MOHAN LAXMAN MAVINAKATTI vs ANIL E.KAGAL

THIS petition is filed against the order passed in Appeal No. 521/1999 decided on 1st January, 2003 by Karnataka State Consumer Disputes Redressal Commission dismissing the appeal of the legal representatives of the deceased (his widow and two sons). The petitioners are the complainants and are aggrieved by the dismissal of the complaint and appeal.

L.B. Mavinakatti, a draftsman was suffering from some weakness and vertigo problem. Later on, he found it uneasy, while climbing a slope. His younger brother, Dr. C.B. Mavinakatti advised him to consult a heart specialist. The deceased was taken to Dr. Shulbha Bhandurge Hospital accompanied by Dr. C.B. Mavinakatti and L.B. Mavinakatti. It is alleged by the complainant that Dr. Anil E. Kagal conducted a B.P. test, ECG test, blood test and urine test which were found to be normal. To find out the real problem the opposite party Dr. Anil Kagal had asked the deceased to undergo a test to strain his chest by "staircase climbing exercise" 20 times on the staircase inside the hospital comprising of about 20 steps. The deceased patient climbed the staircase 5 or 6 times. He got exhausted. The second ECG test was done, around 2.15 p.m. before the patient last breathed. While performing the said exercise L.B. Mavinakatti had severe heart attack and the opponent doctor made effort to save life of the patient but the patient died. According to the complainant/petitioner No. 1 objected the method of opponent''s rude and unscientific method of exercise on the staircase but the opponent/respondent replied that it was a usual method and that he adopted such exercise tests or strain tests. According to the complainant/petitioner the opponent Dr. Anil E. Kagal negligently subjected the patient to excess straining, that to by using the crude and unscientific and unreasonable method of exercising over the staircase and thereby caused death of the father of complainant No. 1. The opposite party No. 1 had no adequate equipment to tackle such emergencies and on account of negligence and deficiency in service, the deceased expired. The complainants/petitioners claimed a sum of Rs. 4 lakh as compensation from the opposite parties for rendering deficiency in service.

The respondents/opposite parties contested the case inter alia on the ground that Dr. Anil E. Kagal conducted physical examination, blood test, urine test and ECG and results thereof were normal. By doing the stress test the opposite party made all the best possible efforts and attempted to know the cause of chest pain of the deceased-L.B. Mavinakatti. When the reports of all the tests were normal Dr. Kagal felt that an exercise test was necessary to determine whether the patient had a heart disease or not? Accordingly, Dr. Kagal asked the patient to walk up and down stairs in his hospital. After seventh trip the patient felt uneasiness and the O.P. 1 who was standing on the foot of the staircase asked the patient to stop further exercise and asked the patient to lie down on the couch. He took the second ECG and soon after the second ECG, the patient had a cardiac arrest which the opponent immediately recognized. Hence, the patient was immediately connected to a cardiac monitor defibrillator which was available in the hospital and the diagnosis of asystole, i.e., cardiac arrest was confirmed. The opponent personally gave cardiac-massage, oxygen, started an intravenous drip and administered injections costing Rs. 3,500 and Rs. 325 from the hospital stock. The opponent was with the patient from the start of exercise test at 1.15 p.m. till his death at 2.45 p.m. To assist him he had two nurses, one Ayah, one ward boy and one lab technician. He was personally monitoring the patient. The State Commission after considering the evidence dismissed the appeal.

THERE could not be any dispute that Dr. Kagal is a qualified allopathic doctor having a M.D. degree and was running an established hospital since many years. THERE could not be any dispute that the deceased was subjected to such an exertion in climbing up and down the stairs. THERE was a definite possibility that the death occurred due to lack of blood supply to the heart while doing the said exercise and the doctor himself admitted that the patient died due to acute Myocardial infraction which means death of muscular tissues of heart due to lack of blood supply. Notwithstanding all good intentions while making a person to undertake a stress test by making him to climb up and down the stairs, it is not possible to accept that it would amount to take all possible care which is required before exercise while monitoring such test. It is also not possible to accept that while climbing down, the deceased was at rest period. However, it may appear to be true that the uncle of the complainant who accompanied the deceased has not been examined and the complainant No. 1, the son of the deceased was not personally aware of the circumstances.

THE District Forum while dismissing the complaint relied upon the opinion of Prof. Leo Schamroth, Professor of Medicines, University of Withwatersrand, Johannesburg, South Africa, World Authority of Cardiology expressing the Electrocardiology of Coronary Artery Disease that "At times pain is atypical, history doubtful and electro cardiogram recorded at rest normal or equivocal under such circumstances, objective confirmation of the diagnosis becomes desirable and the electrocardiographic changes seen in response to exercise may provide this confirmatory evidence."

He also referred to the opinion of Professor Dernard Lipman of Emory University and Edward Massie of Washington University School of Medicines in their test book "Clinical Scalar Electrodardiolography" writes "Cardiologists obviously do not agree that the amount of exercise should be prescribed according to the patients'' age, weight and sec. But believe rather that exercise should approximate the amount of exertion that is known from the patient''s history to bring on symptoms. The actual form of exercise is not important. Stair climbing, knee bending, setting up exercise, and raising dumb bells and hill climbing are some of the forms used and recommended". Thus it is possible to take a view that the stair climbing is one of the forms of exercise which could be observed by Cardiologists. It may also be noted Dr. C.B. Mavinakatti, a qualified doctor and brother of Laxman Mavinakatti, who accompanied the deceased was present but did not object to the method of exercising testing. It may be recorded in terms of Oxford Test Book of Medicine as an extension of the clinical history and examination. This practice is safe, non-invasive, reproducible, simple to perform and in many patients allow a decision to be made regarding the need for coronary Angiography. Since this could be a symptom limited test and as soon as the patient complains of chest discomfort the test is terminated regardless of how many trips he has completed.

