Gorakhpur Tragedy: Findings of the IMA Inquiry Committee

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Dr KK Aggarwal
National President, IMA

The Gorakhpur tragedy, where many innocent lives were lost, has shaken the nation and stirred a debate in the country.

Taking cognizance of the seriousness of the situation, Indian Medical Association (IMA) HQs constituted an Inquiry Committee comprising of Prof KP Kushwaha, Former Principal & Head, Dept of Pediatrics, Medical College Gorakhpur; Dr Ashok Agarwal, National Vice President IMA and Dr BB Gupta, President IMA Gorakhpur Branch.

The committee also asked the following doctors to appear before it to present their case.

• Prof Dr Rajiv Mishra, Principal BRD Medical College, Gorakhpur at the time of the incident
• Prof Dr Satish Kumar, Head, Dept. of Anaesthesia, Medical College, Gorakhpur
• Dr Mahima Mittal, Associate Prof, Dept. of Paediatrics, Medical College, Gorakhpur
• Dr Kafeel Khan, Asst. Prof and Nodal Officer, Encephalitis Ward, Dept. of Paediatrics, Medical College, Gorakhpur
• Dr AK Shrivastava, Superintendent in Chief, Nehru Hospital, Medical College, Gorakhpur

But, the above doctors failed to appear before the Inquiry Committee, which then decided to visit the Dept. of Pediatrics in the Medical College.

People there were hesitant to speak. The scope of the Committee was to only examine the working of the doctors as other issues such as lack of oxygen, inadequate staff and any structural deficiency were being investigated by the Chief Secy, UP Govt.

The committee also took note of the various reports published in the newspapers and other media. The following conclusions were arrived at:

• Oxygen supply was interrupted for a short time on the night of August 10, 2017.
• The liquid oxygen supplier had not been paid his dues since last 5-6 months.
• Cleanliness of hospital and ward was unsatisfactory. Presence of dogs and rats in hospitals is not acceptable by any standards in the hospital premises.
• The hospital was handling these cases and other critically ill patients much more than its capacity.
• There is no facility in Gorakhpur and nearby districts to manage encephalitis.
• There is a lack of staff – paediatricians, nurses and other paramedical staff – in PHCs/CHCs.
• ICUs in 10 districts of Poorvanchal area are not functioning because of lack of staff and other resources.
• No alert was issued by the hospital administration regarding shortage of oxygen, The traeting doctors should have been alerted seven days before the fresh oxygen supply was not received.

According to the IMA, although there is no evidence of medical clinical negligence against Dr Rajiv Mishra and Dr Kafeel Khan, prima facie it appears that a case of administrative negligence against them cannot be ruled out. Hence, administrative inquiry and action may be taken against them.

The recent movie ‘Airlift’ was based on the true story of evacuation – airlifted – of several hundreds of Indians from Kuwait during the first Gulf war and brought back to the country.

Similarly, we read about ‘green corridors’ without any traffic disruptions being set up to transport harvested organs like heart to reach another hospital, where there is a patient waiting to receive the organ. It’s an emergency where time is of utmost importance.

Why can’t the same be done in situations such as the Gorakhpur tragedy, where an epidemic of encephalitis recurs every year and, many children lose their lives every year because of the illness?

In view of this tragedy, IMA has suggested the following to avoid similar situation in the future.

• There should be a state policy to airlift such critically patients in a timely manner to nearby best facilities.
• All patients denied treatment at government hospitals should be reimbursed for the cost of treatment in the private sector at pre-defined rates.
• All hospitals should have back up of one-week supply of all essential drugs, investigations and oxygen.
• IRDA has made it mandatory for all private hospitals to get NABH accreditation. The same should be extended to all government set ups.
• Essential drugs and investigations, not non-essential drugs and tests, should constitute the bulk of the expenditure of the allocated budget to reduce the cost of treatment.
• All payments for health care services should be made either in advance or in time.
• Doctors are clinicians as well as administrators. It is important to make a distinction between clinical medical negligence and administrative negligence.
Disclaimer: The views expressed in this write up are entirely my own

Dr KK Aggarwal

Will we be ready to tackle future epidemics?

