Patient Dies After Knee Replacement Surgery Due to Pulmonary Aspiration: Consumer Forum Directs Apollo Hospital to pay Rs 5 Lakh

Observing that the patient, who had a history of hypertension, Bronchial Asthma, and had Hiatus Hernia and Diverticulosis, had died due to pulmonary aspiration, the Commission observed, "The opposite parties should have taken the care to reduce the risk of pulmonary aspiration. The vomitus produced by the patient should have been drained out instead of going back down her pharynx. "

Thus holding the hospital vicariously liable for medical negligence, the State Consumer Court noted, "The care was given entirely by the hospital staff comprising mainly of the nursing staff & duty doctor. They should have monitored the patient closely and especially after she vomited immediate response was totally lacking. Prompt care and attention was certainly lacking and the sequence of events is clearly indicative of negligence. "

The case goes back to 2011 when the complainant's wife, 56 years of age, was advised to undergo 'total knee replacement surgery' as she was having pain in the right knee. After the operation at the treating hospital, she was shifted from the ICU.

Also Read: Patient Dies from Post-Operative Complications of CABG: Consumer Court Directs Apollo Hospital to Pay Rs 5 lakh Compensation

It had been alleged by the complainant that the patient, who was a known case of Asthma, Hypertension, and Hiatus Hernia was not kept in the ICU and was not monitored. As a result, the patient started having oral secretions and though the Doctor tried to resuscitate, the patient ultimately died within 20 hours of the surgery.

They pointed out that after the patient was given solid food, she vomited and at that time, only the duty doctor attended the patient and didn't call a specialist, which proved to be fatal.

Claiming that the patient was not given due care and attention, the complainant sought relief for gross negligence.

On the other hand, the treating doctors and the hospital submitted before the State Commission that the patient was diagnosed to be suffering from Bilateral Osteoarthritis of both knees and was a known case of hypertension, Bronchial Asthma, and had Hiatus Hernia and Diverticulosis.

After a thorough pre-operative evaluation, she underwent TKR of right knee with Styker Scorpio Knee Implants under spinal anesthesia. They further submitted that after the patient became unconscious and unresponsive, she was immediately taken to IPICU where she intubated and mechanical ventilation was initiated. However, despite all efforts, the patient expired.

They further claimed that the allegation that death was caused because of food particles entering into the lungs is false and the expert opinion obtained by the complainants are baseless.

In order to prove their case, the complainants submitted evidence affidavit of a doctor and a former professor of AIIMS, New Delhi.

Apart from these, the commission also perused the Medical Emergency Team- Criteria And Assessment/ Action Sheet maintained by the hospital and observed, "The onset of hypoxia was sudden and no proper explanation has been 9. provided for this by the opposite parties. Till almost 4 a.m. on 9.3.2011, her SPO2 level was not falling but in the last hour the reading was extremely alarming and this has not been reasoned out by the opposite parties."

In this context, the Commission also took note of the medico-legal opinion given by the Professor of AIIMS, who opined, "Patient had history of long standing bronchial asthma, such patients need extra care post-operatively as their cough reflexes are not as strong as compared to non-bronchial asthma patients and such patients are liable for aspirations."

The professor further opined that the patient was not examined for full 8 hours fully by a doctor and noted, "I find that it is a gross negligence in taking post-operative care which resulted in aspiration of food in lungs resulting in death. I find doctors and hospital grossly negligent in providing care to the patient."

The Commission noted that similar opinion has been expressed by a medico legal foundation as well. The foundation has opined that after operation, the patient had to be monitored for 48 hours carefully. Even though it has been done by the nurses, it was necessary for a doctor to monitor the patient who had a long history of Bronchial Asthma and who had vomited after surgery.

However, the hospital and the doctors contested to these contentions claiming that Vomiting in the post operative period is not uncommon and subsequent to Vomiting a doctor revisited the patient, examined her and found the condition of the patient quite stable.

The Commission further noted that even though the post mortem report is mentioned as "acute cardio-respiratory failure in a patient suffering with the Hypertensive Heart Disease", the opinion is only suggestive and cannot be treated as conclusive when correlated with Case Sheet findings and medical opinion by the Professor.

Further referring to the Discharge Summary provided by the hospital, the Commission noted, "Only at 4.45 am. on 9.3.2011 the Duty Nurse found the patient was having oral secretions, was very drowsy and informed the Duty Doctor opp.party no.4. The medical emergency team was called and the doctor found there was some stridor and saturation was 90%. This is stated by the opposite parties in their Written Version. The fact that there was stridor was not noticed earlier by the nurses constantly checking on the patient every hour. Stridor is a harsh vibrating noise when breathing, caused by obstruction of The fact that the patient was exhibiting these the wind pipe or larynx. symptoms of respiratory distress, the opposite parties gravely neglected to attend on her earlier as stridor is often a medical emergency and securing the airway may be necessary."

"There are several things to be considered if the patient has asthma. An increased risk of surgical complications may arise because of asthma. To reduce the complications an assessment of asthma control and lung function is a must- for the pre-operative evaluation. Surgical anesthesia will need to be planned with the asthma condition in mind. After surgery, the patient with an asthmatic condition will need close monitoring as well as post operative strategies to reduce her chances of developing respiratory issues," added the Commission.

Noting that aspiration happens when something enters the airways or lungs by accident, the State Consumer Court of Telangana further noted,

"The opposite parties should have taken the care to reduce the risk of pulmonary aspiration. The vomitus produced by the patient should have been drained out instead of going back down her pharynx."

"Was immediate care provided to the patient when she vomited at 9 p.m.? Repeatedly the same question surfaces and thorough perusal of the records submitted by the complainant and the hospital reveal that the patient was not closely monitored. Immediate management should have been provided by the surgeon and the anesthesia team. Anesthesia places patients at risk for aspiration. This risk results from the effects of medication, level of consciousness and loss of protective reflexes," further opined the Commission.

Observing that more careful monitoring of the patient was necessary, the Consumer Court noted,

"It is critically important for surgeons and anesthesiologists to have an algorithm for minimizing aspiration events in patients. Was the head -down tilt position followed for the patient? Was her airway secured as rapidly as possible to prevent further soilage and to facilitate airway clearance- was it used on the patient? In cases of severe aspiration - cardio pulmonary arrest can occur. The opposite parties should have been aware of the risk factors, predisposing conditions, and immediate management options."

Thus, holding the hospital vicariously liable for the treatment given to the patient by their empanelled doctors and employees, the Commission noted,

"The care was given entirely by the hospital staff comprising mainly of the nursing staff & duty doctor. They should have monitored the patient closely and especially after she vomited immediate response was totally lacking. Prompt care and attention was certainly lacking and the sequence of events is clearly indicative of negligence."

Partly allowing the complaint, the Telangana State Consumer Disputes Redressal Commission directed the Apollo Hospital to pay Rs 5 lakhs to the Complainant as compensation along with Rs 25,000 as costs within a period of 8 weeks.

To read the case order, click on the link below.