NIRMALA R. PARAB vs KALPANA DESAI

THE complainant Shri Rajaram S. Parab is the father of Mrs. Ashwini Rane, and he filed this complaint on behalf of his daughter, who is like a living vegetable and is unable to understand anything around her. THE case of the complainant is that his daughter Mrs. Ashwini A. Rane was under medical treatment and care of opposite party No. 1, Dr. Kalpana Desai from fifth month of her pregnancy since she had a previous history of thrice miscarriages in the seventh month of pregnancy and opposite party No. 1 had put sutures on the womb of the patient and informed the complainant that sutures will be removed on 2nd May, 1990 and the approximate date of delivery would be 12th May, 1990.

ON 23rd April, 1990, Mrs. Ashwini Rane was admitted to Clinic of opposite party No. 1 in Matunga, with labour pains and was informed by opposite party No. 1 that an immediate caesarian operation was necessary. Opposite party No. 2, Dr. Janak V. Golwala was called in to attend by opposite party No. 1 and at 1.00 p.m. Mrs. Rane delivered a baby boy. Within a span of half an hour, four doctors rushed into the operation theatre and after repeated enquiries with the nurses, the complainant was told that the patient may need to be admitted to another hospital where better equipment and facilities for emergency treatment were available as the blood pressure had suddenly fallen and so is the pulse. The patient was shifted accordingly to the Mata Laxmi Hospital in Sion in ICCU in unconscious state. After five days, complainant shifted his daughter to Lion Bappa Hospital on the advice of opposite party No. 1 as he could not afford the high expenses. He had shifted the patient again after 18 days to the Lokmanya Tilak Hospital at Sion as the patient was still in coma. Eventually the doctors told him to shift the patient to his home with the hope that she might regain consciousness in the homely atmosphere. His daughter is aliving vegetable in bed at house and is being treated still by Dr. Ramani, Dr. Yogesh Parikh and Dr. B.S. Podwal. According to the complainant, the patient is reduced to this stage of brain death due to hypoxia of brain. As per the MRI done on 30th April, 1990, "Diffuse/swelling involving the grey matter in the high convexity region, probably due to hyposis with generalised narrowing of the verticles suggesting cerebral oedema". It is his case that high spinal anaesthesia was administered against the suggested quantity of xylocain (Anaesthesia) being 8 cc., whereas opposite party No. 2 administered 1.2 cc. of xylocain, which is an admitted fact. Complainant argued that this excess dose of anaesthesia caused cardio accelerator fibres blocked and the sympathetic fibres at the thoracic level became immobilised resulting in only the vagal action of the heart. Due to this, the blood kept accumulating in the periphery which explains the blood pressure fall and hence the consequent cut of blood supply to the brain causing the patient to go into coma.

It is also the case that anaesthetist did not maintain airway which is mandatory whereas it was done with endotracheal tube. Oxygen and cardiac massage are a must and he was not sure if this place was equipped with in an emergency. He believed that only two soda bicarb ampules were administered to the patient, which are inadequate and he assumes that clinic did not have adequate quantity.

COMPLAINANT prayed for Rs. 10,00,000/- as compensation from C.Ps and also for expenses from time to time for the recurring expenses for bringing up the child and exemplary damages to the daughter. He has attached the reports and the medical bills alongwith the complaint to substantiate his claim for damages. The learned Counsel Mr. Mokashi, argued for opposite party No. 1 and described this as an unfortunate event but the doctor, opposite party No. 1 as a Surgeon has taken all possible precautions and is in no way responsible for this medical accident. Opposite party No. 1 stated that the brief facts of the case and claimed that there is no specific allegation so far as the opposite party No. 1 is concerned and this petition is not tenable against the opposite party No. 1. When opposite party No. 1 saw the patient on 23rd April, 1990, she found uterine contractions were mild and the head was not engaged. Pelvic examination showed an unfavourable certix with high presenting part. She decided to deliver the baby by doing cesarean section in view of the patient''s history of miscarriages. She stated that pulse, blood pressure and fetal heart sounds were normal and regular. Opposite party No. 1 called for Dr. Janak Golwala to administer anaesthesia and he gave spinal anaesthesia to the patient. Opposite party No. 1 delivered the baby boy and placenta was delivered completely. Injection Metheregin was given. Blood loss was average. The patient was anxious to know the result and the nurse told her that she had given birth to a male boy.

