FIRST APPEAL NO. 481 OF 2014
DR. BIKRAMJIT SINGH SANDHUVersus SIMPLE BHANDARI & 12 ORS.Decided by the Hon’ble NCDRC on 20.10.2020
FACTS: Late Sh. Anshu Bhandari, husband of respondent no.1 and father of respondents 2 & 3 met with a roadside accident at about 7 pm on 17.04.2009 and was taken to Civil Hospital, Jagraon. After giving first aid to him, he was advised to be taken to a well-equipped hospital for further management. The deceased Anshu Bhandari was accompanied by respondent no.1 his wife Mrs. Simple Bhandari at the time he met with the accident and she had also sustained some injuries in the said accident. Both of them were brought to the emergency department of Ludhiana Medicity, a unit of AA Hospital Pvt. Ltd. at about 9 pm. Deceased Anshu Bhandari was in a critical condition at the time he was brought to Ludhiana Mediciti. He was examined by the doctor on duty namely Dr. Pankaj who informed Dr. B. S. Sekhon, MD (Anaesthesia). Dr. B.S. Sekhon examined him at about 9-10 pm and called Dr. Bikramjit Singh Sandhu, appellant in FA/481/2014. Dr. Sandhu examined him at about 09:30 pm. At that time, blood pressure of the deceased was 90/60 and his heart rate was 120. After starting intravenous fluids and inserting a urinary catheter besides giving the pain killers, several investigations were advised by Dr. Sandhu. He was shifted to ICU at about 10 pm and his bed side X-ray and ultrasound was done. The X-ray did not indicate pneumothorax. The ultrasound started at about 10:15 pm and took about 20 minutes. The ultrasound indicated haemoperitoneum and pelvic hematoma. The deceased was discharged from Medicity, Ludhiana at the responsibility of his family members at about 11:30 pm and was taken to CMC Hospital where he expired at about 01:45 am on 18.04.2009. As per the post-mortem report, his death was caused due to hemorrhagic shock resulting from multiple injuries in a road side accident. Alleging negligence in the treatment of late Sh. Anshu Bhandari, the complainants approached the concerned State Commission by way of a Consumer Complaint filed on 09.12.2009.
Defense: The treating doctors had planned a laparotomy for the treatment of haemoperitoneum but the family members of the deceased refused the consent required for the aforesaid procedure and they took discharge at their own responsibility when the patient was in a critical condition and was not in a position to travel upto CMC Hospital.
OBSERVATIONS & LITERATURE: A perusal of the impugned order would show that the State Commission found negligence on the part of Dr. Bikramjit Singh Sandhu and the hospital primarily on the ground that no treatment to the deceased was given for haemoperitoneum and pneumothorax. As far as pneumothorax is concerned, the case of the appellants is that it was not indicated either in the X-Ray report or in the ultrasound report and therefore, there was no basis for giving treatment for pneumothorax to the deceased. An article on evaluating and managing pneumothorax available on page no.408 of the paper-book deals with the diagnosis of pneumothorax and to the extent it is relevant, the said article reads as under:
DIAGNOSIS BY CHEST X-RAY
The diagnosis of pneumothorax is radiologic in all cases except when a tension pneumothorax is suspected. The first and often only test required in a standard anteroposterior (AP) chest film. The diagnosis is made by identifying a viscera pleural line separated by a space without pulmonary vasculature or lung markings adjacent to the chest wall. The overall sensitivity of chest x-rays in detecting pneumothorax is around 80%.Traditionally, expiratory chest x-rays have been thought to have a higher sensitivity than inspiratory films, but the current literature does not support that. Theoretically, the volume of the pneumothorax will not change with the various stages of respiration, which should make it more obvious on expiratory films. Recent studies have refuted this medical axiom, however, and inspiratory films should suffice to rule out a pneumothorax. Supine chest AP films are notoriously inaccurate. Because they result in air spreading out over the anterior chest, supine films often appear normal, even in the presence of significant air. Frequently, the only indication is the “deep sulcus sign”, so named because of the appearance of an essentially deep costovertebral sulcus.
COMPUTED TOMOGRAPHY AND ULTRASOUND
Computed Tomography (CT) is exquisitely sensitive for picking up a small, occult pneumothorax and is the best choice for diagnosing the condition in the supine trauma patient. The more prevalent use of CT scans in trauma patients has led to increased detection of pneumothorax, but the clinical utility of this is unclear. Many of these small pneumothoraces will resolve spontaneously without intervention, although their presence may have management implications in patients requiring mechanical ventilation or air transport or planning air travel. Pneumothorax is frequently and inadvertently diagnosed in the supine trauma patient undergoing CT for other concerns.Another promising modality is ultrasound, preliminary evidence with experienced ultrasonographers both in Europe and the United States show sensitivities for diagnosing pneumothorax approaching 100% in skilled hands. Ultrasound may also be helpful to physicians practicing in an austere environment where radiologic studies are not readily available. With proper training and experience, ultrasound should become a more useful tool for the emergency physician to utilize for the supine trauma patient too unstable for CT. These pneumothoraces can be divided into three classes; simple, communicating, and tension (see table).
