LEKH RAJ vs BHARAJ NURSING HOME

LEKH Raj, complainant claims Rs. 17 lacs as compensation in this case from the opposite party-Bharaj Nursing Home, Jalandhar and Dr. Rachhpal Singh Bharaj, owner and proprietor of the aforesaid Nursing Home. The complainant suffered injuries while going on scooter which hit against parapet of the road on July 11,1995 at 5.30 p.m. He sustained multiple fractures on his left arm and left leg. The accident occurred near Village Pandore Sumlan, on Hoshiarpur-Dasuya Road. A police patrol party took him to the nearest Primary Health Centre in Village Hariana, District Hoshiarpur. The complainant is alleged to have given information to the persons collected about his address. The relatives also reached Primary Health Centre. The complainant was given first-aid and was referred to Civil Hospital, Hoshiarpur. The relatives and the police took the complainant to the Nursing Home of the opposite party at about 8.30 p.m. The complainant was in severe pain and agony, however the opposite party did not properly attend to him. The injuries of the complainant were not got x-rayed. It appeared that the opposite party-doctor did not want to disturb his own night. Some medicines were administered alongwith injections and some weight was put on the leg. The opposite party visited the Nursing Home at about 1 a.m. on July 12, 1995 and the glucose injection needle was reset and he immediately left. It was in the morning that x-ray was got done at about 9.30 a.m. At about 10 a.m. the relatives of the complainant were asked to arrange blood. It was the Radiographer who after examining the x- rays at about 11 a.m. informed the complainant and his relatives about the fractures. It was at 12.30 p.m. that the complainant was referred to C.M.C., Ludhiana vide reference slips Annexures C-l & C-2. At about 4 p.m. on July 12,1995, the complainant reached C.M.C., Ludhiana, by then gangrene had developed with the result the leg of the complainant had to be amputated there. The complainant remained admitted in C.M.C. upto August 18,1995. His left leg and left arm were also operated. He was re-admitted on September 27, 1995 and remained there till October 13,1995. He suffered 90% disability as per certificate Annexures C-3. He also produced bills Annexures C-4 to C-18 and out-door receipts Annexures C-19 to C-20. The deficiency in service attributed to the opposite party is that the complainant was not promptly referred to C.M.C., Ludhiana even after finding vascular injury alongwith two fractures in the arm and the leg referred to above, A big haematoma was also observed in the leg. There was discolour of the skin.

THE opposite party filed their version taking preliminary objections. It was admitted that the complainant was brought to the Nursing Home at about 10.30 p.m. by the police. He was under severe shock. Pulse and blood pressure were not recordable. THE complainant was also smelling of alcohol from his breath. THE complainant had fractures of both the bones of the arm and fracture of left forearm with extensive soft tissue trauma in the left thigh, which was swelling with blue discolouration due to big haematoma. THE limb was flail with deformity and unnatural mobility. In order to recover the patient from shock necessary treatment was given, to save his life. At that critical stage it was wisdom of the doctor to decide to save the limb or the life. On merits negligence attributed to the opposite party was denied. Both the parties led their evidence on affidavits and documents. Expert doctors were produced in the Court and they were allowed to be cross-examined. They are complainant witness No. 1 Dr. Jeewan Parkash, Lecturer, Deptt. of Orthopaedics, C.M.C. & Hospital, Ludhiana, complainant witness No. 2 Lekh Raj complainant himself, affidavits of Vishwanath, Dr. Joginder Pal Singh, Malkiat Singh and Ashok Kumar were produced. Opposite party witness No. 3 Dr. Rachhpal Singh, Orthopaedic Surgeon of the opposite party Nursing Home appeared as his own witness. OPW No. 1, Dr. Joginder Pal Singh, Chhina, Professor and Head, Department of Orthopaedic, Medical College, OPW-2 Dr. Surinder Singh Ajrawat, Head of Orthopaedics Department, Guru Nanak Dev Mission Hospital, Jalandhar City. The bed-head ticket prepared by the opposite party and the medical evidence on admission and treatment given by C.M.C. were produced.

Two questions are for consideration in this case, which are framed as under : 1. Whether there was any negligent act on the part of the opposite party in the matter of diagnosis and treatment given to the complainant ultimately resulting in disability? 2. Compensation, if any, if the complainant is entitled.

