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Judgment
AGGRIEVED by the order dated 09.08.2003 of the Madhya Pradesh State Consumer Disputes Redressal Commission, Bhopal (hereafter, the State Commission) the original complainant has filed this appeal. It may be noted at the outset that while one of the Members of the State Commission allowed the complaint; it was dismissed by a majority order (of another Member, supported by the President).
THE complaint pertained to alleged medical negligence and deficiency in service in the treatment of Kausar Insaf, the 26-year old daughter of the complainant who had multiple stones in her right kidney and ureter. She consulted Dr. Azam Nawaz (opposite party no. 1 - OP 1) of Asma Nawaz Nursing Home, Bhopal for her problems. OP 1, after getting the necessary investigations done, suggested surgery for removal of the stones. Kausar was admitted to the nursing home (OP 4) of OP 1 (and other OPs) on 16.07.2000, underwent the planned surgery on 17.07.2000 and her renal stones were removed. THE complainant alleged that after the surgery, Kausar developed swelling on her face and other parts of the body and blood started to ooze out from the sutures. At about 11:30 p.m. the same night, there was allegedly excessive bleeding from the site of the surgery which Kausars mother, attending on Kausar, immediately brought to the notice of the nurse on duty. However, allegedly, the nurse neither reported this bleeding to OP 1nor did she allow Kausars mother to contact OP 1 on telephone; in fact, allegedly the nurse did not even allow Kausars mother access to the telephone. It was further alleged that though OP 1 instructed the nurse on 18.07.2000 to transfuse the same blood that had been arranged prior to the surgery, no tests were performed before the transfusion. As the blood from the sutures continued to ooze out even on 19.07.2000, OP 1 discussed the matter with the other three OPs and decided to conduct another surgery. However, after the second surgery on 19.07.2000 at about 5 p.m., OP 1 informed the complainant that his daughter was in a serious condition and had to be shifted to another hospital with better facilities. She was accordingly shifted to Vardaan Hospital, Bhopal. After examining the patient on admission to Vardaan Hospital, the Doctors there allegedly informed the complainant that she had a very poor chance of survival. Kausar ultimately died at Vardaan Hospital on 28.07.2000. THE complainant, alleging that his daughter died due to acts of negligence on the part of the opposite parties, filed a complaint before the State Commission and claimed a compensation of Rs.19,30,722.25. THE OP doctors submitted their written version before the State Commission denying all the allegations in the complaint and also filed their affidavits as well as various documents relating to the treatment of Kausar at the nursing home. As noted above, by its majority order the State Commission dismissed the complaint after considering the pleadings, evidence and material brought on record. We have heard Mr. Umesh Nigam, learned counsel for the appellant/complainant and Mr. Deepesh Joshi, learned counsel for the respondents/opposite parties and perused the records. At the time of hearing, both the appellant and OP 1 were also present. 4(i) It needs to be observed at the outset that neither in the memorandum of appeal nor in the submissions of the learned counsel for the appellant before us was there any sensible attempt to show how the findings of the State Commission, based on detailed appreciation of the entire medical record of the patient (made available by the OPs) and relevant medical literature as it is, could be faulted. It is also noted in the order of the State Commission that the complainant made no attempt to produce any medical literature, leave alone expert medical opinion, to show how and when, in the course of treatment of Kausar, any of the OPs committed acts of omission or commission which could amount to medical negligence. (ii) It is indeed unfortunate that the complainants 26-year old daughter, who went in for a surgery to remove renal and ureteral calculi, expired within a short period thereafter. The cause of the death, recorded in the death certificate issued by Vardaan Hospital, was Cardio-respiratory arrest and the diagnosis was, Operated case of rt. renal stone; post-transfusion (delayed) DIC; multiple organ failure. (iii) It will be necessary to first read the relevant medical literature before proceeding with further discussion on the contentions of the parties in this appeal.
