DILBAGH HUSSAIN ALIAS DILBAGH SINGH vs SHARDA NURSING HOME

THIS appeal has been directed by the complainant against order dated 3. 1. 2001 passed by Consumer Disputes Redressal Forum, Patiala (hereinafter to be referred as District Consumer Forum), vide which his complaint was dismissed.

BRIEFLY stated the facts are that appellant (complainant) Dilbagh Hussain @ Dilbagh Singh got himself admitted in the Civil Hospital, Nabha on 30. 10. 1999 at about 4. 00 p. m. as he was having acute pain in his abdomen due to ulcer problem. However, doctor was not available there, so, he shifted to Sharda Nursing Home (respondent No. 1) whose proprietor was Dr. Renu Sharda respondent No. 2. Dr. V. K. Sharda-respondent No. 3 was called to the nursing home who is employed in Government job and he after examination, detected to be a case of appendicitis. It was further told that respondent No. 3 being government doctor could not conduct operation and as such was helping his wife-respondent No. 2. Consequently, he was admitted in the hospital for operation of appendix at about 10. 00 p. m. and was asked to deposit Rs. 4,500 out of which he deposited Rs. 2,000. It was next averred that respondent No. 2 without getting any medical and clinical tests conducted, opened the abdomen from the right side but appendix was found normal. However, during stitching of the portion, leakage started below the chest because of ulcer problem and some fluid also came out of that portion. Thereafter, respondent No. 3 opened the abdomen through midline and found to have large duodenum perforation 2 cms which was closed primarily with an omentum patch to prevent leakage. After performing two operations, his condition became worst and he was referred to PGI, Chandigarh at about 2. 30 p. m. on 1. 11. 1999.

It was further averred that he was thoroughly medically examined by PGI and two x-rays were taken but no final diagnosis was arrived. Thereafter, MRI revealed on 3. 11. 1999 that it was a case of duodenal fistula following primary closure of giant duodenal ulcer perforation. Upon this finding, surgical operation for EL (Easofahgialectomy) and antrectomy and duodenal closure and Gastrojejerlosectomy were conducted and he was discharged on 17. 11. 1999.

IT was next averred that due to negligence of respondents No. 2 and 3 who were assisted by two more junior doctors two wrong operations were performed for which leakage started below the chest because of ulcer problem and he could not walk properly and suffered physically as well as mentally. He was owner of tempo bearing No. PB-11-N-5207 and he used to ply the vehicle earning Rs. 10,000 per month but after operation, he could not do his job or any other work. He had spent Rs. 50,000 on his treatment and thus, claimed Rs. 3 lakh for loss of job, Rs. 1,40,000 as compensation for harassment and mental agony, Rs. 50,000 as medical expenses besides Rs. 5,000 as taxi charges. Respondent Nos. 1 and 2 filed joint reply while respondent No. 3 filed separate reply. Respondent Nos. 1 and 2 stated in their reply that the appellant went to Civil Hospital, Nabha on 30. 10. 1999 at about 4. 00 p. m. and it was diagnosed a case of acute appendicitis. At about 6. 30 p. m. , two relatives of the appellant approached respondent No. 2 and told that the appellant had acute attack of appendicitis and they were not satisfied at Civil Hospital, Nabha. Consequently, they brought the appellant to the clinic of respondent No. 1 and they were told to bring the patient fasting for six hours. They got tests of Hemoglobin, BT, CT, TLC, DLC, urine examination conducted. X-ray abdomen was also conducted and at about 9. 30 p. m. the appellant was brought to the clinic of respondent No. 1 and appellant gave history of pain lower abdomen since one day. On examination, there was tenderness and rigidity on the right side of the abdomen. Liver dullness was on obliterated. At about 10 p. m. , he was shifted to the operation theatre and abdomen was opened through 1 inch long grid-iron incision. There was lot of straw coloured fluid in the abdominal cavity. Appendix was found to be inflamed but the amount of fluid was out of proportion to the condition of appendix, hence, diagnose was revised and diagnosis of perforated peptic ulcer was made. With the consent of relatives of the appellant, upper midline incision was given a big perforation which was leaking in the abdominal cavity of 2 cms was seen in superior part of 1st part of duodenum extending into the pancreas due to which a big nodule was felt (inflammatory mass ). The perforation was closed with difficulty with 2-0 vicryl thread and omentum patch was applied over it to prevent leakage from suture line. A drain was placed in the Morrison pouch and taken out through " long separate incision in the lion and second drain was placed in the Pelvis and taken out from the already placed grid-iron incision. After operation, a closed watch was kept on the drain to detect any early leak from the sutured ulcer. On second post operative day, there was some discharge coming from the first drain with some excoriation of the skin, so, diagnosis of leak from the sutured ulcer was made and appellant was referred to PGI. Thus, it was stated that there was no negligence on the part of respondent No. 2.

RESPONDENT No. 3 in his reply stated that he never checked the appellant and never performed any operation. He denied that he had helped his wife- respondent No. 2 in running the clinic and conducting the operation. Parties adduced their evidence by way of affidavits. After hearing Counsel for the parties, District Consumer Forum found no merit in the complaint as such dismissed it vide order dated 3. 1. 2001.

AGGRIEVED by the said order, complainant has filed the present appeal.

