Assault on doctors and remedies against the same

Junior doctors in West Bengal are on a strike since Tuesday after two of their colleagues were attacked and seriously injured at the NRS Medical College and Hospital in Kolkata by the relatives of a patient who died. Showing solidarity with their colleagues in Kolkata, doctors across the country have joined the protest. The Indian Medical Association (IMA) has called a nationwide strike on Monday. 

Violence against doctors is unacceptable and needs to be condemned. The medical fraternity is very disturbed and concerned about the rising incidents of physical violence and assault or attack on doctors and their staff, clinical establishments, etc.

The government of India had constituted an Inter-Ministerial Committee, which had promised to soon enact a central Act for violence against doctors. But, sadly, this has yet to see the light of the day. It’s time that the medical profession unites and stand firm till the government brings a Bill for violence against doctors in the coming Parliament session.

If the doctors and other healthcare staff, etc. are always under a constant threat and pressure from the ongoing violence and assault then they will not be able to do justice with their profession and also they shall not be able to manage their patients who need emergency treatment and are therefore undergoing risk and danger of their life, properly and promptly.

It is therefore in the interest of public at large that such cases of physical violence against doctors must be condemned and controlled and must not be allowed to happen.

Persons committing such offences and crimes can be punished under the following laws:

Criminal law

The Act of physical violence, assault, attack on doctors, nurses, their staff, clinical establishments, etc. amounts to following criminal offences, which are punishable under the provisions of Indian Penal Code (IPC), 1860:

Criminal conspiracy: Section 120A and Section 120B of IPC

Offences against the public tranquility

Unlawful assembly: Section 141, 143 and 144 IPC.

Rioting: Section 146 IPC, Section 147 IPC and Section 148 IPC.

Affray: Section 159 IPC and Section 160 IPC.

Offences affecting the public health, safety, convenience, decency and morals

Public nuisance: Section 268 IPC, Section 269 IPC and Section 294 IPC.

Offences affecting human body

Hurt: Section 319 IPC, Section 323 IPC and Section 324 IPC.

Grievous hurt: Section 320 IPC, Section 325 IPC, Section 326 IPC and Section 326A IPC.

Act endangering life or personal safety of others: Section 336 IPC, Section 337 IPC and Section 338 IPC.

Wrongful restraint: Section 339 IPC and Section 341 IPC.

Criminal force and assault: Section 350 IPC, Section 351 IPC, Section 352 IPC and Section 355 IPC.

Offences against property

Theft: Section 378 IPC and Section 379 IPC.

Mischief: Section 425 IPC and Section 426 IPC.

Criminal trespass: Section 441 IPC and Section 447 IPC.

Offence of defamation: Section 499 IPC and Section 500 IPC.

Offences of criminal intimidation, insult and annoyance: Section 503, Section 504 IPC and Section 506 IPC.

Offences of outraging, insulting the modesty of women: Section 354 IPC, Section 354A IPC, Section 354B IPC, Section 354C IPC and Section 509 IPC.

If any person commits any of the above mentioned offence, then the doctors and their staff can lodge a police complaint under Section 154 of the Criminal Procedure Code and get an FIR lodged against the said offender.

Civil law

Doctors, hospitals, its staff, clinical establishment, etc. can also file civil suits like suit for permanent injunction, suit for damages and suit for defamation against the aforesaid Acts and offences of physical violence, assault, attack, etc.

Besides the above mentioned remedies under IPC or CrPC, around 15 States and Union Territories (UTs) in India have their respective State or UT legislations on the issue of physical violence or assault of doctors, for example: Delhi Medicare Service Personnel and Medicare Service Institutions Act, 2008; Bihar Medical Service Institution and Person Protection Act, 2011, etc. In all these legislations, punishment is imprisonment which may extend to 3 years or with fine up to Rs. 10,000/- or both and compensation of twice the purchase price of property damaged and loss caused to be recovered as arrears of land revenue on default. However, the said legislations framed by the 15 States or UTs are not effective and also there is no awareness about the same either amongst the doctors or the concerned police authorities.

Then there are laws relating to sexual harassment at the workplace. Women can file a complaint against the offence of sexual harassment at workplace as per the provisions of the Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013 (hereinafter referred to as Act, 2013).

