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Caveat Emptor: How medical negligence works

May 22, 2014

Ushinor Majumdar

New Delhi, April 25, 2014

On April 10, 2014, the air over the empty, dusty streets of New Delhi and Gurgaon was pregnant with anxiety, reflecting the mood of the ongoing Lok Sabha elections. But, that tension did not come close to the uneasiness on the second-floor waiting room of XYZ Hospital’s Intensive Care Unit (ICU), neurosurgery, on that same day. The Rajkumars huddled around each other waiting for a glimmer of hope, a ray of sunshine that could be a doctor or hospital staff who would come and say that the family’s youngest member – 35-year-old Harish – was now recovering. Two days after that, Harish passed away after having spent 10 pain-ridden days in that ICU.

On April 1, this same man, Harish, had driven his mother and himself to the hospital to consult a neurosurgeon. The complaint was a pain in his upper back and he approached the specialist under advise from his orthopedic doctor. According to Harish’s family, the neurosurgeon Dr Pramod Kumar suggested a “micro-dissection of the disc to relieve the pressure on the compressed nerve,” which was causing the pain.

Harish informed Dr Kumar about his medical history of being diagnosed, sometime in 2012, with cancer, specifically pleomorphic rhabdomyosarcoma or ‘sarcoma’. In fact, Harish had been under the care of Dr Nayyar and Dr Singh of the oncology department at the same hospital. Harish’s family were vociferously appreciative of these two oncologists.

In August 2013, Harish had been referred to Dr Moni Abraham Curiacose, renowned head and neck oncologist of Bangalore, who operated on Harish in Narayana Hrudalaya, Bangalore. During this procedure, a large section of the back of his throat was removed surgically and tissue from his thigh was grafted on to the part of the neck removed to recreate it. According to his family and the oncologists, Harish started exhibiting symptoms of possible recovery soon afterwards except trouble in swallowing food which the doctors was a necessary effect of the surgery.

By November 2013, he was visibly healthier and becoming more active. Dr Kumar apparently told Harish that the “disc micro-dissection” was a minor surgery and that would take about half an hour and he would be discharged in a day or two. At night, buckling under the pain, Harish agreed to a ‘Discectomy and artificial disc replacement’ instead of the micro-dissection.

On the night before the procedure, a pre-surgery X-Ray examination was performed on Harish, which become a crucial link in this tale. The procedure lasted nearly five hours after which he was shifted to the ICU from which he was supposed to be moved that very day. But, that was the last room that Harish ever saw in his mortal life. It was only after Harish’s elder sister Radha had made several calls to the hospital that the ICU team informed them that Harish had been shifted there. That was the first major indication that something had gone seriously wrong.

On the afternoon of April 4, Harish’s family was informed that that a post-operative X-Ray showed a large mass in the lungs which they suspected could be malignant and a scan was required. The shocked family asked if they had reported this to the oncology department of the same hospital before surgery because of Harish’s medical history.

“We had no clue that Dr Kumar had not shown the pre operative X-Ray or even consulted with the oncology team before the surgery was recommended. In fact, Dr Pramod Kumar said he was not trained in malignancy (which is no hindrance to neurosurgical practice, unless you don’t call in an oncology consult for a known cancer patient),” said Radha, Harish’s sister.

This is where the pre-operative X-Ray results become crucial. The said examination was conducted at about 11:20 PM on April 1, that is, the night before the neurosurgeon’s procedure. The report is only a few lines, but even a layman looking at the X-Ray slides will notice a large opaque patch over the area where the left lung is supposed to be. The operative part of the accompanying radiologist’s report, which this writer accessed, states “Moderate Sub-pulmonic left-sided pleural effusion noted; cardio-mediastinal silhouette cannot be commented upon.”

The radiologist’s report on this X-ray examination reads as “Study date: 01-04-2014” and “REPORTED ON: 03-04-2014”. This means that the X-Ray report was studied much earlier but the written report by the expert was submitted later as a means of safeguarding against potential liability, which became clear by April 3.

Harish’s cousin, Dr Ram Narayan, a medical graduate and former researcher with one of the top five universities in the United States, says, “The report shows there is fluid in the left lung. The delayed report date shows that either someone skipped looking at the pre-operative X-Ray report and assumed it to be normal. That is the most horrible assumption considering Harish was a cancer patient. Or; someone looked but ignored it. The anesthetist should have seen it before the surgery. The post-dated report suggests that the radiologist signs off as having seen it later only. Unless its standard operating procedure not to wait for a pre-op report from radiologist.”

On the night of April 2, Harish complained of breathlessness and doctors advised that he remain in the ICU. “On April 3, the postop x-ray showed consolidation in the left lung, an additional CT scan showed masses in the left lung with a mass in the right lung. His complained of increased breathlessness,” said Radha.

On April 5, Harish required a ventilator to breathe. On April 8, a pet scan was conducted on Harish and multiple malignant tumours were found in his left lung and a single one in his right lung. On April 9, doctors performed a tracheotomy on Harish believing it might help him breathe. The family members dispute that it helped at all.

The next day, a central vein was inserted to assist his breathing. On April 11, a pleural tap was conducted to drain the fluids from his lungs – the same fluids that had showed on his X-Ray. On April 12, Harish came out of sedation a little after 7 AM in the morning.

