Video reveals ignorance, not negligence: Doctors

Tribune (Excerpts): A viral video shot inside Kashmir valley’s main tertiary care hospital showed a patient with his abdomen slit open and attendants pleading for help and alleging doctors of negligence. An inquiry was ordered immediately. 

The complete picture of the video, however, reveals it was the ignorance of the attendants and not the negligence of the doctors.

The patient, suffered from wound dehiscence and also peritoneal carcinomatosis, a rare type of cancer that can develop when gastrointestinal cancer spread and cause tumors to grow in the thin layer of tissue that lines the abdomen and covers most of the abdominal organs.

In such cases, once the wound has opened up (dehiscence), a time gap is given before secondary suturing.

Wound dehiscence 

Wound dehiscence or opening of the wound along the line of incision, occasionally occurs in surgical wounds postoperatively despite a carefully performed layered closure. It is common in the first week after the surgery.

The risk of wound dehiscence is increased by factors such as wounds in high-tension areas (superior trunk, proximal upper extremities), older age, malnutrition, anemia, diabetes, intra-abdominal infection, poor patient compliance to postoperative advice, drugs such as systemic corticosteroids.

Surgical wounds that heal by primary intention are healed 5-10% after one week and after 1 to 2 months, they are 50% healed. About 80% of normal skin strength is regained several months after the surgery. Hence, it is important to avoid stress during the first few weeks after the surgery.

Even mild activity may adversely affect the strength of the wound sutures. Patients should be advised to limit lifting no more than 15 pounds for two weeks after surgery and only gradually increasing activity as tolerated. Walking can be continued within a day or two of surgery. Elevation of leg to decrease edema in lower extremity wounds may put stress on the healing wound.

What is carcinomatosis?

Carcinomatosis is a condition in which cancer is spread widely throughout the body, or, in some cases, to a relatively large region of the body. It is also called carcinosis.

Peritoneal carcinomatosis

Several gastrointestinal and gynecological malignancies have the potential to disseminate and grow in the peritoneal cavity called peritoneal carcinomatosis. It is often associated with disease progression and poor prognosis.

Peritoneal carcinomatosis has been shown to significantly decrease overall survival in patients with liver and/or extraperitoneal metastases from gastrointestinal cancer. Moreover, overall survival in these patients is usually only slightly influenced by systemic chemotherapy. Hence, peritoneal carcinomatosis is traditionally regarded by the surgeon as a terminal condition.

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

Emedinews: Insights on Medicolegal issues - Insect, spider and scorpion stings and bites

The world's most venomous and poisonous insects are fire ants and the harvester ants

Insect venoms are comprised of amino acid peptides and proteins. Venoms may also contain allergenic proteins, which can trigger a potentially lethal immune response in sensitive individuals Biting and stinging are separate actions in ants. Some ants bite and do not sting. Some bite and spray venom on the bitten area. Some bite and inject formic acid with a stinger. Harvester and fireants bite and sting in a two-part process. The ants will grab hold with their mandibles, and then pivot around, repeatedly stinging and injecting venom.

• Do find out about the poisonous insects, caterpillars, spiders, and scorpions in your area. Learn what they look like and where they live.

• To protect yourself from bee stings when working among flowers or fruits, wear long trousers, long-sleeved shirts and gloves, and cover your head and face as much as possible. Avoid wearing things that attract bees, such as bright flowery clothing, bright shiny jewelry, buttons or buckles, or using scented perfume, soap or shampoo.

• Do not walk outdoors in bare feet or open shoes.

• Do not touch insects, caterpillars, spiders, scorpions, or centipedes.

• Do not put your hands in leaf litter, rotten tree trunks or holes where insects, caterpillars, spiders, scorpions or centipedes might live.

(Ref: IPCS, the United Nations Environment Programme, ILO and the World Health Organization)
(Contributed by Dr Sudhir Gupta)

Emedinews: Insights on Medicolegal issues: What are the organo phosphorous poisons?

They are derived from phosphoric acids and form two series of compounds known as alkyl phosphates, and aryl phosphates

• These are basically chemical insecticides and used to prevent agricultural products but when ingested by humans adversely affect health or may become life-threatening.
• Fatal dose: TEPP 50 mg IM or 100 mg orally/OMPA 80 mg IM or 175 mg orally/ Parathion 80 mg IM or 175 mg orally/HETP 60 mg IM or 350 mg orally/Malathion and diazinon 1g orally
• The fatal period is usually within 24 hours in untreated cases and within 10 days in those treated cases when treatment is not successful. In non-fatal cases, the acute effect lasts for 6 to 30 hours which disappear in 2 to 3 days but may sometime persist for 2 weeks. Complete recovery occurs in 10 days in patients treated early.
• Atropine is the antidote.
• Cause of death is by paralysis of respiratory muscles, respiratory arrests due to failure of respiratory centre or intense bronchi constriction resulting in respiratory failure.

