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Post Script: Is the impossible target system imposed by corporate hospitals landing doctors to face increasing number of medico-legal cases in Hyderabad? It was the first thought that came to mind when i was analyzing this case. Time for an introspection, doctors. The second thought was why mainstream media missed this story.
This case has potential to be used as a case study for M.S Ortho medicos if they are interested in knowing the pitfalls and do's and don'ts of performing a Bilateral Total Knee Replacement (TKR) on a 67-year-old patient.
It is true that a surgeon ought to get benefit of doubt when he performs a procedure in good faith and best of his/her abilities in every case but what Dr Sanjib Kumar Nehera, consultant Orthopaedic Surgeon, Yashoda hospital did in Janakamma's case in March, 2011 could not convince two member judges of Telangana state consumer forum.
Though the surgeon was experienced and conducted many surgeries since past more than 20 years with an MS Ortho followed by qualification of physical Medicine and Rehabilitation, the surgeon Dr Sanjib Kumar Behera was caught on the wrong foot by judges -- Nalla BN Rao and Patil Vithal Rao.
In fact, the surgeon was exposed with just two-three questions during his cross-examination when the case came up.
Q. Can you tell us what are the symptoms of Deep vein thrombosis (DVT) and when does it occur?
Ans. I have to refer book
Q. I put it to you, you have no proper understanding and proper knowledge about DVT?
Ans: It is not true. It's true we have not given an anticoagulants to the patient post- operatively when he was asked
In his cross examination, he further admitted that he did not record "the past ailment history of the patient. It is true I have not mentioned the basic things such as weight, blood pressure, etc."
He further admitted, "Yes, as a surgeon it is incumbent on me to mention as to what are the ailments suffered by the patient in the past, treatment underwent in the past, surgery if any undergone by the patient."
He further admitted, "Yes, as a surgeon it is incumbent on me to mention as to what are the ailments suffered by the patient in the past, treatment underwent in the past, surgery if any undergone by the patient."
A case of negligence or little knowledge?
Well, this particular case found fault with the operating surgeon Dr Sanjib Kumar Behera on both counts. The second part becomes clear when he could not answer the symptoms of DVT while in the first part too, he failed to pass with flying colours.
This can be seen with the observations made by the Telangana state consumer forum judges in their detailed judgment delivered as recently as June, 2017. Excerpts
1. The operating surgeon did not conduct any pre-operative tests and failed to give proper post-operative to the patient. The learned judges quoted from Campbell’s Operative Orthopedics Volume one, Ninth Edition, edited by S.Terry Canale, M.D., on the importance of pre-operative preparation.
- Knee arthoplasty is major surgery. Pre-operative preparation begins immediately following surgical consultation and lasts approximately on month. Patient is to perform range of motion exercises and hip, knee and ankle strengthening as directed daily. Before surgery is performed, pre-operative tests are done: usually a complete blood count, electrolytes, APTT and PT to measure blood clotting, chest X-rays, ECG, and blood cross-matching for possible transfusion. About a month before the surgery, the patient may be prescribed supplemental iron to boost the hemoglobin in their blood system.
2. The operating surgeon failed to diagnose her obese condition and the complications that may arise.
3. He hurriedly performed surgery on both knees that too without the consent of the patient even though she was mentally alert.
4. The patient was mentally prepared to be operated only on her left leg but the operating surgeon suddenly changed plans and made the complainant Sammeta Gopala Krishna, 73 (husband of the patient) to give consent for knee arthoplsaty on both the knees through one Manikya Reddy, an agent of the surgeon.
5. The operating surgeon could not prove that he properly assessed the patient's pre-existing conditions of obesity, diabetes, varicose veins and chronic arthritis before undertaking the bilateral TKR.
Also Read: Wow! IMA looks for anti-depressants in Kishore Kumar songs
Facts of the case
Bilateral TKR surgeries were performed on 14.03.2011 on both the knees of the wife of the complainant. It was alleged by the complainant that he was enticed by one Manikya Reddy, Marketing Personnel working in Yashoda Hospital at the insistence of the operating surgeon.
Initially, the operating surgeons opined that the right leg bones around knee being damaged recommended her knee arthoplasty for the left leg only.
On 22.03.2011, a physiotherapist accompanied by Dr.Rahul, Asst. Orthopaedic Surgeon, Yashoda Hospital, came to the complainant’s wife and insisted her to walk despite herself pleading that her body is not permitting any movement.
However, after two steps the complainant’s wife collapsed, resulting in fracture to her right femur bone and subsequently her death on 23.03.2011 due to pulmonary embolism at the hospital.
Interestingly, the operating surgeon had reportedly fixed the patient's date of surgery on 11.03.2011 being an “ International Conference Day” earmarked for Total Knee Arthoplasty at a discounted package in Yashoda Hospital but it was post-poned after complainant’s wife was admitted in the hospital.
Also Read: Why junior doctors have become temple bells in govt medical colleges?
What's the judgment?
While holding both operating surgeon Dr Sanjib Kumar Behera, Dr.Rahul, Asst. Orthopaedic Surgeon and Dr G Surender Rao, Yashoda Health Care Services Pvt Ltd, guilty of medical negligence for not conducting pre-operative tests and post-operative care of the patient, the judges awarded Rs.7,00,000/- (Rupees Seven Lakhs Only) to the complainant.
The judges took refuge in supreme court's Savita Garg Vs. National Heart Institute, (2004) 8 SSC 56 case that held the hospital vicariously liable for the acts of the doctors. The compensation were to be paid from professional indemnity policies bought by the doctors from The National Insurance Co.Ltd., and The New India Assurance co.Ltd..
Guest Opinion
"Without taking preoperative physiotherapy and varicose into consideration, bilateral TKR can turn out to be risky. I remember such a incident happening with a doctor's mother in a well-known hospital and she eventually developed pulmonary embolism," said physiotherapist Sai Prasad Koosam.
He recalled that the doctor's mother underwent TKR without preoperative physiotherapy despite the fact that she had been diagnosed with varicose grade 2.
"The doctor used to looked down upon physiotherapy and did not bother to inform the operating surgeon about his mother's condition," he added.
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