QUESTION No. 1: The fact that the complainant suffered fracture on his arm and leg and that a big haematoma was also found at the time the complainant was examined by the opposite party stands admitted and otherwise proved. The aforesaid facts are mentioned in the bed-head ticket Ex. OPW1/A. Fluids were injected alongwith certain medicines administered in order to enable the complainant to recover from shock. The expert (CW-1 Dr. Jeewan Parkash) produced on behalf of the complainant during cross-examination had admitted that the treatment given was also for the shock. He further stated that the patient was in shock when brought to the Nursing Home. His leg was not viable. The general condition was poor. He was stabilized initially with the help of intravenous fluids and blood. This was the position when the patient reached C.M.C. & Hospital, Ludhiana on July 12, 1995. The doctor further stated that in case of vascular injury, the repair can be attempted by the Vascular Surgeon within 6 to 8 hours. Unrepaired vascular injury may lead to formation of gangrene. By gangrene he meant death of the part of the body concerned. He admitted that when the patient was admitted in the C.M.C. & Hospital, the gangrene had already developed. The treatment given by the opposite party was brought to the notice of this witness and to a specific question as to whether treatment given was to treat the vascular injury, he answered in affirmative by stating that the treatment given indicated part of the treatment of the vascular injury that is to control the shock. He further stated that observing clinically the vascular injury, the patient was to be referred for vascular repairing to the specialist He repeated that within 6-8 hours thevascular injury could be treated. He could not specifically say about the delay in referring the patient by the opposite party. His specific answer to a question was that if the reference was made at 3 p.m. on July 12, 1995, there would be delay in making the reference. Even if the patient was referred at about 12 noon, there would be delay. He specifically stated during the cross-examination that when the patient is in shock and the blood pressure and pulse were not recordable, then administration of intravenous fluid and blood was the requirement. At this stage, reference may al so be made to the evidence of two other experts produced by the opposite party. OPW-1 Dr. Joginder Pal Singh referred to the procedure for first examination of the patient in such like cases as under: "First priority is to check his blood pressure and other vital signs, and thereafter examine the patient for fracture after his general condition improves". The treatment for haematoma as stated by him is to locate rupture of the artery first. Rupture of the artery and existence of the haematoma as stated would result in gangrene. The pulse of both the legs was required to be observed and compared. If injury to the artery is not repaired within 4 to 6 hours it may cause gangrene as stated above. After six hours it is very difficult to restore circulation. Vascular injury was required to be repaired alongwith the management of the fracture. Blood transfusion in such like cases is necessary. If gangrene had not developed there was no question of amputation. He admitted that the patient had been administered haemoceocl, which is a substitute of blood, promptly. Blood transfusion was also subsequently required. He was re-examined and he stated that general condition of the patient was to be stabilized before referring to specialist for specialized treatment for vascular injury. He further went on to state that the patient would die if he remained in shock and not on account of vascular injury. He further stated that even at the time of reference the patient was still in shock. OPW-2 Dr. Surinder Singh Ajrawat, after examining the record of Lekh Raj patient replied to the questions as to whether the treatment would be given or he was to be referred. He stated that if general condition of the patient was found to be normal he would have been treated. With respect to the vessel injury causing haematoma and existence of fractures of the bone, he stated that it would have taken two hours for causing gangrene. Within four to six hours injury to the vessel should be mended. If not repaired, it may develop gangrene. He further stated if the patient was not in shock x-ray should be done immediately. If Blood Pressure was low it should be treated first. After going through the bed-head-ticket of Lekh Raj, he stated that the blood transfusion was required. At the time of admission as recorded in the bed-head ticket, blood pressure was unrecordable and the patient could not be referred immediately. Since thereafter blood pressure was found to be recordable and hence the patient could be referred. He further stated that the blood pressure was required to be studied for some time say for an hour or so before referring him to the other hospital. With regard to the treatment immediately given to the patient in such cases he stated to immobolize the limb first and thereafter to treat for blood loss and if services of specialist vascular surgeon were available to avail the same. Normally Orthopaedics Surgeons were not supposed to repair the vascular injury. The present is not a case of apparent negligence, the question of the negligence of the opposite parties. In the matter of giving treatment or delay if any in referring the patient for specialised treatment depends upon the opinion expressed by the experts. Thus, it is in the second category of cases that are required to be considered by this Commission, out of the third categories of cases as referred to in the judgment of the Supreme Court in "Indian Medical Association v. V.P. Shantha & Ors.," III (1995) CPJ 1 (SC)=1995 (2) CPC 602.

AS per evidence of the doctors, experts referred to above, immediately the patient was not required to be referred for specialised treatment in C.M.C. The patient was in great shock and the first attempt of the doctor treating such a patient should be and has been to save the life and not the limb as has been suggested during the arguments. The doctors are supposed to take assistance of the computers and they are not expected to work like computers on a pre- conditioned programme as and when patient with the type of injuries referred to above first approaches them. AS is suggested some time has to be taken to examine the patient clinically before starting any kind of treatment. The evidence of the experts referred to above gives tentative estimation of time within which vascular injuries were required to be repaired. Normally such injuries are expected to be treated within six hours if no complications such like appearance of gangrene resulting in causing damage occur. In the book "Care of the Polytraumatised Patient" by H. Tscheme G. Regel, the principles of the management of multiple trauma are described as under: "The principles of the management of multiple trauma are early and simultaneous assessment and resuscitation, followed by a complete physical examination and diagnostic studies to establish the priorities for life-saving surgery (Trunky 1991)".