Simplified Medical Literature on Disseminated Intravascular Coagulation (DIC) 5(i) It was thus DIC or disseminated intravascular coagulation which was the principal condition leading to the multiple organ failure and resultant cardio-respiratory arrest of Kausar. (ii) The authoritative website of the USAs National Heart Lung and Blood Institute has the following information on DIC [http://www.nhlbi.nih.gov/health/dci/Diseases/dic/dic_what.html]: What Is Disseminated Intravascular Coagulation?
Disseminated intravascular coagulation, or DIC, is a condition in which blood clots form throughout the body''s small blood vessels. These blood clots can reduce or block blood flow through the blood vessels, which can damage the body''s organs.
In DIC, the increased clotting uses up platelets and clotting factors in the blood. Platelets are blood cell fragments that stick together to seal small cuts and breaks on blood vessel walls and stop bleeding. Clotting factors are proteins needed for normal blood clotting. With fewer platelets and clotting factors in the blood, serious bleeding can occur. DIC can cause internal bleeding and external bleeding. Internal bleeding occurs inside the body. External bleeding occurs underneath or from the skin or mucosa (the tissue that lines some organs and body cavities, such as your nose and mouth).
THE bleeding that DIC causes may be life threatening. What Causes Disseminated Intravascular Coagulation? Some diseases and conditions can disrupt your body''s normal blood clotting process and lead to disseminated intravascular coagulation (DIC). THEse diseases and conditions include: Sepsis (an infection of the bloodstream) Surgery and trauma Cancer Serious complications of pregnancy and childbirth Examples of less common causes of DIC are bites from poisonous snakes (such as rattlesnakes and other vipers), frostbite, and burns. THEre are two types of DIC: acute and chronic. Acute DIC begins with clotting in the small blood vessels and quickly advances to serious bleeding. Chronic DIC causes blood clotting but usually doesn''t lead to bleeding. Cancer is the most common cause of chronic DIC. Similar Clotting Conditions Two other conditions cause blood clotting in the small blood vessels; however, their causes and treatments are different from the causes of and treatments for DIC. THEse conditions are thrombotic thrombocytopenic purpura or TTP, and hemolytic-uremic syndrome (HUS). HUS is more common in children than adults and more likely to cause kidney damage than TTP. What Are the Signs and Symptoms of Disseminated Intravascular Coagulation? Signs and symptoms of disseminated intravascular coagulation (DIC) depend on its underlying cause and whether the DIC is acute or chronic. Acute DIC develops quickly (over hours or days) and is very serious. Chronic DIC develops more slowly (over weeks or months). It lasts longer and usually isn''t recognized as quickly as acute DIC. With acute DIC, blood clotting in the blood vessels usually occurs first and then bleeding. However, bleeding may be the first obvious sign. Serious bleeding can occur very quickly after developing acute DIC. Thus, emergency treatment in a hospital is needed. With chronic DIC, blood clots are more likely to occur than bleeding. Sometimes, chronic DIC has no signs or symptoms. Signs and Symptoms of Excessive Blood Clotting In DIC, blood clots form throughout the body''s small blood vessels. These blood clots can reduce or block blood flow through the blood vessels and cause the following signs and symptoms: Chest pain and shortness of breath due to blood clots forming in the blood vessels in your lungs and heart. Pain, redness, warmth, and swelling in the lower leg due to blood clots forming in the deep veins of your leg.