As per the provisions of the Act, 2013, the hospitals, clinical establishments, etc. should constitute an Internal Committee for redressing the complaints relating to the sexual harassment at workplace made by any aggrieved women.

Some Remedies

Here are few suggestions to avoid doctor-patient disputes. More suggestions are welcome.

·           There is an urgent need to legislate a Central Act on prevention of violence against doctors while on work and duty. Any act of violence against doctors should be made a punishable, non-bailable offence with imprisonment of up to 14 years.

·           Also, the State Acts on violence against doctors should be advertised and also acted upon by the state government.

·           Workshops, seminars etc should be organize to educate the general public and doctors about the penal provisions in case of violence against doctors. This can be done by the government and professional associations.

·           Patients’ rights should be displayed in every hospital and clinic. Associations should educate their doctors about Etiquettes, conduct, ethics.

·           Patients should be educated about the significance of informed consent.

·           Patients should be educated about triage in emergency.

·           Patients should be sensitized that error of judgment does not automatically mean negligence.

·           There should be a grievance redressal mechanism for both patients and doctors in every health care establishment.

·           Right communication is the key to a strong doctor-patient relationship, based on mutual trust and respect.

·           The charges should be clear and transparent - there should not be a large difference between the estimated cost of treatment and the actual cost of treatment; there should be no hidden charges or kickbacks.

·           It is important to acknowledge the altered dynamics of doctor-patient relationship, which has undergone a paradigm shift from doctor’s right to take decision to patient’s rights to take decision.

·           Rational treatment, rational prescription, transparency in investigations and treatment

·           Hospitals should identify high risk areas and install audio-based CCTV cameras in all sensitive and high risk areas.

·           Bodies of deceased patients cannot be held as hostage for financial disputes.

·           Hospitals should make adequate security arrangements; protection to be given to doctors and nurses working the night shift in particular.

·           Provide transparent daily billing to avoid future disputes

·           CPR and first aid to be available everywhere

·           Briefing to the legal heirs

·           PRO in challenge and high risk areas

·           Nurses and paramedical staff to be trained about soft communication

Besides the doctors and patients who are direct stakeholders in this, the media and police too have an important role to play in preventing violence against doctors and hospital staff.

Guideline for media

·         No media trial

·         Negative news about the doctors should not be published

·         Name of the doctor and patient should not be published.

·         No news story should be reported without proper verification

Guideline for police officers

·           To be sensitized about the violence against doctors Act

·           To be sensitized about the guidelines as laid down by Hon’ble Supreme Court in Jacob Mathew case

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Assistant Ambulance Officers: Save a Life First

Reproduced from: http://www.indialegallive.com/viewpoint/assistant-ambulance-officers-save-a-life-first-65657, published May 19, 2019

The debate over Assistant Ambulance Officers is needless, as in any medical emergency, what is vital is to save the life of the patient, even by a bystander

By Dr KK Aggarwal

A scheme started by the Delhi government in February seems to have run into trouble and has reached the Delhi High Court. A PIL has said that Assistant Ambulance Officers (AAOs) who are assigned the job of driving two-wheeler First Responder Vehicles should also be trained paramedics. However, the Delhi government has said that they will not transport patients and will only give basic medical assistance until an ambulance arrives.

AAOs have been trained in basic life-support techniques, have commercial driving licences and a work experience of more than 20 years. However, in this scheme, there is not much efficacy due to the limited knowledge and training of AAOs. They are not even authorised (or qualified) to administer an injection.

To understand their job, we need to first understand the laws. The government has powers to allow healthcare workers to give treatment under Clause 23 of Schedule K of the Drugs and Cosmetics Act.

As per the Clause, drugs supplied by certain categories of workers are exempted from the provisions of Chapter IV of the Act and the Rules which require them to be covered by a sale licence, provided the drugs are supplied under the Health or Family Welfare Programme of the central or state government. The workers are:

·         Multipurpose workers attached to primary health centres/sub-centres.

·         Community health volunteers under the Rural Health Scheme.

·         Nurses, auxiliary nurses, midwives and lady health visitors attached to urban family welfare centres/primary health centres/sub-centres.

·         Anganwadi workers.

Similarly, malaria workers are given anti-malaria drugs and do malaria testing, ASHA workers are allowed to give Gentamicin injections to newborns and methergine for postpartum haemorrhage, a leading cause of maternal mortality, before the patient is transferred to a hospital.