THE staircase exercise test could be justified earlier. Could it be justified now as in the year 1996 or in the second part of 90s when in accordance with ''Bolam test'' a doctor is supposed to bring to his task a reasonable degree of skill and knowledge and must exercise a reasonable degree of care than other ordinary member of his profession. He should not lag behind other ordinary assiduous and intelligent members of his profession in the knowledge of new advances, discoveries and development in his field. Whether this ''test'' could be said to be standard of a reasonable average, medical professional in the later part of the 90s is a question which stares at us. It is the specific act of negligence on which the whole case hinges.

IF we see in this light and consider the medical literature produced by the learned Counsel for the complainant, it appears that ''staircase exercise'' test would not be in tune with the requirement of the present day. According to Principles and Practice, Edition 4 of Myrvin H. Ellestad, MD, FACC, University of California, Clinical Professor of Medicine. University of California and Director of Research Memorial Heart Institute, California (Ronald H. Startt Selvester, MD; Fred S. Mishkin, MD, Frederick W. James, M.D. Kasu Mazumi, MD) the following equipment and supplies necessary to test safely: "Although it is generally stated that the Master''s test, which requires only a modest workload, is associated with no significant risk, two of the three patients who died in our laboratory exhibited problems at a workload commensurate with the double Master''s test. Therefore, it is strongly urged that all stress testing be bone in a setting where emergencies can be treated efficiently and expeditiously. Monitoring should be continuous. If, for some reason, interference caused by muscle artifact, lead dislodgment or the battery effect of electrode-skin interface, produces an uninterpretable tracing, the test should be terminated. Blood pressure monitoring should be done before, during, and after the test. The standard cuff method is still preferred, although a number of automated devices are on the market."

"Requirement: 1. Continuous ECG monitoring 2. ECG recording when desired, preferably several simultaneous leads before, during, and after exercise. A minimal recording of muscle potential is essential to an artifact-free recording." 3. Repeated frequent blood pressure measurements before, during, and after exercise. Treadmill Test : The use of a treadmill presents a number of advantages because it is possible to adjust the speed and grade of walking to the agility of the subject."

It may be mentioned that various symptoms noted in chapter 6 - Exercise Stress Testing in Braunwald Zipes Libby''s Heart Disease, 6th Edition, certain precautions could be taken if ECG was recorded during test : "In the absence of symptoms, it is prudent to stop exercise when a patient demonstrates 0.3 in V (3mm) or greater of ischemic ST segment elevation in a noninfarct lead without an abnormal Q wave. Significant worsening of ambient ventricular ectopy during exercise or the unsuspected appearance of ventricular tachycardia is an indication to terminate exercise. A progressive, reproducible decrease is systolic blood pressure of 10 mm Hg or more may indicate transient left ventricular dysfunction or an inappropriate decrease in systemic vascular resistance and is an indication to terminate exercise. The test should be stopped if the arterial blood pressure is 250 to 270/120 to 130 mm Hg or greater. Ataxia may indicate cerebral hypoxia."

SINCE this is not possible in staircase exercise test, the treadmill has to be preferred if Dr. Kagal is an MD and is running an established hospital. He should have known very well that the treadmill test is safter than the staircase test since he was supposed to update his knowledge and he was not supposed to lag behind other ordinary assiduous and intelligent members of his profession in the knowledge of new advances, discoveries and development in his field. He was supposed to prefer treadmill test instead of staircase exercise, though we do not accept him a paragon combining the qualities of polymath and prophet. In terms of judgment in Jacob Mathew v. State of Punjab, III (2005) CPJ 9 (SC)=VI (2005) SLT 1=III (2005) CCR 9 (SC)=(2005) 6 SCC 1 case it is evident that there was deficiency in rendering medical service by not opting to take due care and caution in submitting the deceased to a ''Stress Test'' which would be acceptable to a large body of medical professionals. In testing the status of the heart problem of the deceased led to unfortunate death.

AS regards compensation, the complainant claimed Rs. 4 lakh. Break-up of the claim is given below : Seeing the circumstances that the patient was to retire on 30th November, 1996 and might have survived till 65 years of age, we have to deduct from his earned income, the amount which he might have spent on himself, to assess dependency of his wife and children -Mohan Laxman Mavinakatti and Satish Laxman Mavinakatti. The two sons were of the ages of 26 and 28 at the time of death and it has not come on record that they were unemployed or otherwise. In such circumstances it could be taken that the deceased could have spent merely 40% on himself, 40% on his wife and 20% on his children and grandchidren. Accordingly, we feel that a sum of Rs. 3 lakh with interest @ 9% p.a. from the date of payment is required to be paid to the complainant out of which Rs. 2 lakh should be paid to the widow and Rs. 1 lakh to the two sons of the deceased for the benefit of the grandchildren of the deceased. This amount shall be payable by the two respondents Dr. Anil Kagal and the Insurance Company. Revision Petition is allowed accordingly. Revision Petition allowed.