MANAGING DIRECTOR, ROHINI HOSPITAL vs L.SUNIL REDDY

THE opposite parties in C.D. No. 134/1994 on the file of the District Consumer Forum, Warangal are the appellants.

THE case of the complainants is that complainants 1 and 3 are son and daughter respectively while complainants 2 and 4 are widow and mother of late Narasimha Reddy, who was working as Head Master, Z.P. High School, Gavicherla. He was admitted in the first appellant hospital on 13.6.1993 at about 5.00 p.m. as he was suffering from vomitings and motions with blood. Dr. Narender Kumar, who was present in the casualty-ward attended on him. He was discharged on 16.6.1993 after treating for 3 days as he was in Coma and was in a very bad state of health referred him to Medwin Hospital where he died on 17.6.1993 at 8.45 a.m. Even while he was under the treatment of opposite party No. 1 hospital, Dr. Rami Reddy, M.S., F.R.C.S. who had come from Nalgonda having examined the deceased expressed that the treatment given to him was not appropriate, however, he suggested some medicines but it was too late. Hence this complaint. THE appellants in their written version denied the material allegations contained in the complaint as well as deficiency in service on their part. The District Forum found that there is deficiency in service on the part of the appellants and accordingly directed them to pay compensation of Rs. 3,60,000/- with interest at the rate of 15 per cent p.a. from 2.3.1994 from the date of filing the complaint till payment. Hence this appeal.

There is no dispute that the deceased was brought to the appellants'' hospital since he was suffering from vomitings and stool containing blood since morning and was admitted on 13.6.1993 at about 6.00 p.m. in the casualty ward. He was attended by the second appellant. He remained in the hospital for 3 days during which period a number of tests were conducted and blood transfusion and I.V. fluids were given. However, since his condition deteriorated, he went into Coma on 15.6.1993, on 16.6.1993 he was shifted to Medwin Hospital, Hyderabad where he died on 17.6.1993 at 8.45 a.m. While he was admitted in the appellants'' hospital, he was seen by Dr. Y. Rami Reddy M.S., F.R.C.S., who came to Hanamkonda from Nalgonda.

THE dispute is whether the treatment given was appropriate for the ailment and whether it was advisable to go for surgery immediately instead of going for conservative treatment. It is also alleged that according to Dr. Y. Rami Reddy and Medwin Hospital, the treatment given by the appellants'' hospital was not correct. It is also alleged that Dr. Venkat Ram Reddy, did endoscopy, and that the patient was not treated by a Gastroentrologist. We find from Ex. A3 Upper Gastrointestinal Endoscopy report dated 14.6.1993 that Sri L. Narasimha Reddy was referred by Dr. K. Buchi Reddy and Endoscopic Impression was ''Biopsy bit taken for HPE. Chronic gastric ulcer bleeding". Against stomach it is stated "Active Pyloric ulcer at 7 O'' clock 1 cm. x 1 cm. in size. Stomach contained altered blood", and the report is given by Dr. S. Venkat Ram Reddy, Surgeon. Ex. A5 death certificate dated 17.6.1993 of Medwin Hospitals shows that the patient died at 8.45 a.m. due to Cardio Pulmonary Arrest. Ex. A9 shows that Hemoglobin was 8.5 Gms dated 15.6.1993 while Haemoglobin was 9 gms. on 14.6.1993 in Ex. A-10. As per Ex. A-11 dated 13.6.1993 Randon blood Glucose was 203 gms. much above normal. Ex. B1 is the case-sheet, which shows under final diagnosis is : Bleeding Peptic ulcer with Metabolic Encephalopathy. The history of the patient showed that the patient was suffering from Peptic ulcer since 1988. P.W. 1 admitted that there were doctors attending round the clock but alleged that Dr. Buchi Reddy did not visit the patient subsequently and gave instructions only on phone. The case-sheet showed that at the time of admission, he had severe sweating and the diagnosis was bleeding peptic ulcer and his blood group was ''O'' positive. The patient was seen by Dr. Buchi Reddy on 13.6.1993 at 6.30 p.m. and the blood transfusion was started at 9.20 p.m. and two units of blood was given by 5.30 a.m. on 14.6.1993.