(Contributed by Dr Sudhir Gupta)

Emedinews - Insight on medicolegal issues:Silver may also cause toxicity?

Silver nitrate, also known as lunar caustic or lapis infernalis, may cause toxicity when administered internally.

·         It occurs as colorless rhombic crystal and its solution has a styptic metallic taste with acidic reaction. silver nitrate is used externally by doctor as styptic and a destroyer of exuberant granulation and warts

·         It is also used in photography, silver plating and is a chief ingredient of indelible ink and hair dye. Silver proteinate are colloidal silver compound which are used in ophthalmic practice

·         When administered orally it causes severe pain in throat as well as stomach and induces severe vomiting. The vomited matter is flaky white but turns black when exposed to light. Two grams of silver nitrate may cause death in few hours.

·         In case of toxicity, stomach should be washed with milk mixed with sodium chloride in a proportion of 15 gram in 500 ml of milk. Water works as antidote and should be given because it forms insoluble silver salt. The demulcent and purgative should be given to the patient after recovery along with therapy for shock.

(Contributed by Dr Sudhir Gupta)

Emedinews: Insights on Medicolegal issues - Firearm injuries of the head

In most firearm injuries of the head, the bullet passes completely through the skull. As it enters the skull, the bullet produces a clean cut hole in the outer table and a larger hole in the inner table. At its point of exit, these conditions are reversed and the hole in the outer table is larger than the hole in the inner table. 

• These facts are often of importance in determining the direction of fire in bullet injuries of the head. The track of a bullet through the brain tissues varies greatly, depending on the range and stability of the bullet. 
• On the other hand, if it remains high velocity at the time that it impacts with the skull, there may be considerable damage from the cavitation effect within the skull. Fissured fractures often radiate through the vault and base of the skull from the bullet entrance and exit holes.
• In certain bullet injuries of the head, the bullet may fail to emerge from the skull and in these cases an area of bony comminuting is often found at the site of lodgment. 
• When a bullet strikes the head at a tangent, penetration of the skull may final to occur, but the force of the bullet may be sufficient to fragment the inside table at the site of impact. 

(Contributed by Dr Sudhir Gupta)

Emedinews: Insights on Medicolegal issues - Firearm injuries

When bullets produce tracks in dense tissues, such as muscle, liver, spleen and blood, the tissues are compressed ahead of the track by a compression wave, in the form of a shock wave of spherical form.

·         Tissue damage can also be produced at a considerable distance away from the original bullet track. Thus, the urinary bladder, stomach and colon may be ruptured in high velocity wounds situated at a remote distance from the abdominal cavity itself. Intermediate tissue damage. 

·        After a high velocity missile wound has been inflicted on the tissues, several zones of tissue damage can be identified.  The site of the permanent local track is marked by tissues which have been totally destroyed, and this is similar to low-velocity bullets. Surrounding this is a layer of necrotic debris caused by the temporary cavitations effect and secondary missiles, highly contaminated by micro-organisms.

         A variable thickness layer of live tissue surrounds the zone of necrosis, consisting of an inner portion which will prove to be non-viable as a result of the injuries sustained, and an outer portion that will remain viable provided that optimum conditions are provided for healing. Around this zone is normal tissue.

Emedinews : Insights on Medicolegal issues: DNA tests are run at least twice, both independent of each other

No two people, except identical twins, have the same DNA structure

·   DNA testing is done by taking DNA extracts from biological sample putting them into a gel matrix and then using probes to help extract certain markers. Human being has a unique signature that lives within every cell of our body. This signature is commonly known as DNA.

·   Testing can be done on DNA to help determine parentage, ancestry, presence of genetically based diseases and to help identify someone who may have been present at a crime scene

·   Most DNA tests are run at least twice, both independent of each other. This not only builds upon the credibility of the test but also helps ensure that no wrong data or incorrect marker analysis was performed on the first test. If any discrepancies are detected between the two tests then a new sample is used and the entire test is performed again to understand where the discrepancy may lay.

·      We get our DNA from our biological mother and biological father. Each of them contributes 50% of our chromosomes that will make up our DNA – this same DNA will stay with us for our entire lives without change. This is the very reason that makes DNA such a great choice for uniquely identifying a person.

·    Questions may arise as to how accurate DNA tests are. After all, in the past blood tests can not been as accurate as we might have hoped. They often left a bit of uncertainty or could not be conclusive in many areas. But thanks to the uniqueness of DNA almost all of these doubts can be taken away.

·     Modern testing procedures and rules for DNA analysis mean that with rare exception DNA testing results can be guaranteed to be more than ninety percent accurate for most paternity, forensic and genetically based disease analysis. However human error can come into play. A lab may mistakenly switch samples or key in data incorrectly. All of these factors are possible, but also are very rare in occurrence. If there is ever any doubt as to the authenticity or correctness of a test it can simply be performed again to confirm accuracy in another or same lab.