There is also a provision in the Medical Council of India ethics rules where a technician can be trained by a doctor. It does not talk about institutional training. It says: “A registered medical practitioner shall not issue certificates of efficiency in modern medicine to an unqualified or non-medical person.” This does not restrict the proper training and instruction of bona fide students, midwives, dispensers, surgical attendants, skilled mechanical and technical assistants and therapy assistants under the personal supervision of physicians.

Similarly, in cases of a cardiac arrest, even bystanders are allowed to provide cardiopulmonary resuscitation (CPR). There are three phases of cardiac resuscitation lasting a total of 10 minutes. No doctor can reach in 10 minutes in an emergency and that is why a first responder is important.

The first phase of resuscitation is the electrical phase, lasting four to five minutes after sudden cardiac arrest (SCA). Immediate direct current cardioversion is needed to convert an abnormal heart rhythm to a normal heart rhythm. Performing chest compressions while the defibrillator is readied also improves survival. Then, there is the hemodynamic phase or circulatory phase which is from four to 10 minutes after SCA. Chest compressions should be started immediately and continued until just before defibrillation is performed. Then there is the metabolic phase defined as greater than 10 minutes of pulselessness. This is primarily based upon post-resuscitative measures. In these phases, the administration of CPR by a lay person is an important factor in determining patient outcome if the cardiac arrest takes place outside a hospital. Survival after cardiac arrest is greater among those who have bystander CPR as compared to those who initially receive delayed CPR from a trained technician. In addition to improved survival, early restoration in circulation is also seen.

There is also the golden hour in medical practice when immediate care is required. Delay in treatment even by a few minutes can take away a life. In emergency medicine, the golden hour refers to the first hour following a traumatic injury during which time there is the greatest likelihood that prompt medical treatment will prevent death.

If bleeding can be stopped and a person infused with enough fluids within the first hour, most trauma deaths can be avoided. There is also the platinum 10 minutes which refers to the first 10 minutes after trauma when first-aid can be started.

The importance of time in medicine can be gauged from the following:

·         Door to ECG Time: This is an important terminology in the treatment of heart attack. One should get an ECG within 10 minutes of chest pain. A prolonged door-to-ECG time is associated with an increased risk in a heart attack.

·         Door-to-doctor time in paralysis: In an emergency department, the time from the arrival of the patient to initial physician evaluation should be less than 10 minutes in strokes, otherwise the mortality will be high.

·         Door to antibiotic time in community acquired pneumonia is the time to start antibiotics. Guidelines suggest that all patients hospitalised with community acquired pneumonia should receive antibiotics within four hours of admission in a hospital.

·         Door to antibiotic time in meningitis of more than six hours is linked to high mortality.

·         Door to needle time in an acute heart attack is the time before which a clot-dissolving drug should be given.

·         Door to balloon time is less than 90 minutes for angioplasty and stenting in acute heart attack.

Even the Indian Penal Code (Section 92) recognises the importance of an act done in good faith with consent. It says: “Nothing is an offence by reason of any harm which it may cause to a person for whose benefit it is done in good faith, even without that person’s consent, if the circumstances are such that it is impossible for that person to signify consent, or if that person is incapable of giving consent, and has no guardian or other person in lawful charge of him from whom it is possible to obtain consent in time for the thing to be done with benefit.”

In that sense, motorcycle first responders are important. They are not doctors and will give life-saving intervention only when required. Under Section 88, the same Act is not an offence if done with consent. Calling an ambulance is an implied consent.

In this whole issue, there is the question of paramedics. Are there enough paramedic courses, colleges and councils? From the Red Cross, one can do a short course on first-aid and qualify to be a paramedic. But is that enough?

The answer lies in training and not the degree as far as first-aid is concerned. It is important to manage the golden hour and hand over the patient to qualified doctors with the arrival of a proper ambulance.

Time is of essence in medical care and if basic first-aid is being given, why quibble about whether the person has a paramedical degree or not?

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Beware of Fake News: Always look for evidence of a story

Yesterday was 1st April, which has customarily been celebrated as April Fool’s Day. And practically, all of us have been inadvertently victims of a hoax or prank by a friend on this day, at some point of time or the other. But this was all good fun and in good spirits.

But, now fake news or hoax is flooding the social media as it has become “the platform” for exchange of news or information, which can be either true or false.

