Cardiac arrest and death during elective stenting

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No surgery is safe. In every so-called safe surgery, one should take consent about unexpected complications and chances of death on the table or proximal optimization technique (POT) stenting.

A new European registry analysis presented at the Congress of the European Association of Percutaneous Cardiovascular Intervention (EuroPCR) 2019 has identified high rates of unexpected cardiac arrest and death in patients undergoing elective percutaneous coronary intervention (PCI).

An analysis of more than 113,000 elective cases performed at high-volume PCI centers shows that 330 patients arrested during PCI, or one per 344 procedures.

Of these, 162 patients actually died on the table (20%) or during the first 24 hours (29%), corresponding to one death per 702 procedures. Survival was independent of the cause of cardiac arrest. Mortality in these patients is always around 50% if someone arrests on your table.

Patients with a low SYNTAX score or normal ejection fraction typically arrested because of a technical complication, the proportion arresting because of cumulative ischemia rose with increasing SYNTAX score and worsening ejection fraction. Prognosis was worse if the LVEF was less than 35% and the SYNTAX score more than 30; mortality was inversely related to both.

Among the 29 patients who underwent salvage coronary artery bypass graft surgery, mortality was quite high, at 62%.

All patients who were referred for surgery with a coronary perforation died.

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

Institutions liability is much more than treating doctors liability

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The Hon’ble Supreme Court in Malay Kumar Ganguly v. Dr. Sukumar Mukherjee, (2009) 9 SCC 221, case has preferred Bolitho test to Bolam test.

Bolitho test: A legal test that modified the 1957 Bolam test, which the English courts had been using to determine medical negligence by a doctor or nurse. In Bolitho v City and Hackney Health Authority, 1997, Lord Browne-Wilkinson restricted the boundaries of Bolam, stating

(1) “The court should not accept a defence argument as being ‘reasonable’, ‘respectable’ or ‘responsible’ without first assessing whether such opinion is susceptible to logical analysis”, and

(2) “However, where there is a body of medical opinion which represents itself as ‘reasonable’, ‘respectable’ or ‘responsible’ it will be rare for the court to be able to hold such opinion to be other than represented”.

The Supreme Court redefined medical negligence saying that the quality of care to be expected of a medical establishment should be in tune with and directly proportional to its reputation.

The decision also says that the court should take into account patient’s legitimate expectations from the hospital or the concerned specialist doctor.

In the instant case we are of the considered view that there is negligence in the treatment rendered to the Patient with respect to the time and manner in which the Patient was shifted from the 3 floor ICU to the 12 floor ICU, the unexplained cause for Bradycardia, which is not in accordance with what was laid down by the Hon’ble Supreme Court in Savita Garg, the absence of medical record specifying the treatment rendered to the Patient between 9 a.m. to 10.30 a.m. in the ICU.

Having regard to the fact that the Patient was in the Hospital for a period of 8 months; in a coma for a period of almost three years; the bills filed towards medical expenses amounting to 16,93,010.00 (excluding the mediclaim amount of 3,75,000/-) and the expenses incurred post discharge, when the Patient was in a coma, and also the mental agony suffered by the Patient’s family, the aspect of restitutio in integrum, and the Patient’s age, we are of the view that awarding an amount of 30,00,000/- (Thirty Lakhs) to be paid by the Hospital would meet the ends of justice.

We also award costs of 1,00,000/- (One Lakh) to be paid by both the Doctors jointly and severally as we hold that ‘Duty of Care does not end with the Surgery’.

In the result, this Appeal is allowed in part and the order of the State Commission is set aside and we direct the Hospital to pay an amount of 30,00,000/- (Thirty Lakhs) and costs of 1,00,000/- (One Lakh) to be paid by both the Doctors jointly and severally. Time for compliance four weeks from the date of receipt of a certified copy of this order, failing which the amount shall attract interest @ 9% p.a. from the date of filing of the Complaint till the date of realisation.

NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI FIRST APPEAL NO. 101 OF 2016 (Against the Order dated 27/11/2015 in Complaint No. 87/2006 of the State Commission Maharashtra) 1. PANKAJ R. TOPRANI & 3 ORS. Vs Bombay hospital and others

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

Courts should make guidelines and leave it to the medical boards and not handle the cases themselves?

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Now and then women approach the courts for termination for pregnancy on medical grounds. Instead of approaching the courts, the government should come out with clear cut guidelines, based on which the medical board can take a decision in such cases.

Like in MCI ethics regulation 6.7 “ …the question of withdrawing supporting devices to sustain cardio-pulmonary function even after brain death, shall be decided only by a team of doctors and not merely by the treating physician alone…”

The following two cases illustrate this.

Terminations under 20 weeks isn’t our business: High Court

Unwanted pregnancies under 20 weeks can be medically terminated by doctors directly, and the woman need not be referred to medical board nor be asked to approach courts for remedy, the Madras high court has said. The court also said doctors & police officials need to be sensitized to the issues surrounding unwanted pregnancies as they often misconstrue the provisions of Termination of Pregnancy Act.

Coming to the rescue of a woman who wanted to terminate her eight-week-old fetus forced on her by a man known to her, Justice Anand Venkatesh said if a criminal case is pending, samples will be taken for DNA test of both mother & the conceptus (fetus & placenta).

In all cases, where a victim girl suffers an unwanted pregnancy & where the length of pregnancy does not exceed 20 weeks, the victim girl need not be referred to the medical board & the termination of pregnancy can be done as per the provisions of Act. The victim girl should not be unnecessarily made to knock the doors of this court.

Madras High Court allows termination of 26-week pregnancy

The Madras high court has allowed the termination of a woman’s 26-week pregnancy after medical tests revealed that the fetus had health complications and the child would require multiple and extensive surgeries with a remote chance of survival.

The Trichy woman moved the court seeking permission to terminate the pregnancy after the legally permissible gestation time of 20 weeks. Scan reports during the 18th week of her pregnancy revealed that the fetus seemed to have dilated ventricles — a brain condition.

The court, subsequently directed her to appear for a medical examination at the Tuticorin Government Medical College Hospital, where a medical board comprising a paediatrician, neurosurgeon, neurologist, cardiologist & obstetrician assessed her previous medical reports & subjected her to various tests & filed a report before the court.

The medical board was of the unanimous opinion that the woman should be allowed to abort the fetus. The bench cited the medical expert’s opinion & said, “Even if the child in the womb is born, its survival will be medically remote as it has to confront numerous surgeries, which cannot assure its longevity.” In such circumstances, if the pregnancy is not ordered to be terminated, the woman would be subjected to mental trauma & hardship, the court ruled.

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

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