Recent murder of a doctor by the husband of a patient

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On Tuesday evening, the husband of a pregnant woman, who died due to alleged negligence during surgery by a lady anesthetist of ESI hospital, murdered the treating doctor in Tuticorin district of Tamil Nadu.
This is a matter of national shame and the time cannot be more apt for the medical community to unite for their safety. In most States, “Prevention of Violence and Damage or Loss to the Properties Act” has been passed by the respective Governments. In Tamil Nadu, the Tamil Nadu Medicare Service Persons and Medicare Service (Prevention of Violence and Damage or Loss to Properties) Act 2008 has already been passed and should have been invoked by the Police at the first instance of violence by the patient’s relations. The Government only registered an FIR under section 302 IPC but should also have booked the case under Prevention of Violence and Damage or Loss to Properties Act 2008.
I am surprised that there was a strike or a protest against this case only in Tamil Nadu. All the respective medical associations in the country should have responded aggressively to this incident and pressurized the Government of Tamil Nadu and the Centre to implement this law all over the country in every State and also to expedite the trial of such cases so that others do not dare to indulge in such types of acts.
About the case
On December 30, Mahesh from Aavudaiyaarpuram in Tuticorin (30 years) brought his wife Nithya (24 years) with 24 weeks’ pregnancy to ESI hospital at Beach Road where Dr. K. Sethulakshmi served as anesthetist cum medical officer. The Doctor found that Nithya’s 6-month old fetus had died in the womb and suggested to do a surgery to remove the dead fetus for safety of the life of the mother. During the surgery, Nithya developed HELLP syndrome (Hemolytic anemia, Elevated Liver enzymes and Low Platelet count), a life-threatening complication in later stages of pregnancy. She was transported to a nearby private hospital but died on the way.
1. Was the assault on the doctor justified?
No, it’s illegal and against the law.
2. Was there a medical negligence?
Only an enquiry can tell. Prima facie HELLP syndrome has high mortality.
3. Can an anesthetist operate?
Both yes and no. Yes in emergency, if she is trained, she has done a house job in gynecology and she has been operating, in emergent situations, if gynecologist is not available and only after a full informed consent.
4. The why she did not transfer the patient to nearby hospital in time for surgery?
This is one question which needs to be investigated.

What is HELLP syndrome?
• HELLP syndrome is hemolysis with a microangiopathic blood smear, elevated liver enzymes, and a low platelet count
• It develops in 1 of 1000 pregnancies
• It also develops in 10 to 20 % of pregnancies with severe preeclampsia / eclampsia.
• Most cases are diagnosed between 28 and 36 weeks of gestation.
• Most present with pain and tenderness in the mid epigastrium, right upper quadrant, or below the sternum.
• Many present with nausea, vomiting, and malaise
• Hypertension and proteinuria may be present in 85% cases.
• Characteristic schistocytes are seen on blood smear.
• Indirect bilirubin is raised along with a low serum haptoglobin concentration (≤25 mg/dL).
• Platelet count <100,000 cells/microL.
• Serum LDH >600 IU/L or total bilirubin >1.2 mg/dL.
• Serum AST >70 IU/L.
• The outcome is generally good
• Serious complications such as abruptio placentae, acute renal failure, subcapsular liver hematoma and retinal detachment may occur. If they occur, one must immediately deliver.
• Pregnancies ≥34 weeks of gestation should be delivered
• Pregnancies < 34 weeks of gestation: One may like to deliver after a course of glucocorticoids to accelerate fetal pulmonary maturity
• For gestations < 30 weeks with an unfavorable cervix, one can go for cesarean delivery
• Dexamethasone does not accelerate resolution of laboratory abnormalities or reduce the risk of maternal complications.
Can an anesthetist do LSCS?
1. An anesthetist is an MBBS.
2. An MBBS is a graduate in surgery and hence he/she cannot be legally denied the right to perform surgery.
3. But in today’s scenario one will have to apply the Bolams’ law.
4. He/she can operate provided it’s an emergency; or has adequate training; or has been performing LSCS regularly; or no qualified gynecologist is available/ accessible at that time and required infrastructure is available and that to after proper informed consent.
5. AP Medical Council guidelines: “What Can an MBBS Doctor do:-
(1) Can perform Minor Surgical Procedures for which he is trained in MBBS Course and Houseman Ship.
(2) He can do Deliveries and its related procedures as trained.
(3) He can do National Programmes like Tubectomies & Vasectomies.
(4) In emergencies if a qualified surgeon is not available in the near vicinity as a life savings measures he can do first aid and a Surgical Procedure based on his experience.
(5) He should not do Elective Major Surgical procedures and the care should be taken to refer to a nearby Hospital where a Surgeon / Gynecologist available.
6. In Surinder Kumar (Laddi) and Anr. V. Dr. Santosh Menon and Ors. 2000;(III) CPJ 517, the Punjab State Consumer Commission also held that there is no bar against an MBBS performing a Caesarean section merely on the ground that the doctor does not have a qualification in Gynae-Obs.
(Input Dr M C Gupta)