IN the Text Book of Short Practice of Surgery by Bailey & Love''s revised by Charles V. Mann, R.C.G. Russell, Norman S. Williams, 22nd Edition at page 678 it is stated under ''Chronic Gastric Ulcer'' that the patient is usually beyond middle age ... IN many instances the patient appears anaemic and this is often confirmed by Haemoglobin estimation. This should be associated with vomiting. For the diagnosis of gastric ulcer, it is suggested on p. 680 that endoscopy is valuable in the diagnosis of shallow gastric ulcers that do not show on radiography, in checking the results of medical treatment in cases of chronic gastric ulcer, in the differential diagnosis between a chronic Peptic ulcer and a Carcinoma.... This is exactly what was done by the Surgeon and there is no deficiency in diagnosis. Under treatment of chronic uncomplicated Gastric and Duodenal Ulcers, it is stated as follows : "the treatment in the first instance be conservative (medical). There is no doubt that the patient benefits from close and continuing collaboration between surgeon and physician, and that this collaboration is improved when each has a clear understanding of both conservative and surgical therapy. The management of the two conditions is similar in some respects, but there are important differences."

Under Chronic gastric ulcer, it is stated as follows : "Prior to the institution of treatment accurate diagnosis is essential. Endoscopic inspection and biopsy of the ulcer must be performed and specimens sent for the CHO test for Helicobacter pylori; in general, the size of the lesion is best assessed radiologically."

While the diagnosis is made on the basis of radiographic finding and endoscopy, the need for surgery is suggested among other things when there is perforation or bleeding. (P-681). The aims of operation : "Surgical treatment for peptic ulcers aims to cure the ulcers with the maximum effectiveness, and the minimum danger and side effects". (P. 682). Hence it appears that the patient has to be first treated conservatively and after the endoscopy and confirmation, surgery is advisable in chronic cases. At page 686 under ''Special Types'' "Chronic Peptic Ulcer : Slight bleeding due to trauma from solid food occurs frequently from all chronic peptic ulcers; such bleeding is demonstrated by finding traces of blood during gastric analysis and occult blood in the stools. With advancing age and the associated arteriosclerosis, there is an increasing risk of severe haemorrhage due to the erosion of an artery in the base of the ulcer. Occasionally, the artery is of considerable size". In the first instance blood transfusion should be given since the haemoglobin will be at a lower level. Under ''Management'' on P-687 it is stated : "......Conservative (Medical) or surgical regimen ? This decision should be made by joint consultation and co-operation between the physician and surgeon."

In the present case, as per the case-sheet, the patient was suffering from Ulcer since 1988 and also did not follow regular diet habits, the chances of improving with conservative treatment are less. However, in the initial stages endoscopy was done to diagnose the extent of the disease and blood transfusion was given to him basing on Haemoglobin count which is according to the suggested regimen. Hence on this count we do not find any deficiency.

HOWEVER, the only question that arises is whether immediate surgery was necessary or not and if done, would it have saved the life of the patient ? The complainants have not filed the case sheet of Medwin nor they have examined any expert and filed any literature to throw light on this aspect.

WE have only the evidence of P.W. 4, who is no other than the surgeon, Dr. S. Venkat Ram Reddy, who had seen the patient on 14.6.1993 morning and did endoscopy. As per his evidence after seeing the patient, he advised that the treatment given by the physician should be continued. When he again saw the patient on 15.6.1993, the condition of the patient had deteriorated and there was bleeding also but he did not undertake to perform surgery as in his opinion, the condition of the patient was too critical and he would not withstand surgery. He has asserted and also as per Ex. C1, he was trained in Endoscopy by Dr. D. Nageswar Reddy and had performed more than 200 Upper GI Endoscopies independently. In Warangal, he was the only one to conduct Endoscopy and there was no other Gastroentrologist available, as such we do not see any deficiency on this count. The patient was seen by a qualified surgeon and we do not agree with the contention that the surgery would have saved the life of the patient. The patient was continuously monitored and opinion of the surgeon taken. Hence we do not see any deficiency or negligence on the part of the appellants. Dr. Y. Rami Reddy, M.S. F.R.C.S., who had seen patient and as alleged by the complainants, he found deficiency in treatment but he was neither examined nor any affidavit filed on his behalf. The patient was brought too late to the hospital and in spite of best efforts, he could not be saved. The appeal is, therefore, allowed setting aside the order of the District Forum dismissing the complaint but in the circumstances without costs. Appeal allowed.