We discuss trauma management in each of four different periods : (1) Acute or resuscitation (1 to 3 hours). (2) Primary or stabilisation (1 to 72 hours). (3) Secondary or regeneration (3 to 8 hours). (4) Tertiary or rehabilitation (after the 8th day).

It further refers "Surgical shock is not always adequately represented by haemodynamic parameters such as blood pressure (BP) and heart rate (HR) (Strum et all 1979,1991); maximal rsuscitation is therefore recommended, starting before admission to hospital". At page 844 it is observed as under : "The primary period of treatment starts when all vital functions have been stabilised. Adequate ventilation, haemodynamic stability and control of intracranial or internal haemorrhage should have been achieved".

At page 845 it makes observations as under: "Muscles lose their function after two to four hours of ischaemia; irreversible destruction may develop after four to six hours". In the book "Judgment and Approach for Management of Severe Lower Extremity Injuries" by Robert L. Walton. MD and Douglas M. Rothkopf, MD, on the subject of vascular injuries at page 529, it is observed as under : "Service trauma to the lower extremity is frequently associated with injury to major blood vesels alongwith impending or actual ischemic compromise. The high incidence (60%) of associated multi-system injuries in this setting carries a significant risk for morbidity and mortality and directly reflects the magnitude of injury in these patients. Early attempts to salvage traumatized legs by revasculariztion resulted in a high rate of secondary amputations. Although amputation rates in more recent series remain alarmingly high (20 to 40%), some authors advocate the need for aggressive management even in the face of associated trauma".

At page 532 it is observed as under : "Several authors have attempted to devise a method for predicting the prognosis for lower limb salvage following vascular injury. Lange et al defined absolute indications for lower extremity amputation to be either complete anatomic disruption of the posterior tibial nerveor crush injuries with warm ischemia tiems greater than six hours. Howe et al found a relationship between ultimate limb survival and the internal of warm ischemia, the level of arterial injury, and the quantitative degree of soft tissue and bone injury. By combining these variables, a limb salvage index was devised that identified lower extremities likely to require amputation".

Thus it would appear that after six hours of receipt of the injuries to the vessel untreated would cause damage i.e. gangrene. The injuries were suffered by Lekh Raj at about 5.30 p.m. on July 11, 1995. He was taken to Primary Health Centre of Village Hariana from where he was referred to Civil Hospital, Hoshiarpur (Annexure C-20). The patient reached Bharaj Nursing Home of the opposite party at about 8.30 p.m. on that very day. This would show that about three hours time had already elapsed when the patient was examined by the opposite party. Since the patient was in shock; blood pressure was unrecordable because of the two fractures- on on the arm and other on the leg and there existed a big haematoma on account of injury to the vessel in the leg, treatment to stabilise the patient by administering fluids through intravenous coupled with some medicines was required and given. Support to the leg was also provided. Since the patient was in shock it was not considered necessary to have x-ray immediately. Sometime must have been taken for clinical examination of the patient and for providing aforesaid treatment as expressed by experts referred to above. It was necessary to allow the patient to come out of shock. It is futile to argue as suggested by the Counsel for the complainant that immediately at 8.30 p.m. doctor-the opposite party should have referred the patient to C.M.C. as no treatment for the vessel injuries could be provided by the opposite parties. There is fallacy in this argument. The attempt of every doctor initially would be to bring the patient out of shock and thereafter to decide about the nature of treatment to be given. Journey to Ludhiana from Hoshiarpur even by road would have taken about two hours. By that time obviously the maximum period of six hours as referred to in the books for providing treatment to the vessel injuries would have expired and the damage ultimately caused to the patient of amputation of the leg could not have been attributed, to any act on the part of the opposite parties.

IN the context of negligent act on the part of the opposite parties, it was further argued that even in the morning at the time of referring the patient to C.M.C., Ludhiana the condition of the patient was still under shock. It has been explained that blood pressure at that time was recordable and before that time requisition for blood has already been made, it is also the part of the treatment. The amputation of leg is not on account of negligent act on the part of the doctor but in fact is on account of injuries suffered. The complainant has thus utterly failed to prove negligent act of the opposite parties either in the matter of providing treatment or in the matter of alleged delay in referring the patient to C.M.C., Ludhiana.

IN view of the fact that the complainant had failed to prove negligent act on the part of the opposite parties, it is not considered necessary to decide as to how much amount of compensation the complainant would have been entitled to. For the reasons recorded above, this complaint fails and is dismissed. However, there will be no order as to costs. Complaint dismissed. _____________