(Contributed by Dr Sudhir Gupta)

Emedinews: Insights on Medicolegal issues - Doctor should have good grasp of the legal process

The percentage of patients injured by medical negligence who actually file a lawsuit is very small. The estimates range from one in 8 to one in 10, and of those who file lawsuits, only one in three receives any compensation - American college of legal medicine

·         Prophylactic awareness by physicians of malpractice liability, coupled with the adoption of preventive programs, should minimize allegations of malpractice.

·         Victory is achievable when preventative alertness diminishes the need for aggressive legal defense. Competently trained, experienced physicians and surgeons are mindful of legal liability. They follow a course of medical and surgical care that is commensurate and consistent with their skill, knowledge, ability, and experience. Such physicians and surgeons, when accused of medical malpractice, rarely lose in a court of law.

Emedinews - Insight on medicolegal issues: Defeat a negligence claim by showing the absence of elements of medical negligence

If a physician can show that no physician-patient relationship exists, this “no duty” defense may suffice to defeat the plaintiff’s action. Where there is no duty owed to the patient by the physician, a negligence claim generally fails.

• Doctors generally have no duty to treat new patients or patients of years past, with some exceptions. This may be true even where the physician is “on call”. In some cases, even though a physician treats or diagnoses a condition, a duty exists only between the physician and the patient’s employer.

• Courts rarely hold that the “no duty” defense applies and have even held that a simple telephone consultation between a physician and emergency department personnel may be sufficient to create a professional relationship between the physician and patient, with the attendant requirement to comply with such duty. Pre-certification review of a case may also create the potential for liability.

• Physician who wishes to withdraw from the care of certain patients, plans to relocate his or her practice, or simple retires must notify affected patients in a manner in which an ordinary and reasonably prudent physician would do so in the same circumstances. Such notice is best made in writing and mailed postage paid to the patient’s last known address.

• All patients receiving ongoing care for potentially serious ailments should be notified by certified mail, return receipt requested, at the last known address. Such patients should be informed that their physician will continue to see them for emergencies during a certain fixed and reasonable period of time. The physician may recommend a successor physician, provide a list of suitable physicians or offer to forward records or copies of records (at reasonable or no cost) to another physician chosen by the patient.

(Ref: American College of Legal Medicine, The Medical Malpractice Survival Handbook)

(Contributed by Dr Sudhir Gupta)

National conference on Insight on medical issues

Medical accident is not medical negligence : Inaugurating, a daylong national conference on "Insight on Medicolegal Issues", Hon’ble Justice A K Sikri, Hon’ble Judge Delhi High Court said that a better and continuous patient–doctor relationship can reduce most of the litigations occurring in the field of medical care.

Addressing a gather of over 300 doctors, Hon’ble Justice Vipin Sanghi, Hon’ble Judge Delhi High Court, said that a medical professional is not supposed to possess and provide maximum degree of knowledge skills and care. He is only expected to provide and possess an average degree of care, knowledge and skills.
Dr. H S Rissam, Member, Board of Directors, Medical Council of India, in his address said that most important thing a doctor must maintain is proper records of the patient and take informed consent for undertaking any treatment.

Padma Shri & Dr. B.C. Roy Awardee, Dr. KK Aggarwal, President Heart Care Foundation of India, said that medical accidents are not synonymous with medical negligence. Medical accidents are now classified as sentinel events or events which are unexpected and end up in complications or untoward effects. Quoting a recent US Study, Dr. Aggarwal said that wrong site surgical operations are the third most common sentinel events all over the world. All sentinel events will end up into a claim. These events may or may not be medical negligence.

Dr. A K Aggarwal, President Delhi Medical Council said that there are a number of ‘never events’ which should not happen while treatment is given. Citing an example, he said that leaving a surgical instrument or a sponge inside the abdomen will fall under ‘never events’ and is not pardonable. In the US, insurance companies have started refusing to pay for the treatment of such events.

The faculty included eminent doctors and advocates. Senior advocates who spoke on the occasion were Mr. Mukul Rohtagi, Mr. Ajay Agrawal, Ms Priya, Ms Meenakshi Lekhi, Mr. M C Gupta,
Mr. Sidhartha Luthra and Ms Indu Malhotra.

The medical faculty included Dr. Ranjit Roy Chaudhury, Dr. H S Risam, Dr. Navin Dang, Dr. Neelam Mohan, Dr. N P Singh, Dr. Sanjiv Malik, Dr. Anupam Sibal, Dr. Ajay Gambhir, Dr. Vijay Aggarwal, Dr. Girish Tyagi and Dr. Sudhir Gupta etc.