OPPOSITE party No. 1 sutured first layer of the uterus with chromic catgut No. 1 and then opposite party No. 2 informed her that he could not palpate the patient''s pulse and that cardiac arrest was in contemplation. OPPOSITE party No. 1 stopped suturing further and gave cardiac massage to resucitate the patient. OPPOSITE party No. 1 states that opposite party No. 2, the Anaesthesist intubated the patient. Oxygen was given continuously and injection of Atropine, Efcorline, Soda Bicarb, Mephentin and Calcium Gluconate, Intracardiac injection Adrenalin were administered. Dr. Sadanand Shetty, consulting Cardiologist was called and the ECG he took, reported to be normal. Later opposite party No. 1 sutured the uterus and the abdomen, on Dr. Shetty''s advice, the situation was explained to the family and the patient was transferred in an ambulance to the Hospital. The Consulting Neurophysician Dr. K. Ravishankar looked after the patient alongwith Dr. Shetty. Opposite party No. 1 submitted that the complaint made by the complainant before the Maharashtra Medical Council, there was no complaint of negligence or carelessness on the part of opposite party No. 1. One the other hand, complainant admitted that opposite party No. 1 made hectic efforts to resuscitate and relieve the patient and gave immediate treatment. (The learned Counsel for opposite party No. 1 pleaded that opposite party No. 1 was not negligent in rendering services as a Surgeon to the patient and also puts the complainant to strict proof of the averments and submitted that the complaint may be dismissed with costs). An affidavit was filed by Dr. Diwakar Patkar, a Consulting Obsterician and Gyanecologist, where he opined that all normal norms and steps of surgery were followed and that there were no dangerous mishaps during this operation. The phenomena of Cardiac arrest is a known complication and that could take place inspite of all adequate precautions taken. On behalf of opposite party No. 2 Dr. Janak V. Golwala, learned Advocate Mr. Hegde stated that the doctor obtained a consent letter from the patient and having consented to be responsible for the consequences of anaesthesia being administered, the applicant is now estopped from claiming damages. He then, eleborately stated events on 23rd April, 1990 that he went to Matunga Clinic at 12.10 p.m. alongwith his bag containing all equipments, drugs etc. and listed out thirteen items. Doctor examined her clinically and stated that she was well built and well nourished. Her pulse and B.P. were recorded to be normal and later he started IV with 20 No. Venflow and 5% Dextrose. He checked the Hospital equipment and he was satisfied of the same and kept ready ten items on the table like laryngoscope, Endotracheal tube, Caerdal Bag (Adult), Caerdal Bag (Pediatric) etc. After running 300-400 ml. of Dextrose, he washed up for spinal anaesthesia.

OPPOSITE party No. 2 in his written statement explained why he preferred to administer spinal anaesthesia to the patient. He stated, (a) Oxygenation to mother and new born is good compared to general anaesthesia, (b) Less chances of regurgitation, (c) Both hands are free to check pulse, B.P. etc. He used Hypertonic 5% Ligrocain 1.2 ml. for anaesthesia in a sitting position and took nearly 10 seconds to inject and the patient was moved to lie down with pillow below her head and bed sheet under her back to give left lateral tilt. He then checked the patient''s pulse and B.P. which was 90 per minute and 110/ 20 mm. Hg. He also checked and controlled level of spinal anaesthesia by needle pricks and level of ideal just above umbilicus.

