Faulty Insertion of Double Lumen Tube at Manipal Hospital: NCDRC Upholds negligence

New Delhi: In a recent case of alleged medical negligence, the National Consumer Disputes Redressal Commission was seen upholding the State Commission's Decision of medical negligence on the part of doctors of Manipal Hospital on faulty insertion of double lumen tube. The commission however, refused to enhance the compensation of Rs 5 Lakhs as determined by the lower court.

Though the doctor that inserted the double lumen was a qualified anaesthetist, the  court was also seen making strong observations against the hospital stating that even though there was an  availability of experienced anesthetists like Dr. Prabhu Shankar and HOD, Dr. Nagaraj Gowda, the procedure was done by a trainee anesthetist.

The case goes back to year 2003, when a patient underwent thoracotomy surgery for carcinoma of left lung with left pneumonectomy at the Manipal Hospital, Bangalore. It was performed by Dr. Nithyanand Shetty, Cardio Thoracic Surgeon assisted by Dr. Sameer Rao , a Cardiac Surgeon at OP1. Post operatively, the patient was shifted to ICU for recovery. After regaining consciousness, he experienced severe hoarseness of his voice and he could barely speak. He immediately inquired with the doctors, but he was informed that he would regain his voice after few months. With no improvement, the patient also underwent speech therapy but to no relief.

The speech therapist referred him to Dr. Shankarshana, who performed Fibre Optic Laryngoscopy (FOL) and opined that the patient had posterior subluxation of left Arytenoid and issued the report accordingly. He also informed that there was very little hope of cure because only limited treatment options were available. Thereafter, the patient stated that he immediately approached the Manipal hospital wherein Dr. Malathi advised him to consult Dr. E. V. Raman, the HOD of ENT for the opinion.Dr. E. V. Raman performed laryngoscopy of the patient using Hopkin’s Rod Telescope. The patient alleged that  Dr. Raman admitted verbally that there was a problem with left Arytenoid, but he was hesitant to give it in writing whereas he offered the patient the refund of amount paid for laryngoscopy. The complainant further opted for another opinion from an eminent ENT surgeon, Dr. D. M. Ankelesaria at Mumbai. On 23-10-2004, Dr. Ankelesaria examined him by FOL and confirmed that the patient had anterior subluxation of arytenoid with left vocal cord paralysis

The patient then filed an appeal with the district consumer court alleging medical negligence on the part of the doctors and the hospital. It was alleged that the anaesthesia was administered to the patient using Double lumen tube, Cuffs and Stylet (aluminium), by a trainee anaesthetist, Dr.  Singh , despite knowing that, the Cardio-thoracic anaesthesia using Double lumen tube was to be administered only by an expert anaesthetist i.e. Dr. Nagaraj Gowda, the Head of Department. the patient alleged that the hospital engaged Dr. Prabhu Shankar and a trainee, Dr. Singh to administer anaesthesia. The Double lumen tube was inserted by Dr Singh which caused injury to the patient’s vocal cord. Due to wrong and repeated insertion of the tube, it resulted in irreparable damage to the patient.

The district consumer court, upholding negligence, directed the hospital to pay Rs 5 lakh to the patient. Both parties, the hospital and the patient approached the State Commission challenging the order, but the state commission dismissed the appeals. Hence, both parties (the hospital challenging the decision of negligence and the patient demanding enhancement in compensation)  approached NCDRC.

The commission went through submissions of both the parties in detail. The commission also went through the expert opinions of ENT Surgeons, who opined on the post operation
subluxation of arytenoids.  The observations of the court are summarised as below

The question now is ‘who performed intubation during the induction of anesthesia? It is an admitted fact that Cancer lung Surgery is a specialized surgery. It needs proper and specialized anesthesia at the hands of experienced anesthetist. The intubation by Double lumen tube needs much experience and expertise also. In the instant case, Dr. Nagaraj Gowda, the HOD of Anaesthesia, who was supposed to administer anesthesia to the patient but it was administered by one Dr. S. K. Singh, the anesthetist, who was on deputation to the OP-1/hospital for training in Cardiac anesthesia. In our view, delegation of crucial duty itself was a breach of duty of care. was not a reasonable practice, as the better degree of care and skill was expected from Manipal Hospital.

Thus, in our view, the dislocation of left Arytenoid process was due to forcible and repeated insertion of the Double lumen tube (ETT). Even-though, it was a known complication but it was the result of the failure of duty of care. Even-though, Dr. S. K. Singh was a qualified anesthetist, but he was a trainee anesthetist. It is pertinent that the State Commission categorically observed that the record maintained by OP-1/hospital and evidence of Dr. Nagaraj Gowda itself was contradictory. It was not clear, whether Dr. Nagaraj Gowda was present in the operation theatre or not at the time of administration of anesthesia by Dr. S. K. Singh. We are unable to understand that despite availability of experienced anesthetists like Dr. Prabhu Shankar and Dr. Nagaraj Gowda, how they allowed Dr. S. K. Singh to administer anaesthesia.

Thus, considering the material on record, the medical literature, in our view, the dislocation of left Arytenoid was only due to traumatic cause, which subsequently led to vocal cord paralysis. The Recurrent Laryngeal Nerve (RLN) injury will not cause dislocation of arytenoid. It was the result of faulty insertion of Double lumen tube during administration of anesthesia to the patient.

 

The court upholding the lower commission decision of medical negligence, stated that State Commission has awarded just and proper compensation and refused to enhance the compensation.

Attached is the judgement below