WE have heard Counsel for appellant Mr. O. P. Nagpal, Ms. Promila Nain, Advocate for respondents and carefully gone through the file. The appellant wanted to examine Dr. J. D. Vij of P. G. I. , Chandigarh and many efforts were made to summon him but appellant failed to produce him. However, his Counsel had cross-examined respondent No. 2 Dr. Renu Sharda. In her cross-examination, Dr. Renu Sharda stated that the appellant had come to her clinic on 30. 10. 1999 at about 9. 30 p. m. and at that time his blood pressure, pulse rate and temperature were normal. However, he was complaining of acute pain in the right iliac fossa. He did not give history of ulcer problem. Relatives of appellant produced before her, blood test report, plain x-ray abdomen report and these reports only showed raised TLC and DLC. She next stated that relatives of appellant had come to her at about 6. 30 p. m. and she advised blood test and plain x-ray of the abdomen. She denied that she did not give any such advice or that no such tests were got conducted. She further stated that appellant was operated for appendicectomy through grid- iron incision at 10. 30 p. m. on 30. 10. 1999 and at that time Dr. Gurcharan Singh Sidhu , MD was the anaesthesiatic. She denied that she was not conducting any operation other than gyaenocoloy operations. She denied that Dr. V. K. Sharda conducted the operation upon the appellant and she helped him during the operation. She further stated that on clinical examination, she had observed it to be a case of acute appendicitis and the appellant had also told her that he was having appendicitis. She had suggested fee for operation for Rs. 4,500 and Rs. 2000 were paid in advance. She had started operation through grid-iron incision and on opening the abdomen, the condition of the appendicitis was not very acute. The amount of the peritoneal fluid was present in the peritoneal cavity which was out of proportion and as such her opinion was revised and she opined that it was a case of perforated peptic ulcer. Thereafter, abdomen was opened through separate supra umbilical midline incision and large ulcer was seen over the first part of the duodenum which on the superior aspect that was going posterioly into the pancreas. As an emergency operation for perforated duodenum ulcer, primary closure was done. It was stitched with omentum patch and then operation was done for peptic ulcer. She denied that the leakage below chest started after grid-iron incision. She denied that she referred the appellant to PGI as his condition had become worst due to her negligence.

Appellant had not led any evidence to prove that ulcer leak (duodenal perforation) was the cause of negligence of respondent No. 2. In many instances a diagnosis of acute appendicitis is made but at laparotomy some other acute abdominal condition is found out which itself required urgent operation. In the present case it was stated to be a case of appendicitis. The appellant had also stated that he was having pain in the abdomen due to appendicitis but respondent No. 2 on opening abdomen through 1 inch long grid-iron incision found that there was lot of straw coloured fluid in the abdominal cavity. Appendix was found to be inflamed but the amount of fluid was out of proportion to the condition of the appendix, hence, she revised her opinion and diagnosed it as a case of perforated peptic ulcer. Sometime acute peptic perforation could be confused with acute appendicitis. It has been so mentioned in the book Maingot''s abdominal operations tenth edition page No. 1202 under the heading differential diagnosis of acute appendicitis to the effect that clinical features and special investigations are all non-specific and a list of differential diagnosis is long in deed. In many instances a diagnosis of acute appendicitis is made but at laparotomy some other acute abdominal condition which itself require urgent operation is discovered. Thus, acute duodenal perforation can be confused with acute appendicitis. Therefore, operation was not wrong. If respondent No. 2 had not operated upon appellant, then he would have died of septicemia. Therefore, keeping in view all the circumstances of the case and with the consent of relatives upper midline incision was given, a big perforation which was leaking in the abdominal cavity 2 cms was seen in the superior part of the duodenum extending into the pancreas due to which a big nodule was felt (inflammatory mass ). The perforation was closed with difficulty with 2-0 vicryl thread and omentum patch was applied over it to prevent leakage from suture line. A drain was placed in the Morrison pouch and taken out through " long separate incision in the lion and second drain was placed in the pelvis and taken out from the already placed grid-iron incision. This operation was done for acute perforation.

IT has been observed in the relevant part of the book Farquharson''s test book of operative surgery page NO. 388 that simple closure is the quickest and most appropriate method of dealing with the perforated duodenal ulcer. Retractors are arranged to give the best possible access and any viscera which intrudes is packed off, closure is achieved by inserting 3 or 4 gauge O sutures of an absorbable material such as chronic catgut vicryl or Dexon which are passed through the entire thickness of the gut wall. The central suture which crosses the perforation is tied last, so, that less likely to cut out of the oedematores gut wall. An additional layer of seromuscular lambert sutures is not recommended. Further laparotomy with evacuation of fluid in the peritoneal cavity and suture of the perforation with omental patch as described by Graham has been the most common operation for perforated duodenal ulcer which had been done in this case. Thus, it is not a case of conducting two wrong operations or it is not proved on file by medical evidence that due to wrong operation performed, there was leakage below the chest because of ulcer problem. The documents Exs. C. 4 to C-19 in no way prove negligence on the part of respondent Nos. 2 and 3. Hence, we hold that there is no negligence on behalf of respondents. We concur with the reasoning given by the District Consumer Forum and hold that there is force in the appeal. Consequently, it is dismissed.

COPIES of this order be communicated to the parties, free of charge. Appeal dismissed.