HEADACHES, speech changes, paralysis (an inability to move), dizziness, and trouble speaking and understanding due to blood clots forming in the blood vessels in your brain. These signs and symptoms may suggest a stroke. Heart attack and lung and kidney problems due to blood clots lodging in your heart, lungs, or kidneys. These organs may even begin to fail. Signs and Symptoms of Bleeding In DIC, the increased clotting activity uses up the platelets and clotting factors in the blood. As a result, serious bleeding can occur. DIC can cause internal bleeding and external bleeding. Internal Bleeding Internal bleeding can occur in your body''s organs, such as the kidneys, intestines, and brain. This bleeding can be life threatening. Signs and symptoms of internal bleeding include: Blood in your urine from bleeding in your kidneys or bladder. Blood in your stools from bleeding in your intestines or stomach. Blood in your stools can appear red or as a dark, tarry color. (Taking iron supplements also can cause dark, tarry stools.) Headaches, double vision, seizures, and other symptoms from bleeding in your brain. External Bleeding In DIC, external bleeding can occur underneath or from the skin, such as at the site of cuts or an intravenous (IV) needle. External bleeding also can occur from the mucosa (the tissue that lines some organs and body cavities, such as your nose and mouth). External bleeding may cause purpura or petechiae. Purpura are purple, brown, and red bruises. This bruising may happen easily and often. Petechiae are small red or purple dots on your skin. Other signs of external bleeding include: Prolonged bleeding, even from minor cuts. Bleeding or oozing from your gums or nose, especially nosebleeds or bleeding from brushing your teeth. Heavy or extended menstrual bleeding in women. How Is Disseminated Intravascular Coagulation Treated? Treatment for disseminated intravascular coagulation (DIC) depends on its severity and underlying cause. The main goals of treating DIC are to control bleeding and clotting problems and treat the underlying cause. Acute Disseminated Intravascular Coagulation People who have acute DIC may have severe bleeding that requires emergency treatment in a hospital. Treatments may include blood transfusions, medicines, and oxygen therapy. (Oxygen is given through nasal prongs, a mask, or a breathing tube inserted through your mouth or nose and into your windpipe.)
A blood transfusion is a safe, common procedure. You receive blood through an intravenous (IV) line in one of your blood vessels. Blood transfusions are done to replace blood loss due to an injury, surgery, or illness. Blood is made up of various parts, including red blood cells, white blood cells, platelets, and plasma. Blood is transfused either as whole blood (with all its parts) or, more often, as individual parts.
IF you have DIC, you may be given platelets and clotting factors, red blood cells, and plasma (the liquid part of blood). Chronic Disseminated Intravascular Coagulation People who have chronic DIC are more likely to have blood clotting problems than bleeding. IF you have chronic DIC, your doctor may treat you with medicines called anticoagulants. These medicines, which also are called blood thinners, help prevent blood clots from forming. They also keep existing blood clots from getting larger. [Note: 1. Emphasis supplied throughout. 2. We have excerpted the foregoing medical literature for its simplicity of description, instead of the medical textbook excerpts furnished by the OPs because the latter are naturally heavy with medical terms that are not easily understood. More important, for our purposes in this appeal, the details in the cited medical textbooks are no more elucidating and authoritative than the foregoing popular information given in the website of this, one of the most advanced, institutes in the world in the relevant medical discipline.] (iii) Therefore, to summarise: DIC is a condition in which the human bodys normal blood coagulation mechanism gets affected, leading to formation of number of small blood clots throughout the bodys smaller blood vessels which then reduces or chokes off the flow of blood in the blood vessels, causing damage to bodys vital organs. DIC can be caused by a variety of pathophysiological factors, like some diseases, surgery, traumatic injury like burns, certain serious gynaecological and childbirth related complications, snake bite, etc. (One of the medical textbooks, viz., Wintrobes CLINICAL HEMATOLOGY, Ninth Edition, Volume 2, Part V, Table 69.4 produced by the OPs also cites intravascular haemolysis (transfusion of incompatible blood) as a cause of DIC). DIC can be acute or chronic. Acute DIC, which develops quickly over hours or days, involves excessive blood clotting in the small blood vessels and develops rapidly into serious bleeding. Chronic DIC, on the other hand, which is caused most commonly by diseases (cancer, in particular), develops over weeks/months and though also involving excessive clotting, it does not usually lead to bleeding. DIC can cause internal bleeding and external bleeding. Internal bleeding can occur in organs like the kidneys, intestines, and brain. This bleeding can be life threatening. Signs and symptoms of internal bleeding include: Blood in urine from bleeding in kidneys or bladder; blood in stools from bleeding in the intestines or stomach; and headaches, double vision, seizures, and other symptoms from bleeding in the brain. In DIC, external bleeding can occur underneath or from the skin, such as at the site of cuts or an intravenous (IV) needle. External bleeding also can occur from the mucosa (the tissue that lines some organs and body cavities, such as the nose and mouth). External bleeding may cause purpura or petechiae. Purpura are purple, brown, and red bruises. This bruising may happen easily and often. Petechiae are small red or purple dots on the skin. Other signs of external bleeding include prolonged bleeding even from minor cuts; bleeding or oozing from the gums or nose, especially nosebleeds or bleeding from brushing teeth; and heavy or extended menstrual bleeding in women. Treatment for DIC involves treating the clotting and bleeding problems and the underlying cause of the condition.