OPPOSITE party No. 2 was talking to the patient while the operation was being performed and remembered that the patient was alert and conscious. There were no signs of adverse effect of anaesthesia and pulse & B.P. were normal and blood colour was red to indicate proper Oxygenation. On delivery of baby. Injection Rethergin IV was slowly given. To the patient''s query, she was informed that she has a son and found her happy. While uterus was being stitched, after checking pulse, B.P., Injection for twiz 15 mg. and Compose 5 mg. diluted with distilled water was given. Suddenly he noted her pulse had disappeared and B.P. was not recordable and he informed opposite party No. 1 immediately. OPPOSITE party No. 1 intubated the patient with endotracheal tube to ventilate with Oxygen. He then administered Injection Atropine, Injection Hephentine, Injection Calcium Gluconate, Injection Effoorlin, Injection Sodabicarb Injection Adrenalin diluted in 10 ml. IV. slowly. Injection Adrenalin-intracardiac. Meanwhile, opposite party No. 1 gave external cardiac massage. The nurse informed other doctors. Dr. Ajay Shah, A Gynaecologist, Dr. Aspi Raimanwalla, Cardiologist, Dr. Shetty came into help. In response to their efforts/the pulse reappeared after 4 to 5 minutes. B.P. gradually rose and pupils were reacting to light and patient started breathing spontaneously. ECG taken by Cardiologist Dr. Shetty was normal. On the advice of Dr. Shetty, the patient was moved to Mahalaxmi Hospital alongwith Oxygen cylinder and he followed up the patient for one month. Opposite party 2 narrated the incident with details and pointed out that cause for such an accident in obscure. According to him, the cardiac arrest might have probably occurred due to, (a) Amniotic fluid Emblolism, (b) Ido syncratic reaction to drugs like Fortwin Diazepam, uonocain, (c) Side effects of Methergin leading to Coronery and cardial vaso construction, and (d) Pulmonery embolism. In order to ascertain a definite diagnosis of the cause, post-mortem would have been useful, but in the present case, patient being alive that possibility was out of question. Opposite party No. 2 clarified various aspects of spinal anaesthesia regarding dossage, administration and factors affecting level of spinal anaesthesia with references to text books. He argued that on hypothetical basis, the question of negligence cannot be attributed to him as he discharged his duties to the best of knowledge, experience and in confirmly with the known course of treatment and procedure. He also contended that complainant lacks locus standi to maintain this complaint as the child of the patient is the legal heir.

Findings: To start with, we do not agree with opposite party No. 2 regarding the maintainability of this complaint on the basis of parents not having the locus standi and only the child of the patient is the legal heir could file this complaint. Parents are maintaining the upkeep of the patient who is helpless and remains as a vegetable in bed. Parents are required to spend for the medical treatment of the daughter and hence can claim the compensation. Another contention of opposite party No. 2 that the patient signed the consent form knowing risks are invoked in anaesthesia based surgeries and so cannot later claim any damages arising out of the event is not acceptable to us. Merely signing the consent form does not exclude doctors'' responsibility if he is negligent, in carrying his duties. We do not accept these above contentions raised by opposite party No. 2. As far as opposite party No. 1 is concerned, complainant himself has not made any submissions against opposite party No. 1 in front of us or with the Maharashtra Medical Council. He indulges in hypothetical assumptions but has not tendered any expert evidence to show any negligence on the part of opposite party No. 1. Opposite party No. 1 on the other hand immediately gave cardiac massage to the patient and rushed all the other doctors and Cardiologist. Emergency treatment as expected in medical standards has been given and arranged to shift- the patient to another Hospital for better ICCU facilities. We did take the affidavit of Dr. Vivek Diwakar Patkar into consideration and find opposite party No. 1 had followed all normal norms and steps of surgery and took adequate precautions. The fact that she sutured womb of the patient considering the previous miscarriages and took her in for an immediate caeserian operation when she came in ten days before the expected date of delivery, we are convinced that she acted according to the correct medical norms.