The New York Times defined “fake news” on the Internet as false articles deliberately fabricated to deceive readers, generally with the goal of profiting through clickbait. Clickbait is content whose main purpose is to attract attention and encourage visitors to click on a link to a particular web page (Toronto Public Library. https://www.torontopubliclibrary.ca/spotfakenews/).

Whenever we come across a news story, we want an evidence or proof of that. The evidence can be in six different forms in the most to least importance piece of evidence.

1.     Pratyakṣa (प्रत्यक्ष) or directly perceived by any of the five senses. This is the strongest piece of evidence. In this we have seen, heard, tasted, smelt or felt the evidence with our own senses. It is not through hearsay or based on gossip. Original research is the classical example and given the maximum weightage.

2.     Anumāna (अनुमान) or inference is the next most reliable evidence. It is a research analysis based on observations, previous findings and applying reason or hypothesis. Observing smoke and inferring fire is an example of Anumana. It is based on pratijna (hypothesis like null’s in medicine), hetu (a reason), and drshtanta (examples). All our medical researches based on statistics are based on this principle.  Systematic reviews, meta-analysis, guidelines come in this category.

3.     Upamāna (उपमान) is based on comparison and analogy. We assume things based on one or more observations. Like in an epidemic of dengue we presume fever deaths due to dengue only.  All observations studies come in this segment

4.     Arthāpatti (अर्थापत्ति) means postulation, derivation from circumstances.

5.     Anupalabdi (अनुपलब्धि) means non-perception, negative/cognitive proof based on principal negation or differential diagnosis. You rule out other causes and then presume an answer.

6.     Śabda (शब्द) means relying on word, testimony of past or present reliable experts. The interpretation is important but least reliable in terms of evidence.  

Making false claims is unethical.

·         MCI Ethics 6.8 (h) Endorsement: A medical practitioner shall not endorse any drug or product of the industry publically. Any study conducted on the efficacy or otherwise of such products shall be presented to and / or through appropriate scientific bodies or published in appropriate scientific journals in a proper way”.

·         The Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954 is an Act of the Parliament of India which controls advertising of drugs in India. It prohibits advertisements of drugs and remedies that claim to have magical properties, and makes doing so a cognizable offence. The law prohibits advertising (claims) of drugs and remedies for inducing miscarriage or preventing conception in women, improving or maintaining the capacity for sexual pleasure, correction of menstrual disorders, curing, diagnosing or preventing any disease or condition mentioned in an included schedule (54 diseases under this restriction Appendicitis, Arteriosclerosis, Blindness, Blood poisoning, Bright's disease, Cancer, Cataract, Deafness, Diabetes, Diseases and Disorders of brain, Diseases and Disorders of the optical system, Diseases and Disorders of the uterus, Disorders of menstrual flow, Disorders of the nervous system, Disorders of the prostatic gland, Dropsy, Epilepsy, Female diseases (in general), Fevers (in general),Fits, Form and structure of the female bust, Gall stones, kidney stones and bladder stones, Gangrene,Glaucoma, Goitre, Heart diseases, High/low blood pressure, Hydrocele, Hysteria, Infantile paralysis, Insanity, Leprosy, Leucoderma, Lockjaw, Locomotor ataxia, Lupus, Nervous debility, Obesity,Paralysis, Plague, Pleurisy, Pneumonia, Rheumatism, Ruptures, Sexual impotence, Smallpox, Stature of persons, Sterility in women, Trachoma, Tuberculosis, Tumours, Typhoid fever, Ulcers of the gastro-intestinal tract, Venereal diseases, including syphilis, gonorrhoea, soft chancre, venereal granuloma and lympho granuloma).

Spreading false news is punishable under Section 66A of the Information Technology Act, 2000 “Punishment for sending offensive messages through communication service etc.”, which states as follows: “Any person who sends, by means of a computer resource or a communication device-

(a) Any information that is grossly offensive or has menacing character or

(b) Any information which he knows to be false, but for the purpose of causing annoyance, inconvenience, danger, obstruction, insult, injury, criminal intimidation, enmity, hatred or ill will, persistently by making use of such computer resource or a communication de4vice, or

(c) Any electronic mail or electronic mail message for the purpose causing annoyance or inconvenience or to deliver or to mislead the addressee or receipt about the origin of such messages, Shall be punishable with imprisonment for a term which may extend to three years and with fine.

