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    Suggested precautions
    Facts of the case
    Patient's allega...
    Doctor's defense
    Findings of the ...

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Table of Contents   
Year : 2009  |  Volume : 2  |  Issue : 2  |  Page : 13
Consumer and criminal courts bound to take appropriate medical opinion before issuing notice to doctors - Supreme Court

   Suggested precautions 
  1. "Every doctor should, for his own interest, carefully read the Code of Medical Ethics which is part of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 issued by the Medical Council of India under Section 20A read with Section 3(m) of the Indian Medical Council Act. 1956."

  2. "Life is surely more important than side effects."

  3. "Current practices, infrastructure, paramedical and other staff, hygiene, and sterility should be observed strictly."

  4. "No prescription should ordinarily be given without actual examination."

  5. "The tendency to give prescription over the telephone, except in an acute emergency, should be avoided."

  6. "A doctor should not merely go by the version of the patient regarding his symptoms, but should also make his own analysis including tests and investigations where necessary."

  7. "A doctor should not experiment unless necessary and even then he should ordinarily get a written consent from the patient."

  8. "An expert (proper consultant) should be consulted in case of any doubt."

  9. "Full record of the diagnosis, treatment, etc. should be maintained."

  10. Instances of negligence per se :
    1. "Removal of the wrong limb.
    2. Performance of an operation on the wrong patient.
    3. Giving injection of a drug to which the patient is allergic without looking into the out-patient card containing the warning.
    4. Use of wrong gas during the course of an anesthetic, etc."

  11. Criminal liability will be attracted against the erring doctors if he/she:
    1. "Leaves a surgical gauze inside the patient after an operation.
    2. Operates on the wrong part of the body.
    3. Removes an organ for illegitimate trade."

   Facts of the case Top

  • The patient was suffering from chronic renal failure due to bilateral polycystic kidneys. He was undergoing hemodialysis and investigations were underway to find a suitable donor for kidney transplant. He was suffering from high fever but refused to get admitted despite repeated advice of the nephrologist (OP), hence a broad spectrum antibiotic Ampoxim 500 mg four times a day and tablet Crocin for fever were prescribed. On the ninth day of fever the patient finally got admitted. Investigations revealed high creatinine: 13 mg, high blood urea: 180 mg, and low hemoglobin: 4.3 g. Urine culture and sensitivity test showed severe urinary tract infection due to Klebsiella species (1 lac/ml.) and that the infection could be treated by Amikacin or Methenamine Mandelate. Blood culture report showed a serious infection of the blood stream (Staphylococcus species). The patient was administered Amikacin injection 500 mg, twice a day, for three days for urinary tract infection. Capsule Augmentin (375 mg.) was administered three times a day for blood infection and the patient was transfused one unit of blood during dialysis. The temperature of the patient rapidly subsided.

  • On the third day of the treatment, the patient got himself discharged despite medical advice to the contrary. The patient was advised injection Amikacin (500 mg.) twice a day. On the third day of discharge, the patient complained to the nephrologist (OP) that he had slight tinnitus (ringing in the ear) and was immediately advised to stop Amikacin and Augmentin.

  • The patient was successfully operated for kidney transplant in another hospital and returned to his home town. The patient alleged negligence on account of hearing loss.

  • On the directions of the court, AIIMS appointed a medical expert who opined that:

    • the drug Amikacin was administered as a life-saving measure and was rightly used as the sensitivity test showed that the organisms were sensitive to Amikacin;
    • it was impossible to foretell about the sensitivity of a patient to a drug, thereby making it difficult to assess the contributions toward toxicity by the other factors involved;
    • literature on Amikacin mentions that in a life-threatening infection adult dosage may be increased to 500 mg every eight hours but should not be administered for longer than 10 days; and
    • hearing loss in renal patients is a complex problem which is a result of many adverse and unrelated factors and is more likely to be the result of a multifactorial effect than the response to a single agent.

   Patient's allegation/s of medical negligence Top

It was alleged that prescribing Amikacin 500 mg twice a day for 14 days was excessive dosage and caused hearing impairment. It was also alleged that the infection was not of a nature so as to warrant administration of Amikacin. The patient filed opinion of the Chief of Nephrology at Fairview General Hospital, Cleveland, Ohio in support.

   Doctor's defense Top

  • It was stated in defense that urine culture reports clearly showed that the patient was resistant to other antibiotics and could only be treated by Amikacin, as Methenamine Mandelate could not be used due to his chronic renal failure. Amikacin was administered after test dosage. It was further stated that on receiving complaint of slight tinnitus 'X' was marked on the discharge card as well as his wife was also directed verbally to stop injection Amikacin and capsule Augmantine.
  • Medical experts agreed that in severe circumstances, if there is no substitute, Amikacin can be given for a longer period but if the patient develops complications then it should be stopped immediately and hearing loss was reversible in most of the cases after discontinuation of the drug.
  • The urologist who had performed kidney transplant stated that when the patient was admitted under his care he did not complain of hearing problem. The senior nurse who had cared for the patient also deposed similarly.

   Findings of the court Top

  • The supreme court directed all the consumer and criminal courts in India, to issue notices to doctors/hospitals in case of alleged medical negligence only after getting proper medical opinion holding them prima facie negligent.
  • The court held that nephrologist (OP) was faced with a situation where the patient had kidney failure, urinary tract infection, and blood infection, and hence was justified in taking drastic steps to save the life of the patient. The court further observed that the situation was aggravated by the noncooperation of the patient who seemed to be of an assertive nature as deposed by the witnesses.
  • Regarding overdose, the court observed that antibiotics are usually given for a minimum of five days, but there is no upper limit. On the contrary, giving lesser dose creates other complications because it can cause resistance in the bacteria to the drug.
  • As regards hearing loss, the court observed that there is no known antibiotic drug which has no side effect. Moreover, the nephrologist (OP) was desperately trying to save the patient's life and hence refused to hold him responsible merely because there was impairment in hearing of the patient.
  • The court drew adverse inference after perusing cash memo produced by the patient which showed that he continued to take Amikacin for seven days even after he had been instructed to stop it.
  • Hence the nephrologist (OP) was not held negligent.