REGARDING opposite party No. 2 the complainant has made a specific grievance that the suggested quantity of xylocain (Anaesthesia) is 8 c.c. whereas opposite party No. 2 administered 1.2. c.c. The quantum of anaesthesia prescribed for patients is between 1 to 1.5 ml. According to Miller, 1.2. to 1.8 m. according to Wyeli and 1.25 to 1.5 ml. as per Gray-Nunn. We have gone through the standard anaesthesia procedures and the common norms of post operative analgesia. Opposite party No. 2 kept constantly the level of anaesthesia just above the umbilicus i.e. between umbilicus and xiphisternum (T6 T12) by ascertaining with needle pricks. Patient was given spinal anaesthesia in sitting position and then later was made to lie down with a rest of a pillow under the head and a blanket under the back to give an angular posture. Since Cardioaccelator fibres of heart are supplied by T1 & T2 the question of spinal anesthesia causing blockage of Cardio accelator fibre does not arise. Opposite party No. 2 was talking to the patient during operation and she asked about the child and this whole scenario took more than fifteen minutes from the time anaesthesia was given. This also disproves the claim that adverse effect of anaesthesia as such reaction would have taken place within 10 minutes. Here hypoxia/cardiac arrest occurred after 26 minutes after giving anaesthesia. High Spinal anaesthesia causes 2 possibilities where patient starts vomiting and severe hypertension will be observed by the Surgeon or the maternal hypotension leading to reduced placental blood flow which will lead to foetal distress. In the present case, baby was normal, B.P. was normal, till 26 minutes after the anaesthesia was administered. It proves that spinal anaesthesia was not high but low which was required. We have noted few observations from H.E. Tunstall''s "Anaesthesia for obsterics", that out of a sample of 37, anaesthetic deaths of 18 died of hypoxic cardiac arrest and the cause was obscure. It is observed that pulmonery embolism is the leading cause of maternal deaths and in about 80-90% cases it occurs without any previous clinical manifestations of deep vein thrombosis. Although other major causes of maternal mortality have decreased, the disorder of amniotic fluid embolism still remains to be a problem. According to the text on Amniotic Fluid and Maternal Mortality/Morbidity, it is described as "Amniotic Fluid with its particulate matter enters the pulmonary circulation, causing respiratory distress, systemic hypotension, cardio vascular collapse. Convulsions and death in the majority of affected women. There are no warning signs or symptoms. There are no known therapeutic modalities other than support of the Cardiovascular respiratory system and symptomatic treatment of the bleeding". It continues to say "Hopefully, once the underlying mechanism of this condition is understood, specific therapy can be aimed at the causative insult. Meanwhile, it can be expected that this sudden catastrophic disorder will continue to be highly lethal, with maternal mortality rates i.e. 75% to 90% range.

