New Delhi: The National Consumer Disputes Redressal Commission recently held Kerala based Hospital and a Facio Maxillary Surgeon, vicariously guilty of medical negligence while conducting interdental wiring on a patient suffering from maxillo facial injuries.
Observing that the doctors of the hospital had not even adopted even the basics of ABC of trauma while handling the patient, who died from asphyxia, the top consumer court directed them to pay Rs 30 lakh as compensation to the family of the deceased patient.
"The act of omission is evident as the doctors working in KVM Hospital did not follow the basics of ABC of trauma by which one doctor lost her life. Therefore, we hold vicariously, the Hospital (Opposite Party No. 1) and Dr. Ravindran Nair - the Facio-maxillary Surgeon (Opposite Party No. 7) for breach in the duty of care," ordered the NCDRC bench.
Back in the year 1999, the patient, Dr. Sudha had been brought to KVM Hospital after a major road accident. After examining, the doctors had diagnosed her suffering from maxillo facial injuries. C.T scan of the head had been done and it had revealed no significant intra-cranial injury. Similarly, the Patient's X-ray of neck and chest did not reveal any fracture of the 6th cervical vertebra.
At the hospital, Dr. Ravindran Narain, the Facio-maxillary Surgeon had performed the wiring procedure with the help of other doctors (Anesthesist and Plastic Surgeon) for the fractured maxilla. During the procedure, there was a sudden spurt of bleeding resulting in airway obstruction and consequently, the patient died due to oxygen insufficiency.
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It was alleged by the Complainants that the doctors had failed to secure the patient's airway, prior to the wiring and they rather performed tracheostomy or Intubation. Further, the complainants alleged that the Postmortem report of the deceased clearly showed that the patient's air passage was full of blood and her finger nails were blue, which was suggestive of her death due to hypoxia i.e. insufficiency of oxygen.
Alleging medical negligence by improper clinical evaluation and wrong treatment from the doctors at KVM Hospital, the Complainants filed a complaint before the State Commission seeking compensation of Rs. 20,00,000 with 12% interest.
On the other hand, the doctors filed a joint reply and denied the allegations of negligence leveled against them. KVM Hospital and its Casualty Medical Officer filed separate versions and submitted that the patient had major facio-maxillary fractures with bleeding from mouth and nostrils at the time of admission.
The doctors of the Hospital submitted that they had conducted all emergency investigations including blood investigations, X-ray of the skull including upper cervical spine and C.T. scan of the head with scanogram of the upper cervical spine. Thereafter, Dr Nair, the facio-maxillary surgeon had been called from Medical College, Alleppey for attending the patient. The doctors further submitted that the patient was fully conscious and well oriented and answered all the questions regarding the previous history. On examination, the airway was patent and the patient did not experience any difficulty in breathing. Moreover, at the time when the patient was taken to the Operation Theatre, the bleeding was not active.
It was further submitted that one of the doctors discussed with the patient, who herself was a doctor, regarding the possible need of a tracheostomy, for which the patient had given her consent in case of absolute necessity. Hence, it was the consent given only for First Aid under a local anesthesia to prevent further bleeding from the maxillary fracture and then to shift her to another center for definitive surgery.
They also informed the court that the condition of the patient did not warrant tracheostomy or any intubation as she had no difficulty in breathing before or during the First Aid procedure. As the wiring was near to complete, the patient complained of breathlessness due to severe bronchospasm. As mask ventilation was difficult, the Anesthetist tried auro-tracheal intubation, but it was difficult to visualize the larynx through laryngoscope.
Therefore, the Plastic Surgeon had been asked to continue with an emergency tracheostomy and the procedure became practically difficult as the patient was struggling. Following this, the Oro-tracheal intubation was tried again and intubated. But it was impossible to ventilate through the tube as the 'bag' was too tight, due to severe Bronchospasm (Reflex Shrinking of lumen of the air passages). Immediate and prompt measures were taken to facilitate ventilation, including endotracheal suction and bronchodilator drugs. As the ventilation through the oro-tracheal tube was still difficult, the Anesthetist again proceeded with tracheostomy with the help of an ENT Surgeon, a colleague of the Patient who volunteered to come in and help. The patient developed cardiac arrest and immediately cardio pulmonary resuscitative (CPR) was started.
After considering the matter, the State Commission had dismissed the complaint by holding it as an 'error of judgment.' It observed that "if there was an error of judgment in not resorting to tracheostomy earlier, the same cannot be treated as negligence on part of the opposite party doctors."
Being aggrieved, the complainants appealed before the NCDRC bench seeking relief. The counsel for the Complainant argued that the treating doctor had not examined the patient properly and acted casually by failing to proper airway assessment and active steps to protect the airway prior to the major surgical procedure. Claiming that the maxillo-facial surgery was completely unnecessary, the counsel submitted that the patient's life could have been saved by tracheostomy or intubation which could have secured the airway.
After considering the submission, the NCDRC bench referred to the Clinical notes and also perused the relevant medical literature on Trauma Management. It was noted by the Commission that the first priority in the care of all trauma patients is the affirmation of a patent airway to ensure adequate oxygenation and ventilation. The ABCs of trauma resuscitation begin with the airway evaluation, and effective airway management is imperative in the care of a patient with critical injury. At this outset, the top consumer court also referred to the Advanced Trauma Life Support (ATLS) Protocol. This protocol consists of Airway maintenance with Cervical spine protection, Breathing and Ventilation, Circulation with Bleeding control, and Disability: Neurological examination.
