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2012| May | Volume 5 | Issue 5
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August 25, 2012
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CASES
Care and caution in admitting patients with psychic problems or suicidal tendencies
May 2012, 5(5):63-64
Hospitals and nursing homes admitting psychic patients must be doubly cautious. Providing a full-time nurse or attendant in appropriate cases must be considered as a standard protocol. Another option would be to advise the patient's relatives / friends to always remain with the patient, or even a written assurance can be taken from them regarding the aforesaid. In case there is even an iota of doubt in providing appropriate care, the patient must be transferred to another facility at the earliest or admission must be refused.
Prescribing drugs especially those that have dangerous side effects, requires caution and contemplation. Appropriate instructions regarding the possible complications must be given to the patient and in the case of a hospitalized patient to the nursing staff. (In this case, the allegation against the psychiatrist (OP) was that, although Sertalin was administered to the patient, which results in a suicidal tendency, yet the patient was not properly monitored.)
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Failure to record a simple, innocuous medical act - Court draws adverse inference
May 2012, 5(5):75-76
Every medical act must be duly and appropriately recorded. Failure to record even a simple and innocuous act may at times result in grave consequences. (In this case, the patient had alleged that re-surgery was performed on the fourth day of surgery, whereas, the orthopedic surgeon (OP) stated that it was merely dressing of the wound. The court upheld the allegation observing that, "If it was a dressing of the wound, then it should have been in a regular manner and hospital's record should show it, but no such evidence has been produced by the appellant (the orthopedic surgeon").
If the patient consults another doctor, even if it is without your knowledge, there is no reason to feel offended. Expressing your displeasure before the patient should be avoided at all cost. (In this case, the patient alleged that after he was put on traction, he took an x-ray from another doctor, who told the patient that the surgery was not properly performed, and when this x-ray was disclosed to the orthopedic surgeon (OP) he scolded the patient. Probably the patient drew his own conclusions and the next step was that he got himself hospitalized in another hospital and later sued the orthopedic surgeon (OP) for medical negligence).
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All emergency patients, consumers - Failure to provide medical help, deficiency of service
May 2012, 5(5):61-62
It is legally compulsory to provide all possible medical aid to emergency patients as per the Supreme Court. The consumer courts have held that all emergency patients are consumers even if they have not paid anything to the doctor / hospital, and hence, in the case of any deficiency of service they can approach the consumer courts against the doctor / hospital. The courts view failure to give proper medical aid to an emergency patient, rather seriously. (In this case the court has observed that it was awarding, "exemplary penalty so that in future any young boy / person may not die due to the act of persons like respondent No. 2 (doctor)." Please remember that due to an order of the Supreme Court giving proper medical aid to an emergency patient is mandatory in India and not following the same could invite action even for contempt of Supreme Court and consequently imprisonment for up to six months.
In cases where even first aid is not given to an emergency patient in the
bona fide
belief that delay would be counterproductive, it is advisable that some documentation is done recording the exact condition of the patient and the reason/s for not extending any medical help.
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Taking photographs of the injured / affected parts - A healthy practice
May 2012, 5(5):73-74
Taking photographs of the injured / affected parts before starting treatment, at regular intervals, during the course of treatment and at the time of completion of treatment or discharge, is a healthy practice, especially among certain specialties like orthopedics and plastic surgery. These photographs have therapeutic value, can be used for academic purposes, and can also help as a valuable tool in legal defense.
Patients who are weak or require high and expertise care or constant monitoring, ought to be treated differently and with special attention. Failure to provide this extra care could be negligence. (In this case, the court held the hospital (OP) negligent for prematurely discharging a patient who had pre-existing complicating medical conditions. The court observed that such patients could not be discharged at an earlier date, like a normal patient).
Doctors must avoid interacting in front of the patient. The patient often interprets it in his or her own way, and at times a careless remark by a doctor sows the seeds of suspicion in the patient's mind. (In this case, the patient had alleged that the plastic surgeon had scolded the orthopedic surgeon (OP) in front of the patient for premature discharge).
In case the patient is referred to another consultant, the date/s or the period within which the patient must consult should be specifically written, and a proper reference letter, with complete contact details of the other doctor, should be written specifically and given to the patient.
In case an
Inpatient Department
(IPD) patient is advised to consult a consultant post discharge, this advice must be specifically recorded in the discharge card.
Taking a second opinion, especially in serious and complicated cases, is always advisable.
Premature discharge could be construed as negligence.