“He appeared to be in pure agony and we asked for a doctor, who came nearly an hour later. He had trouble breathing and it kept diminishing till his life ebbed from his body and my little brother flew to the sun,” said Radha, adding, “We do not know if the lung mass shifted due to the surgery, if the breathlessness got aggravated, if infections led to the critical condition – nothing is clear and will never be.”

While Harish was going through all of the procedures inside the ICU, his family was going though a surreal experience outside. At different points it was different problems. Sometimes, the ICU staff were not able to get in touch with the doctors, or one of the doctors was out of town or the oncologists were not aware that a cancer patient they had treated was undergoing a surgery. There seemed to be no coordination and the doctors were either not available and when hospital staff was appointed to communicate with the doctors, they too were difficult to track down. The family feels they were not kept abreast of what happened at different stages.

Just like the over-played coalgate scam, during treatment, Harish’s file went missing from the ICU itself. But, one department was the most efficient – the billings department. Any cost above Rs 20,000 was promptly conveyed to the family and the cashier insisted on prompt payments.

Early on, a ‘global head’ of XYZ hospital convened a meeting of all the specialists and the management. Hospital staff Shankar Tiwari was designated as the coordinator.

“At this meeting, XYZ hospital’s director Harinder Dhillon mentioned that they don’t have an  “electronic system in place to check if a patient with previous cancer history met a doctor of another department. We regret the inconvenience caused and we now will assign you a coordinator.” However, the history given by my brother and the previous medical records that he brought clearly indicated that Dr Nayyar and Dr Singh were treating him for his cancer. Harinder Dhillon closed with a simple-but-chilling statement “negligence due to non verification of the pre operative x ray with the oncology team”,” said Radha.

If this statement was indeed said at that meeting, it need not be stressed that this is an open and shut case of medical negligence. Only an expert can investigate into if Harish Rajkumar’s life could have been extended, if this whole mess could have been avoided and his life saved. It opens up a crucial abscess in medical care in the country – one that the Supreme Court has taken note of.

In October 2013, the apex court delivered a landmark judgment awarding compensation of nearly Rs 12 crore to Dr Kunal Saha who lost his wife (a US-based psychologist) to ‘medical negligence’. As per an earlier decision of the Supreme Court, health was determined as a ‘fundamental right’ and the judges commented that the decision should serve as a “deterrent and a reminder to those doctors, hospitals, the nursing   homes and other   connected establishments who do not take their responsibility seriously.”

Medical care is a sensitive issue and a man will pawn all their belongings to ensure proper medical care for themselves and their families. Because medical science is a complex subject, no layman knows their rights and do not wish to aggravate doctors who are attending to a family member.

On April 10, that is exactly what Harish’s family was discussing in hushed tones. And after a loss, only few will challenge a medical facility and even fewer will report on it. The doctors in this terrible tale did not wish to comment on or off the record. The hospital administration were distraught on receiving inquiries from a journalist.

The XYZ healthcare group is easily one of the largest and a well-renowned healthcare provider. The top management of XYZ group have ‘impeccable’ credentials and are a household name in the country.

The ‘global head’ of this group did not believe that there was a ‘story’ in this tale and tried to convince as much. Over the telephone, he told this writer on two different calls that the hospital had tried to provide ‘palliative care’ because there was not much they could do for the patient. He chose not to address queries about the conduct of the doctors and the hospital staff, especially that of Dr Pramod Kumar, who did not bother to consult oncologists despite the pre-operative X-Ray results. This global head sent a few cursory lines to this writer:

Thankyou for sending in your query. In our view this does not merit a story, as you will see from our below mentioned response. However, in the event you do plan to go ahead, would request you to please incorporate it and attribute it to a spokesperson from XYZ,  

Warm regards  

‘_______’ (‘global head’)  

The patient with a history of rhabdomyosarcoma (a malignant cancer in his neck muscles) came to us  in severe agony with extreme neck and left arm pain resulting from a prolapsed cervical disc. As medical management had failed, a disc surgery was successfully undertaken, after careful evaluation, as a palliative measure. This completely rid him off his pain. Unfortunately, and quite independently, his cancer had spread with multiple metastatic lesions in both his lungs as well, resulting in his short life expectancy. All along, the case was reviewed and multiple consultations by a highly experienced team of Neurosurgeons, Oncologists, Pulmonologists and other domain experts were provided.  He eventually succumbed to the disease despite the persistent and best efforts of our doctors.”

Under contract law, the legal maxim Caveat Emptor means ‘Let the Buyer Beware’.

———–

All names have been changed on request of the deceased patient’s family who did not wish to pursue this matter. However, it is published because it might be of use to someone somewhere. Several promotional articles appear about the above-mentioned Dr Pramod Kumar under his real name. These articles, including some published by mainstream media outlets, claim he is a great neurosurgeon. While this article does not raise a contention about his neurosurgery, it aims to point out how a simple step (whether on oversight or complacence) could lead to a death due to medical negligence. We will never know if Harish could have been treated for the tumours in his lungs and if his life could have gone on for another few months or more. But, that choice was not the doctors to make without consulting oncologists.

—-xxx—-

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