The operation went uneventful and even in the recovery room Patient showed signs of allergy from 9.00 P.M. onwards till 10.00 P.M. Thereafter, patient developed cardiac arrest and the patient was attended immediately by OPs 3 & 4 along with a team of doctors including a Cardiologist etc. The resuscitation was started, DC shock was also given. The cardiac activity was noticed, and the patient was shifted to ICU. The patient had developed epileptic convulsions despite administration of anticonvulsant drugs, therefore, the opinion of the Neurologist was necessary. As per the medical record of the NSS hospital (OP-2), the resuscitation was started immediately and the patient was put on ventilator. For convulsions, antiepileptic drugs were administered. Similar treatment was continued at Medical College Hospital till 20-08-2000. After 10 days of treatment at Medical College Hospital, Kottayam, patient passed away due to septicemia. The cause of septicemia was due to initial appendicitis and peritonitis, which was further aggravated. The post mortem revealed the cause of death as septicemia and not due to overdose of anesthesia.

On the basis of foregoing discussion, we do not find any negligence on the part of OPs 1 to 4. It was a case of acute appendicitis and emergency operation was properly performed. There was neither overdose of anesthesia nor any complication of anesthesia. It is pertinent to note that, the patient was conscious and coherent for one hour post-operatively. After one hour of the surgery, the patient developed cardiac arrest. Therefore, it was not an allergic reaction. The doctors at OP2-hospital immediately attended to the patient and performed CPR as per standard procedure. The patient also showed signs of status epilepticus, therefore, due to non-availability of CT Scan, the patient needed to be shifted to medical college. In our view, it was proper decision of OPs 3 & 4 to refer the patient to a higher centre i.e. Medical College, Kottayam; it was not negligence. The referral to KMCH was at proper time, it was not negligence. There is no need to interfere in the order of the State Commission. Hence, the first appeal is dismissed.

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