People who have acute DIC may need blood transfusions, medicines, and other life-saving measures. People who have chronic DIC may need medicines to help prevent blood clots from forming in their small blood vessels. Discussion (i) First, from the facts on record and the medical literature discussed above, it is clear that Kausars was a case of acute DIC she had none of the physical symptoms nor any of the pre-disposing factors to warrant a suspicion of chronic DIC.
(ii) The main allegations in the complaint (and corresponding grounds in the memorandum of appeal) which could be construed to suggest, albeit vaguely/indirectly, medically valid causative factors for the development of DIC in Kausar were that (a) she had excessive bleeding at about 11.30 pm of 17.07.2000 which was not attended to despite attempts by Kausars mother to inform the OP doctors implying that as a result of her surgery Kausar developed DIC the same night and (b) none of the OP Doctors was present during the first transfusion of blood to Kausar on 18.07.2000 implying that she developed DIC as a result of transfusion of incompatible blood on 18.07.2000.
(iii) In other words, the questions that need to be examined are (a) did Kausar display symptoms of onset of acute DIC very late in the night on 17.07.2000 following the surgery, or (b) whether her DIC was the result of incompatible blood transfusion on 18.07.2000 (because the transfusion was allegedly not supervised by any of the OP doctors) or was the surgery that she underwent alone the cause of her DIC? If (a) was the case, the next question would be was there undue delay on the part of the OP doctors in diagnosing Kausars condition and also in treating her for DIC? This latter question would not be as relevant if the case was that Kausar developed DIC because of incompatible blood transfusion on 18.07.2000, for the blood transfusion got over at about 5 pm on that day and, according to the medical record, Kausar displayed signs of DIC in the morning of 19.07.2000 and the diagnosis was confirmed in the early afternoon of 19.07.2000, i.e., within 24 hours.
(iv) (a) The allegation of excessive bleeding late in the night of 17.07.2000 was according to Kausars mother who attended on her while Kausar was at the Nursing Home of the OPs. However, Kausars mother did not file any affidavit in support of this crucial allegation. (b) Secondly, careful perusal of the post operative medical record of Kausar for 17.07.2000 (entirely in the handwriting of OP 1) shows that till 10 pm on that date, Kausars general condition was fair; she had no fever; her pulse was almost normal by 6 pm; there was no soakage (of blood) in the dressing at the surgical wound till 10 pm and neither the drained fluid from the site of the surgery nor the urine showed any signs of excessive bleeding. (c) If Kausar did have excessive bleeding from the site of the surgery (or, from the bladder or the surgical drain) at about 11.30 pm on 17.07.2000 as alleged, it stands to reason that there would also be unmistakable signs of such bleeding on the next morning, i.e., 18.07.2000. However, the medical record of 18.07.2000 (once again in the handwriting of OP 1) shows that when OP 1 examined her at 9 am, he found her blood pressure to be low (110/60) and he advised a haemoglobin test and also transfusion of one unit of blood at 12 noon (according to the pathological report of 6 pm of the same date, Kausars haemoglobin level had dropped to 9.2 gm as against 10 gm prior to the surgery). The observations recorded by OP 1, however, do not show any symptoms of excessive internal bleeding (the latter evident from the recorded observation of mild hematuria and watery red colour of the surgical drain output). Notably, there was no mention of any soakage or otherwise of the dressing around the surgical wound, in an otherwise detailed record of physical examination by OP 1. The record also shows that though Kausars blood pressure improved to 120/80 mm just before the start of blood transfusion at 12 noon on 18.07.2000, it ranged less - between as low as 96/70 mm and 120/70 mm during the transfusion. Even at 10 pm that night, her BP was only 100/70 mm though her general condition was described as fair, she was afebrile and her pulse rate was 84/min. Again, there was no recorded observation about the extent of bleeding in the urine or the drain output or soakage of the dressing at this time.
