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Improper Management of Pressure Support Ventilation: Fortis Hospital told to pay Rs 55 lakh


Improper Management of Pressure Support Ventilation: Fortis Hospital told to pay Rs 55 lakh

Ludhiana: In a case of alleged medical negligence, the Punjab State Consumer Disputes Redressal Commission has directed Fortis hospital, Ludhiana to pay a compensation of Rs 55 lakh to the deceased patient’s family. The hospital was held vicariously liable for negligence on behalf of doctors and staff in management of the Pressure Support Ventilation.

The case relates to the patient, Rita Jain, who was admitted to the hospital on 20.5.2016 for the surgery of ‘Right Cerebellar Cystic Mass’ in her brain, – a Hemangioblastoma.

The surgery, was performed the next day under the care of Dr Vishnu Gupta, Senior Consultant, Dr Ravneet Kaur, Medical Officer and other Doctors and paramedical staff of the hospital.

Post surgery the patient remained in the MICU till 10.30 P.M. on 22.5.2016 when immediately it was noticed that the patient was having bleeding around the area of surgery. A repeat surgery was performed as urgent surgery. The patients family alleged that after this surgery, the patient was showing good signs of recovery even started manifesting bodily gestures through her eyes and limbs. Thereafter the patient was put on Artificial/Mechanical Ventilation by way of Oral Tracheal Intubation

Later, the patient was shifted from the mechanical ventilation to Pressure Support Ventilation (PSV). In pursuance of the same, Tracheostomy was done to enable PSV for the patient.

 Before the court, patient’s family alleged that prior to the shifting of the patient to PSV, the patient was showing signs of good recovery in every respect and was moving all limbs along with eye contact and was even obeying commands. It is further averred that artificial respiration in the form of mechanical ventilation is in itself a specialized branch of medical science requiring thorough expertise and knowledge in the said subject. Any hospital especially the one undertaking surgeries requiring post surgery recovery are expected to be fully equipped and having well trained staff and doctors to deal with artificial/mechanical respiration.

Alleging that subsequent to the shifting of the patient to PSV, the staff of the hospital was not even possessing the basic expertise to handle PSV mechanism, hence leading to death, the family moved the state consumer forum. It was further alleged that abnormally excessive air/oxygen was inserted into the patient, which resulted in serious injury to the lungs of the patient causing a fatal cardiac arrest.

The death summary stated cause of cardiac arrest was pneumothorax i.e. an injury which resulted from the excessive oxygen in the lungs. It was the gross medical negligence of the doctors and the staff present at MICU, who did not even maintain the correct pressure of PSV, they contended.

Supporting the claims, they relied on report by Dr R K Sharma, who after examining the entire record, had given a report that due to improper supply of oxygen by PSV method lungs of the patient had collapsed, which was dangerous to life and resultant death of the patient has occurred.

Rebutting the said allegations, the hospital contended that throughout the period of mechanical ventilation, lung protective ventilation strategy was followed. On the issue that the hospital staff didn’t have the expertise, the hospital stated that the staff is fully qualified to handle the PSV system and record of the patient was maintained regularly.

The counsel for the hospital averred that the patients in MICU are managed by the team that includes the Primary Consultant and Team of Intensive Care Physicians, who have more than 15 years of experience in the field of critical care.

Hearing all the contentions made by both the parties, the bench presided by honourable Justice Paramjeet Singh Dhaliwal and comprising Kiran Sibal as a member, noted the incompetence of the staff in handling the PSV, the bench asserted,

“PSV many a times results into severe type of pneumothorax in people, who need mechanical assistance to breathe. It can create imbalance of air pressure within the chest. Resultantly lung collapses completely, sometimes in parts as well… There is failure on the part of doctors and other supporting staff to adhere to the ordinary level of skill and diligence possessed and exercised at the same time by them. It is true that medical professionals are not expected to be of highest possible degree of professional skills, but they are bound to employ reasonable skill and care…