Referring to this, the top consumer court noted, "From the literature, it is evident that the treating doctors in the instant case failed to do the basic of ABC protocol for high velocity trauma management, thus it was their failure in the duty of care. In our view, the State Commission erred to observe the duty of doctors therein and merely holding it as an 'error of judgment', dismissed the Complaint."
At this outset, the Commission referred to the Judgment of House of Lords/English Courts in Whitehouse vs. Jordan where it had been held that "The true position that an error of judgment may or may not be negligent it depends on the nature of the error." Referring to this the NCDRC bench noted, "Thus, in our considered view, the instant case is not an "Error of Judgment" but the breach in duty of care from the doctors, who treated the patient. Resultantly, the patient died."
"We further note that the treating doctors failed in their duties to act with reasonable degree of skill and knowledge. They have not exercised a reasonable degree of care to handle the emergency by adopting basics of ABC of trauma," it further noted.
Holding the doctors guilty of medical negligence, the NCDRC bench also referred to Supreme Court order in the case of Dr. Laxman Balkrishan Joshi Vs Dr. Trimbak Bapu Godbole and Anr., A.S. Mittal and Ors. vs. State of U.P. and Ors., and Spring Meadows Hospital v Harjyot Ahluwalia.
Referring to these judgments, the Consumer Court noted, "We necessarily looked into ATLS protocols, which were derived from extensive research in the U.S. to rapidly assess and give emergent treatment to victims of car crashes and ones especially involving fatalities. Further, it is also a fact borne from research that if there is a fatality or fatalities from a car crash at the scene of accident itself or a death en route to hospital, the risk of survivors who actually reach the hospital are at an increased risk of succumbing from similar injuries even if obvious, visible or otherwise. A high level of suspicion and constant surveillance of the survivor-victims needs to be done frequently and thoroughly investigated for any internal trauma which may not be apparent immediately and there is no procedure for dispensing with resuscitation as required, reassessment, head to toe examination and investigations followed by period of observation to ensure survivor survival and safety."
Opining that the doctors were negligent, the Commission noted, "Merely because in the instant case, the victim - Dr. Sudha was conscious, coherent or vocal, this simply cannot deviate from the fact that even a simple radiograph of neck, chest and/or CT scan were not carried out. Further a head injury can also lead to brief periods of conscious lucid interval only to deteriorate later and can fool the inexperienced medical practitioner and hence there is need for vigilance and hence there is need for restrain to fully stabilise the patient, investigate the patient and only then take up for surgical intervention. The absence of clinical examination of the C-spine and radiographs or X-ray of the chest or X-ray of pelvis above is nowhere to be seen in the hospital notes particularly when a co-passenger has suffered fatality should be enough to raise the suspicion of any doctor to `very high` regarding likely mortality in the survivor-victims. It transpires that upon autopsy, it was discovered that there was a fracture of the C6 vertebrae. Without assessment of such an injury and without even a reasonable period of observation, it is seen that the maxillo-facial surgeon with undue alacrity attempted to undertake inter-dental wire fixation for fracture of the mandible and effectively shut access for easy or effective oro-tracheal intubation."
"Further there is no record as whether intranasal tracheal intubation apparatus or even a fibre-optic device was available or kept ready for any eventuality. Unfortunately, the secretions from the mouth and throat in absence of any suction mechanism caused aspiration into the air pipe and that despite making feeble and ill-trained attempts to obtain a `surgical airway` only made matters worse by further pooling of blood in the air-pipe. All these events appear ill-planned and ill-executed and complications ill-managed, eventually leading to aspiration, asphyxia leading to death of a person, who would have survived with systematic and expert management," it added.
Therefore, the NCDRC bench mentioned in the order, "No doubt that interdental wiring is used to treat fractures of the mandible, and this is not a comment on choice of procedure. But it is clear that the procedure was undertaken without proper assessment of airway, risks to patient from Cervical spine injury and without even allowing stabilization of the patient and seems to be taken up with undue haste. Harm was certainly caused due to overenthusiastic interventions which should have been postponed to a suitable time. There is absence of effective medical notes to show if an Anaesthesiologist was available or even present at the time of the procedure.Thus it was not a case of Error of Judgment, but a negligence."
"Based on the foregoing discussion, medical negligence is attributed upon the hospital and treating doctors therein," it held.
Directing the hospital and the doctor to pay Rs 30 lakh as compensation, the Commission noted, "The act of omission is evident as the doctors working in KVM Hospital did not follow the basics of ABC of trauma by which one doctor lost her life. Therefore, we hold vicariously, the Hospital (Opposite Party No. 1) and Dr. Ravindran Nair - the Facio-maxillary Surgeon (Opposite Party No. 7) for breach in the duty of care. The Complainants have prayed compensation of Rs. 20 lakh before the State Commission in the year 2001. We are now in 2022, thus, in the ends of justice and considering the peculiarities of this case, lump-sum compensation of Rs. 30 lakh is just and proper. The Opposite Party No. 1 is directed to pay Rs. 25 lakh and the remaining Rs. 5 lakh shall be paid by the Opposite Party No. 7. The total amount shall be paid equally (Rs. 15 lakh each) to the Complainants Nos. 1 & 2. The entire amount shall be paid within 3 months from today, failing which, it shall carry 7% interest per annum, till its realization."
To read the NCDRC order, click on the link below.
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