(v) The medical literature relied upon by the OPs and considered by the State Commission shows that the possible causes of DIC include transfusion of mismatched/incompatible blood. However, from the documents of the Blood Bank produced on record, there is no room to hold that there was any transfusion of mismatched blood to Kausar. These documents show that the blood group and type of Kausar had been ascertained as A Rh+, prior to the surgery at pathological clinic and the blood which was transfused on 18.07.2000 as well as on 19.07.2000 belonged to the same group and Rh type and was issued after due testing by an authorised blood bank, namely, Bhopal Blood Bank.
(vi) We may, however, notice some unusual features of the medical record of this case, produced by the OPs. The entire record discussed above is in the handwriting of OP 1 alone (except two pages of input-output and pulse/temperature charts). Secondly, at the commencement of the blood transfusion, OP 1 specifically wrote: Watch for rigor, Ghabrahat, pain in loin, chest pain, Haematuria Pulse & BP every half hourly during Blood transfusion A plain reading would show that the above-mentioned were meant to be instructions to the paramedical staff that would normally administer the blood transfusion. And yet, the record of the actual blood transfusion is once again in the handwriting of OP 1. In fact, the entire medical record written out by OP 1 appears to be too perfect to be true. This has to be also viewed against the allegations that no doctor was present at the time of the first blood transfusion and that the OPs refused to hand over a set of copies of the medical record when the complainant asked for it soon after Kausars death. When we specifically questioned OP 1 about these aspects in the course of hearing of the appeal, OP 1 stated that at the relevant time he conducted, on an average, 2 surgeries per day and also recorded his observations himself.
(vii) How and why Kausar developed DIC after her renal and ureter calculi surgery cannot thus be ascertained with any degree of accuracy at this stage, particularly because none of the triggering factors, except the surgery per se listed in the medical literature on record appears to be applicable to her case. However, that, according to the settled legal position on the subject, cannot be held as an instance of medical negligence by the OPs. There is no evidence that the surgery was not carried out properly or, that there was any signs of excessive external or internal bleeding during 17-18.07.2000 or, that incompatible blood was transfused to Kausar on 18.07.2000 or, that there was any undue delay in attending to Kausars drop of blood pressure and excessive bleeding observed on 19.07.2000. When the unexplained general (and uncontrollable) bleeding was noticed during the second/exploratory surgery on 19.07.2000, the records show that steps were taken to ascertain the cause by ordering immediate blood tests and obtaining the result on telephone. Confirmation was also sought from the Bhopal Blood Bank about compatibility of the blood transfused to Kausar and it was reported by the latter the same day that the blood transfused was indeed compatible. When the suspicion of DIC was confirmed by an unduly high level of FPD (fibrin degradation products) arrangement was made without delay to transfer the patient to a nearby hospital with ventilator facilities to handle the complication. In fact, these acts on the part of the OPs reflect due care, not negligence. Finally, the appellant did not produce the medical record of admission to and treatment at the referral hospital (Vardaan Hospital) from which some additional relevant information could have been gathered. Our discomfort with the picture-perfect medical record (as discussed above) notwithstanding, we would be loath in such a situation to conclude that the appellant was able to make out a prima facie case in support of any limb of his allegations of medical negligence against the OPs.
AS a result, despite our profound sympathies with the bereaved appellant, the appeal is dismissed, leaving the parties to bear their own costs.