The conduct of the Doctors and the other para-medical staff of opposite party No.1-hospital clearly shows that appropriate degree of professional skill, which may be the indicative of reasonable skill and degree, was not applied in this case and this is not expected from a reputed hospital, like opposite party No.1. It certainly fell below the standard of a reasonably competent staff in the concerned field in the said hospital. The principle of res-ipsa-loquitur (things speak itself) is sufficient to describe the proof of the fact, which is sufficient  to support an inference that opposite parties were negligent”

The bench then noted that the family was able to prove on record that the surgeries were successful and everything was going well but only after putting the patient on PSV, which was not properly managed, which resulted into imbalance of pressure of air/oxygen and which collapsed the lungs of the patient and ultimate death of the patient.

“It certainly amounts to medical negligence and deficiency in service in giving post-surgery treatment to the patient,” the bench affirmed.

However, the bench noted that there was no medical negligence or deficiency in service on the part of doctors who performed the surgeries upon the patient, the post-surgery care was not given properly by the doctors and other staff of the hospital. Therefore, holding the other doctors and paramedical staff of the hospital, who was handling the PSV of the patient post-surgery, negligent, the court ordered the hospital to pay Rs 55 lakh to the patient’s family. The bench stated,

“Hospital is vicariously liable for the medical negligence and deficiency in service on the part of all its Doctors, Nurses, Para-Medical Staff etc. It is, therefore, held that only opposite party No.1-Hospital is liable for the death of the patient.”




Source: self
18 comment(s) on Improper Management of Pressure Support Ventilation: Fortis Hospital told to pay Rs 55 lakh

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  1. While doing tracheostomy also patient may have pneumothorax

  2. Opinion of Dr r k sharma who is forensic medicine expert should not be considered appropriate as it requires immense technical knoweledge to comment in this case and only person having atleast 12yrs of ICU experience with pg qualification in medicine pulmonary medicine or anaesthesia or people having critical care qualification should be considered as expert witness. Otherwise wrong judgement will happen

  3. user
    Dr Dibanath Chakrabarty August 28, 2018, 5:47 pm

    It does not need much to identify a pneumothorax and correct the same, failing which liability comes on the ICU, irrespective of the years of experience. It\’s not possible protect the position of the ICU where pneumothorax claiming life goes undetected.

  4. The judgement given by these morons will be easily overturned in higher courts. Neither the hospital nor the staff – medical and prarmedical – can be held guilty of known complications of a procedure. The way judgement is given, one wonders whether universal influencing factor of percentage is at work here also.

  5. THe court has observed correctly that a complication has occurred . Pneumothorax is a well known complication of mechanical ventillation and that itself does not constitute negligence. No evidence has been shown to prove that ventillation pressures were high or that there was a delay in diagnosis of pneumothorax and its management . Either the judge relied exclusively on the expert witness opinion which as quoted does not seem sound at all, if not of, malicious intent, or the judge is too biased and thinks every medical complication needs to be penalised . May be it would be safer in all ventillated patients to maintain charts to demonstrate regular ventillation pressures and tidal volumes achieved. Was the consent for ventillation clear about these complications of ventillation ? These are the points we should take home from this unsound and unsubstantiated judgement. If we have good lawyer trained in fighting medical litigation, it should be possible to reverse this judgement in a higher court of law

  6. My comments
    1. Poorly written article with incomplete details
    2. Patient had first surgery-bleeding- reoperated. What is the time frame ?
    3. Was she ventilated all this time?
    4. Required tracheostomy, makes me think ventilation was prolonged? Why respiratory or neurological causes?
    5. Terms “ mechanical ventilation “ and PSV are used very loosely describing these as two different things. PSV is a type of mechanical ventilation only. Term is used for PEEP-Peessure support, spontaneous mode of ventilation.
    6. Incidence of iatrogenic pneumothorax in ICU is as low as 2-3% from all causes, so it’s not so common.
    7. PSV (if the term used in its standard meaning) cannot guarantee “lung protective ventilation” as two major mechanisms of lung injury namely volutrauma and barotrauma can potentially happen ( as in this mode neither volume nor pressure is controlled)