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Appointing substitutes / locum in emergencies
May 2012, 5(5):71-72
In case of personal emergencies a doctor can hand over the patient, even serious or emergency patients, to a suitable substitute / locum. The following precautions must be taken in such a situation:
Before leaving the patient, ensure that all the necessary arrangements are in place.
Inform the patient / relatives / attendants about your inability to manage the patient further.
After appointing a substitute / locum duly inform the patient and in appropriate cases provide the contact coordinates of the substitute / locum to the patient. A formal introduction of the locum / substitute to the patient, if possible, is always advisable. Duly record these facts in the patient's medical records.
Brief the locum / substitute properly and completely about the patient.
Hospitals and nursing homes must ensure that whenever nurses or junior doctors inform a patient's condition to another doctor over the phone, it must be duly recorded in the patient's medical records.
The time to perform an elective surgery / procedure must be decided after taking into account the patient's condition and when it is medically indicated, but this decision remains the prerogative of the doctor, although the patient should be consulted and his / her convenience should also be taken into account. (In this case, the court, while rejecting the patient's allegations that the surgery ought to have been performed immediately on admission has very aptly observed that, "the doctors cannot be expected or compelled to perform the surgery forthwith and the doctor alone is the best judge, to choose the time for surgery, though it may be emergency, as they have to think / diagnose and observe the consequence of the surgery also").
Once a surgery / procedure is scheduled, proper planning of all the arrangements, requisition of doctors and material required must be made well in advance, and the medical records must duly record the aforesaid. (In this case, the court has approvingly taken note of the fact that the gynecologist (OP) had made all the arrangements for the next day's surgery and had meticulously recorded the same in the medical records of the patient).
The transferring hospital has the responsibility of arranging the appropriate transportation facilities, informing the doctors, and making the suitable arrangements in the center where the patient is being transferred, in advance.
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Thoughtfulness and purposefulness in allotting rooms to patient
May 2012, 5(5):69-70
Contemplation and thoughtfulness is required in allotting rooms to a patient. Factors like age of the patient, requirements of the particular ailment / disability, convenience of the patient, and so on must be taken into consideration.
In case the patient makes a request for a particular room it must be considered sympathetically, and if possible, it should be granted. (In this case, one of the allegations was that the patient who had delivered a baby, who was kept in the Neonatal Intensive Care Unit (NICU), had requested that a room be allotted to her near the NICU, so that it would be convenient for her to feed her child, but the same was refused.)
Insisting or pressurizing the patient to consult a particular consultant is both illegal and unethical.
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Necessity of preserving non-medical records
May 2012, 5(5):65-66
It is advisable that even non-medical records are prepared properly and kept for a longer period, like records showing name and number of patients admitted or seen in the OPD, number of life-saving equipment present in working condition, steps taken to regularly maintain the equipment, steps taken to control infection in Operation Theater (OT) / Intensive Care Unit (ICU), and so on. This protocol becomes mandatory in cases where a legal problem is anticipated or when a patient has met with a medical mishap. (In this case, the allegation was that the patient died as the ICU and mechanical ventilators were not provided and the hospital's (OP) defense was that both were not free at the relevant time. On the specific directions from the court, the hospital (OP) had to produce relevant records showing how many ventilators were in working condition and the patients who were using them at that point of time.)
Hospitals and nursing homes must ensure that sufficient number of beds in the ICU and equipments like ventilators are present, in working condition. In case a patient needs them and none are free, the patient has to be transferred to another facility at the earliest. The underlying reason for transfer must be duly recorded in the medical records as well as the transfer note / summary.
Regular maintenance and repair of equipment must be given priority, especially life-saving equipment or those used in emergencies. In a hospital or nursing home, especially government, the consumer court may even hold the person responsible for maintenance of equipments personally liable and direct him / her to pay compensation.
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Keeping machines / equipment near the patient - Indispensable in certain cases
May 2012, 5(5):67-68
Failure to keep certain machines / equipment as per standard protocol, especially those required in emergencies, or delay in putting a machine / equipment to use, could be termed as deficiency of service and negligence. (In this case, it was alleged that the heart and lung machine was not in the Catheterization Laboratory (Cath Lab) when the patient was undergoing angioplasty, and the cardiologist (OP) was seen running and bringing it from another room when the patient suffered complications. The court observed that not keeping the machine in the Cath Lab and delay in putting it to use was negligence.)
In case of failure of any equipment, delay in using the equipment when indicated, or such other types of deficiencies, both the doctor and the hospital are liable to pay compensation to the patient.
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