Explanation – For the purposes of this section, terms “electronic mail” and “electronic mail message” means a message or information created or transmitted or received on a computer, computer system, computer resource or communication device including attachments in text, image, audio, video and any other electronic record, which may be transmitted with the message.”

Identity theft, cheating by personation, sharing obscene material in electronic form are also punishable under the IT Act as follows:

·         Section 66C of the IT Act, 2000: Punishment for identity theft- Whoever, fraudulently or dishonestly make use of the electronic signature, password or any other unique identification feature of any other person, shall be punished with imprisonment of either description for a term which may extend to three years and shall also be liable to fine with may extend to rupees one lakh.

·         Section 66D of the IT Act, 2000: Punishment for cheating by personation by using computer resource – Whoever, by means for any communication device or computer resource cheats by personating, shall be punished with imprisonment of either description for a term which may extend to three years and shall also be liable to fine which may extend to one lakh rupees.

·         Section 67 of the IT Act, 2000: Punishment for publishing or transmitting obscene material in electronic form – Whoever publishes or transmits or causes to be published or transmitted in the electronic form, any material which is lascivious or appeals to the prurient interest or if its effect is such as to tend to deprave and corrupt persons who are likely, having regard to all relevant circumstances, to read, see or hear the matter contained or embodied in it, shall be punished on first conviction with imprisonment of either description for a term which may extend to three years and with fine which may extend to five lakh rupees and in the event of second or subsequent conviction with imprisonment of either description for a term which may extend to five years and also with fine which may extend to ten lakh rupees.

·         Section 84B of IT Act, 2000: Punishment for abetment of offences: Whoever abets any offence shall, if the act abetted is committed in consequence of the abetment, and no express provision is made by this Act for punishment of such abetment, be punished with the punishment provided for the offence under this Act. Explanation – An act or offence is said to be committed in consequence of abetment, when it is committed in consequence if the instigation, or in pursuance of the conspiracy, or with the aide which constitutes the abetment.

·         Section 84C of IT Act, 2000: Punishment for attempt to commit offences- Whoever attempts to commit an offence punishable by this Act or causes such an offence to be committed, and in such an attempt does any act towards the commission of the offence shall, where no express provision is made for the punishment of such attempt, be punished with imprisonment of any description provided for the offence, for a term which may extend to one-half of the longest term of imprisonment provided for that offence, or with such as is provided for the offence, or with both.

A person who spreads false news can also be prosecuted under various sections of the Indian Penal Code.

·         Section 177 IPC: Furnishing false information.—Whoever, being legally bound to furnish information on any subject to any public servant, as such, furnishes, as true, information on the subject which he knows or has reason to believe to be false, shall be punished with simple imprisonment for a term which may extend to six months, or with fine which may extend to one thousand rupees, or with both; or, if the information which he is legally bound to give respects the commission of an offence, or is required for the purpose of preventing the commission of an offence, or in order to the apprehension of an offender, with imprisonment of either descrip­tion for a term which may extend to two years, or with fine, or with both.

·         Section 416 IPC: A person is said to “cheat by personation” if he cheats by pretending to be some other person, or by knowingly substituting one person for another, or representing that he or any other person is a person other than he or such other person really is. Explanation.—The offence is committed whether the individual personated is a real or imaginary person.

·         Section 419 IPC: Whoever cheats by personation shall be punished with imprisonment of either description for a term which may extend to three years, or with fine, or with both.

·         Section 499 IPC: A person who by words either spoken or intended to be read, or by signs or by visible representations, makes or publishes any imputation concerning any person intending to harm, or knowing or having reason to believe that such imputation will harm, the reputation of such person, is said, except in the cases hereinafter expected, to defame that person.

·         Section 500 IPC: A person who defames another shall be punished with simple imprisonment for a term which may extend to two years, or with fine, or with both.

Fake news was named as the Word of the Year by Collins Dictionary in 2017.

Fake news is deliberate misinformation and disinformation not only in the social media but also in the regular mainstream media. The intent is to mislead.

Hence, it becomes extremely important to recognize fake news and differentiate it from genuine news.

There should be a law against fake news as it can generate social unrest in the community and polarize society into groups. Agitations may be an unwanted consequence of fake news.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA