Surgery Instead of Conservative Treatment: NCDRC slaps Rs 22 lakh compensation on doctors

New Delhi: Observing that instead of surgery, the doctors could have treated acute acalculous cholecystitis (AAC) by conservative treatment method with antibiotics and source control, the National Consumer Disputes Redressal Commission recently held three doctors guilty of medical negligence.

After the surgeons and the anesthetist removed the gallbladder of the 30-years-old patient, she died. Holding the doctors guilty, the top consumer court has directed them to pay Rs 22 lakh as compensation to the daughter of the deceased.

Holding the doctors guilty, NCDRC stated in the judgment, "It is pertinent to note that, prior to operation, the patient's hemoglobin (9.9 g%) and blood pressure (100/70) were not normal, therefore, in case of acute acalculous cholecystitis (AAC) instead of surgery, initial step in treating acalculous cholecystitis should be conservative with antibiotics and source control. In the instant case, the decision of OP-1 was hurriedly taken. The operation was not an emergency or lifesaving, therefore, the OPs should have ruled out other causes of AAC and waited till proper diagnosis."

The history of the case goes back to 2004 when the wife of the Complainant had been operated by Dr. M.P Jha for removal of gall stones. Dr. Jha had been assisted by Dr. Khurshid Ahmad and Dr. Animesh Priya as an anesthesiologist. Allegedly, the operation continued for around 4 hours and the patient had died inside the Operation Theatre (OT). 

Following the death of the patient, Post mortem (PM) had been performed at Patliputra Medical College and Hospital (PMCH) and the report stated that the death was sue to bacteremia and septicemia. Therefore, being aggrieved the Complainant had filed the complaint before the District Forum at Dhanbad. He had also filed a criminal complaint under Section 304- A/34 of the IPC.

After considering the matter, the District Forum had allowed the complaint against all the doctors and directed them to pay Rs 5 lakh to each of the Complainants with 9% interest p.a. and also pay Rs.25,000/- as litigation cost. Thereafter the doctors had approached the State Commission, which also received a plea from the complainants seeking an enhancement of compensation.

Consequently, the State Commission partly allowed the application for enhancement and directed Dr. Jha and Dr Ahmad to pay Rs 15 lakh each to the Complainants with 9% interest p.a. from the date of filing of the complaint. However, the State Consumer Court had exonerated Dr. Animesh Priya, the Anesthesiologist from the liabilities. Therefore, the guilty doctors approached the NCDRC bench.

After considering the arguments made by the counsel for all the parties, the top consumer court also perused the entire material on record, reviewed the medical literature on cholecystitis and also checked the medical record.

The counsel for Dr Ahmad argued that he had only assisted Dr Jha in the operation and he didn't have any role in performing the operation. However the State Commission had held him guilty and mentioned in the order, "in such a serious condition, it was highly improper on the part of both the appellants to hastily abandon conservative treatment and perform "open surgery" without, even for a moment considering the option of "percutaneous cholecystectomy".

Referring to the Medical Record, the NCDRC bench noted that on clinical examination and based on USG and other investigations, it was diagnosed as a case of acute cholecystitis. Therefore the patient was admitted to Navjivan Clinic. Immediately standard conservative treatment was started with I.V. fluids, broad spectrum Antibiotics, Analgesics and Anti Emetic drugs. Since the pain worsened, Dr. Jha had decided to stop the conservative treatment and operate the patient as per standard principles of surgery. 

Accordingly, he explained the risks and possible complications of operation, anesthesia, and took informed written consent from the patient and her husband, The patient had been operated at 5 PM and shorty afterwards, the patient started having breathing troubles, which was treated with appropriate drugs and the patient had been given blood transfusion. Although the vital parameters had been restored to normal, the breathing problem persisted and oxygenation level started decreasing. All resuscitative measures failed for improving the condition of the patient and she developed the sudden cardiac arrest. Therefore, despite all resuscitative measures, the patient could not be saved and she ultimately died.

At this outset, the top consumer court referred to the USG report and mentioned, "It is evident from the report of USG, there was no stone(s) in the gall bladder and it was not life-saving or emergency surgery. It appears the OP-1 took hasty decision to operate the patient. Even, we note the doctors including Anesthetist gave fitness to said surgery. The patient was taken for surgery at 5.30 pm and declared dead at 9.00 p.m. which creates lot of doubts on the treatment of OPs."

The NCDRC bench also noted that the operative notes had revealed that Dr Jha had completed the dissection successfully and the gallbladder had been removed. "There was some extra bleeding from the liver bed (more than usual). This was controlled by putting 4 pieces of geleo-sponge and stitching the gallbladder end. At the time of shifting the patient to her bed, she felt breathing trouble, it was managed by the Anesthetist. It is pertinent to note that the urinary catheter showed blood stained urine, but the OPs-1 and 2 failed to rule out the causes of the same," noted the bench.

Although the Postmortem report revealed that the patient had died due to septicemic shock, NCDRC observed, "However, report expressed possibility of re-exploration cannot be ruled out, which creates shadows in our mind. On careful perusal of Post Mortem report, it is clear that no drain was put after gall-bladder operation. The re-operation was done to ligate the bleeding vessels and to put a drain. Moreover, there was no other indication to open the abdomen. In the instant case, emergency Cholecystostomy was necessary to drain bile or pus, and the conservative treatment should have been continued till recovery."

The doctors had alleged that the patient was already in septicemia and therefore, removal of gallbladder was absolutely necessary for avoiding fatal complications. However, the top consumer court did not agree and noted,

"We do not agree with this contention of OPs because primarily they failed to rule out the other causes of septicemia by proper investigations like blood culture, liver function test etc."

"It is pertinent to note that, prior to operation, the patient's hemoglobin (9.9 g%) and blood pressure (100/70) were not normal, therefore, in case of acute acalculous cholecystitis (AAC) instead of surgery, initial step in treating acalculous cholecystitis should be conservative with antibiotics and source control. In the instant case, the decision of OP-1 was hurriedly taken. The operation was not an emergency or lifesaving, therefore, the OPs should have ruled out other causes of AAC and waited till proper diagnosis," it further noted.

The top consumer court had also gone through standard books on Surgery and research articles and it observed that,

"The initial step in treating acalculous cholecystitis should be similar to treating other infections, i.e. antibiotics and source control. Then, cholecystectomy or drainage by percutaneous cholecystostomy should be done. Intravenous antibiotics administration early plays a critical role in fighting the infection and achieving source control. The percutaneous cholecystostomy tube should be placed by the interventional radiologist to secure the drainage of the gallbladder. Percutaneous cholecystostomy controls acalculous cholecystitis in more than 85% of the patients. Compared to open cholecystectomy, percutaneous cholecystostomy has shown lower morbidity, fewer admissions in the intensive-care unit, decreased length of stays, and lower costs. Moreover, the overall rate of complications of percutaneous cholecystostomy is approximately 2%, which is considered low especially that it is mostly used in critically ill."

"Then, cholecystectomy or drainage by percutaneous cholecystostomy can be done. Percutaneous cholecystostomy has shown a high success rate in controlling cases of acalculous cholecystitis. Successful percutaneous cholecystostomy is associated with very good outcomes and rapid improvement," it added.

Although the NCDRC bench opined that the amount of compensation awarded by the State Commission was just and adequate, it also noted that the State Commission had erred in exonerating the anaesthetist. Therefore, it observed,

"To sum up the discussion, it is apparent from the record that informed consent is not on record. The OP1 and 2 failed to rule out other causes of AAC by conducting investigations like Liver Function Tests, Typhoid /Malaria etc. The pre-aesthetic check-up details are not available on record. Therefore, the Anaesthetist Dr. Animesh Priya (OP-3) is also liable for his failure of duty of care for not doing pre-anaesthetic check-up and also failed to ascertain the facilities available for resuscitation in the hospital. The State Commission erred by exonerating OP-3."

"Further, we can't ignore the operative note which has recorded bleeding. Therefore patient suffered hypotension and he was transfused Haemaccel and 2 units of blood. Thus, possibility of intraabdominal bleeding can't be ruled out. In our considered view all the OPs have failed in their duty of care towards the patient. It was not a reasonable standard of practice, thus, negligence. Though role of Dr. Khurshid Ahmad was limited to assist the OP-1 during surgery but as a surgeon he has duty towards the patient and decision making. Therefore, he cannot be totally exonerated from the liability. Therefore, the Order of the State Commission is modified to the extent of their (all OPs) liabilities. In the ends of justice, in our view, all the Opposite Parties are liable for the death of patient. Accordingly, the captain of the ship Dr. M. P. Jha (OP-1) shall pay Rs. 15 lakh and Dr. Khurshid Ahmad (OP-2) & Dr. Animesh Priya (OP-3) shall pay Rs. 5 lakh and Rs. 2 lakh respectively to the Complainants," it further noted.

However, taking note of the fact that the son of the deceased had died and her husband had remarried, the top consumer court directed the doctors to pay the compensation to the daughter of the deceased and mentioned in the order, "We cannot ignore the fact that the Complainant No. 1 got remarried and Complainant No. 3 died during the proceedings before the State Commission (Para-22). Therefore, the entire amount (Rs.22 lakh) shall be paid to Ms. Shikha Rani, daughter of the deceased within six weeks from today. In case of delay beyond six weeks, the amount shall carry interest @ 9% p.a. till its realization."

To read the order, click on the link below.

https://medicaldialogues.in/pdf_upload/ncdrc-compensation-181020.pdf

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