TENSION PNEUMOTHORAX.
| Type | Definition | Management |
| Simple pneumothorax | No communication No communication with outside air and no mediastinal shift. | Observation if small and asymptomatic Aspiration, observation and repeat chest X-Ray |
| Communicating pneumothorax (“sucking chest wound”) | Open hole in chest with free communication to outside air. | Cover hole, then tube thoracostomy and admission |
| Tension pneumothorax | Flap-valve effect creates increasing intrathoracic pressure with hemodynamic compromise | Needle decompression, tube thoracostomy and admission |
| Catamenial pneumothorax | Occurs in women during menses from thoracic endometriosis | Observation, aspiration or tube thoracostomy Refer for preventive procedues and hormonal therapy. |
A tension pneumothorax occurs when an injury creates a flap-valve effect, permitting ingress but not egress of air from the thoracic cavity. Each time the patient takes a breath, more air enters into the thoracic cavity. The result is increasing intrathoracic pressure with subsequent shifting of the mediastinal structures to the opposite side. If the pneumothorax may present with tachycardian, hypotension, jugular vein distension, tracheal deviation, and absent breath sounds on the involved side. The diagnosis should be based on clinical, not radiographic findings.
HELD: It would thus be seen that though X-ray chest is one of the diagnostic tools to confirm pneumothorax, the sensitivity of the chest X-ray in detecting pneumothorax is only about 80%. The medical literature extracted hereinabove would show that CT Scan would clearly pick up even small pneumothorax and is the best choice for diagnosing the complainant in the supine trauma patient. The literature would also show that ultrasound scan, if done by a good Sonologist, has 100% accuracy in diagnosing pneumothorax. The literature also shows that ultrasound may be a more useful tool for emergency diagnosis of pneumothorax. In the present case, there is no evidence of Dr. Sandhu having advised CT Scan of the deceased. The medical literature extracted hereinabove would show that patients with tension pneumothorax may inter-alia have tachycardia and hypotension. The record of the hospital would show that the Blood Pressure of the deceased 90/60 and his pulse rate was 120 at the time he was brought to the hospital. Therefore, not only he had tachycardia, he also had hypotension. Therefore, clinical symptoms indicating tension pneumothorax were certainly present. The question which arises for consideration is as to whether Dr. Sandhu can be said to be negligent in not treating the deceased for pneumothorax/tension pneumothorax despite the above referred clinical symptoms, relying upon X-ray report and ultrasound which did not indicate pneumothorax/tension pneumothorax. It is quite possible that some other doctor, in place of Dr. Sandhu might have advised CT Scan of the deceased or might have started treatment for pneumothorax/tension pneumothorax despite the X-ray report and ultrasound report, considering the tachycardia and hypertension noticed during the clinical evaluation of the patient. Such an approach might have been more prudent but, not treating the patient in pneumothorax/tension pneumothorax would not constitute negligence in the treatment of the patient when the ultrasound report and X-ray report did not give any indication of the aforesaid ailment. This would be a case of error of judgment but not a case of negligence as far as the failure to treat the patient for pneumothorax/tension pneumothorax is concerned. It is an admitted position that the haemoperitoneum was suspected in the clinical evaluation and was confirmed in the ultrasound report. This is not the case of the appellants that the deceased did not have symptoms of haemoperitoneum and did not require treatment for the same. The case of the appellants rather is that they had planned laparotomy for the treatment of haemoperitoneum but the laparotomy could not be done, the family members of the deceased having refused consent sought by them for performing the said procedure. The case of the complainant is that no consent for performing laparotomy was sought from them and in fact, no worthwhile treatment was given to the deceased and that was the reason they had to shift him to CMC Hospital even at a time when the deceased was in a critical condition. There is absolutely no documentary evidence of the appellants having sought consent to perform laparotomy on the deceased for the purpose of treatment of haemoperitoneum. Had such a consent been sought and refused, this would certainly have been noted in the record of the treatment maintained in the hospital. Seeking of consent to perform laparotomy on a patient admitted in a highly critical stage and denial of such a consent by the family members despite they being present in the hospital, was too important a fact to be inadvertently omitted from being noted in the treatment record of the patient. The appellants have relied upon the record of the hospital prepared at the time when the patient was discharged on the request and at the responsibility of his family members. It was specifically noted in the record that the patient was in a critical condition and was not in a position to travel upto CMC Hospital. But, there was no mention of the consent for performing laparotomy having been sought and refused. Thus, the alleged seeking and refusal of consent for laparotomy was not recorded either at the time the consent was sought nor at the time the patient was discharged from the hospital against the advice of the treating doctors. In fact, considering the critical condition of the patient at the time haemoperitoneum was conformed in the ultrasound report, no consent from the family members of the deceased was necessary and the treating doctor could, in such an emergency, have gone ahead with the procedure without seeking such a consent, in order to save the life of the patient. For the reasons stated hereinabove, I have no hesitation in holding the finding of the State Commission that despite haemoperitoneum having been confirmed, no attempt was made by the hospital and the treating doctor to undertake laparotomy even till the patient was discharged at about 11:30 pm. There was a time lag of about one hour between confirmation of haemoperitoneum through ultrasound report and the discharge of the patient from the hospital on the responsibility of his family members. Every minute is important in the case of such a critically injured person. Therefore, the appellants were clearly negligent in the treatment of the deceased by not undertaking laparotomy even till the time he was discharged at about 11:30 pm. Coming to the quantum of compensation, the learned counsel for the appellants submits that the legal heirs of the deceased have been awarded compensation of about Rs.14 lacs by the Motor Accident Claims Tribunal. Considering all the facts and circumstances of the case, including the age of the deceased, I feel that a compensation amounting to Rs.15,00,000/- to the complainants would be justified. The payment in terms of this order shall be made within two months from today failing which it shall carry interest @ 9% per annum from the date of order of the State Commission.