AFTER discussing the standard method of treatment, as elucidated in medical literature here above referred to, we find that the method of treatment adopted by both Dr. Desai, and Dr. Golwala is fully supported by the contemporaneous medical cases papers. They have given the details as to how the treatment was given when there was possibility of cardiac arrest. Necessary injections were given, necessary massage was carried out, endotracheal tube was inserted for air passage and all such steps as necessary to meet emergency were quickly adopted and followed. Treatment, therefore, given by Doctors was the established treatment and there was, therefore, no question of negligence. It cannot be lost sight of that the patient was taken out of cardiac arrest and survived. In normal course, the end would have been fatal but because of the timely treatment, the patient could be retrieved form cardiac failure. When the doctors found that the patient could be put under better management with necessary infrastructure, the patient was advised to be removed to another Hospital, where ICU facilities were available. The patient was treated there for some days and thereafter was sent to another Hospital viz. Lion Bappa Hospital. Lastly, the patient was treated at Nair Hospital, and was brought home on 29th May, 1990. In this regard, there is affidavit of opposite party No. 1, Dr. Desai, which has not been controverted by the complainant. Dr. Desai has stated on oath that she herself made arrangement to transfer the patient in ambulance with adequate supply of Oxygen and with proper care and caution. The Anaesthetist and Dr. Desai accompanied the patient to the ICCU unit and stayed overnight with the patient. Dr. Desai visited the Hospital and later on the residence of the patient possibly everyday, out of her concern for the well being of the patient. These statements are not controverted. We may further, point out that Dr. Desai has stated that Mr. Ashok Rane, the husband of the patient all along appreciated the services rendered by the doctors and surprisingly the father of the patient rushed to the Medical Council and also complained to the State Commission. Here, we may also point out that in the initial stages, when the complaint was lodged before the Medical Council, the story of the complainant was simple and that is. Dr. Desai operated successfully but after sometime, the doctors were seen rushing for treatment of the patient. He has categorically stated that he did not wish to denigrate any of the doctors in their reputation and that he was not motivated to make complaint out of vengeance. On the other hand, according to the complainant. Dr. Desai successfully carried out the caesarian operation and took out the baby boy successfully. This was the happy news to the mother, who was the patient. But surprisingly, the palpitation had stopped and the pulse was missing. Now with these statements, it is difficult to attribute any negligence to any of the doctors. It is seen that he did not appear before the Medical Council and possibly no penal action has been taken either against Dr. Desai or against Dr. Golwala. However, with the lapse of 2 years, the complainant radically improves upon the story of the complaint. In the complaint he has made a grievance that his daughter Ashwini was reduced to a vegetable because of hypoxia of brain, which is equivalent to brain death. The MRI done on 30th April, 1990 has shown that there was "diffuse/ swelling involving the grey matter in the high convexity region probably due to hypoxia with generalised narrowing of the verticles suggesting cerebral oedema. The only possible cause and reason which could have led to brain hypoxia is a high spinal anaesthesia. The normal dose of 8 c.c. was to be given but the opposite party No. 2 Dr. Golwala had administered 1.2 c.c. xylocaine, which resulted in cardioaccelerator fibres obstructing the blood cloat. He has also stated that the drugs which were out of normal use were administered and that there was shortage of 2 soda-bicarb ampoules. This dose was not enough. These are clearly the improvements which the complainant has made after a lapse of about 2 years. The event took place in 1990, whereas the complaint is lodged in 1992. In the initial stage before the Medical Council, no such grievance was made and hence one can come to the conclusion that the allegations are after-thought and are not bona fide. Dr. Golwala in his detailed affidavit has given the explanation regarding the spinal anaesthesia and the adequate dose of 1.2 c.c. to the patient. We may also indicate that the patient was transferred from Mata Laxmi Hospital to Lion Bappa Hospital and at that time the case papers also indicate details of the treatment given to the patient at Matunga Clinic, Jyoti Hospital, where Ashwini was operated. Now these documents will clearly establish that the treatment as canvassed by the doctors was given to the patient. It cannot be stated that the details are inserted afterwards. The case papers were drawn up at the time of treatment and in view of this, we are unable to uphold the case of negligence against the doctors. We are also unable to understand as to why the husband did not make complaint and why the parents have come to the Redressal Forum. Lastly we would generally observe that the patients have the tendency to blow out of proportion the grievance against the doctors. When the patient does not recover the patient presumes that doctors are responsible for his ill- health. They spare no opportunity to blame the reputation of the doctors. In this case, the father of Ashwini approached Medical Council, approached also the Press and the Video Media and has thus tried to injure the reputation of the doctors. We have indicated here before that the doctors gave the appropriate treatment at the appropriate time. It is unfortunate that Ashwini could not revive to normalcy but then that stage of health has to be attributed to the patient and not to the doctors. We therefore, censure the contention of the complainant, who has mudsling the repudiation of both the doctors. However, without any more comments, we pass the following order. ORDER The complaint is dismissed with, however, no order as to costs. Complaint dismissed. ___________________