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In the public debate on the Gorakhpur tragedy, several reasons were put forth as to why these deaths occurred. That several factors collectively led to this tragedy is the undeniable truth. Rather than trying to pinpoint who is to be blamed, our focus instead should be preventing further outbreaks in the future.

Dealing with the aftermath of a tragedy is important as also, how we choose to deal with it. And the question that we all should be asking ourselves in this regard is “what can we do to prevent future epidemics” and not “what should have been done and was not done”.

Will we be ready to tackle future epidemics? The answer to this depends on what corrective measures we take today.

A long-term strategy needs to be formulated to deal with such outbreaks. A well-planned surveillance and response system should be in place, which can be mobilized quickly when needed. We need better investment in preparedness.

We have to work together to stop the next outbreak, not only in Gorakhpur, but also any epidemic in the country. Dengue, for example, occurs in epidemic proportions every year.

The Indian Medical Association (IMA) has suggested the following to avoid more incidents like the Gorakhpur tragedy.

• There should be no shortage of staff – doctors, nurses and other supporting staff. Staff deficit affects patient care. Shortage of staff should be supplemented with the services of locum doctors.
• Private doctors can be hired, but only for locum jobs, not as regular doctors.
• The practice of “moonlighting” as is prevalent in the US should be allowed in India.
• There should be a uniform system for Govt. doctors: either practice is allowed or it is not allowed.
• All patients who are denied treatment at government hospitals should be reimbursed for the cost of treatment in the private sector at predefined rates.
• All hospitals should have back up of at least one-week supply of all essential drugs, investigations and oxygen.
• To reduce the cost of treatment, essential drugs and investigations – not non-essential drugs and tests – should constitute the bulk of the expenditure of the allocated budget.
• All payments for health care services should be made either in advance or in time.
• Insurance Regulatory and Development Authority (IRDA) has made it mandatory for all private hospitals to get NABH accreditation. The same should be extended to all government set ups.
• Every death should be audited to find out the probable cause of death and whether it was a preventable death so that future such deaths can be prevented from occurring.
• In any case of negligence, one should differentiate between administrative negligence and medical negligence.

Disclaimer: The views expressed in this write up are entirely my own.

Dr KK Aggarwal

AES Update: This is not the time for a “blame game”

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The recent tragic deaths of children due to encephalitis in Gorakhpur medical college have hit the headlines in the last few days. These deaths also generated a lot of debate on the issue. Unfortunately much of the debate centered on “finger pointing”. This is not the time for a “blame game”.

This is not the first outbreak of acute encephalitis syndrome (AES) in the region. Many such outbreaks have been occurring for several years now and each epidemic has taken a heavy toll of lives.

By now there should have been a state of the art hospital to manage AES patients. There should have also been a research facility to examine why the area is vulnerable to AES, establish effective surveillance systems, plan a response plan, predict future outbreaks etc.

This is the time to look to the future and not talk of the past or even the present outbreak. Drawing from the lessons of the past years, we must be able to anticipate such local outbreaks and be ready to respond to them systematically and in a timely manner to contain them. A research center focusing on AES will help to identify early warning signals for such impending outbreaks.

Anticipation and preparedness will enhance efforts to control and prevent future outbreaks of AES. All stakeholders have equally important roles to play in prevention of any epidemic.

Some key points on AES

• Encephalitis is inflammation of the brain parenchyma. It presents clinically as neurologic dysfunction (altered mental status, behavior, or personality; motor or sensory deficits; speech or movement disorders; seizure)
• Viruses are the most commonly identified infectious causes of encephalitis. Around 10% cases may be due to Japanese encephalitis, scrub typhus and herpes simplex each. Enterovirus and other viruses also cause AES. Bacteria, fungi, and parasites may also cause encephalitis. In many cases of encephalitis, the etiology remains unknown despite extensive evaluation.
• The WHO’s guidelines for JE surveillance recommend syndromic surveillance for JE meaning that all AES cases should be reported (NVBDCP, 2009).
• The NVBDCP 2009 guidelines on management of AES have recommended classification of a suspected case as follows:
o Laboratory-confirmed JE: A suspected case that has been laboratory-confirmed as JE.
o Probable JE: A suspected case that occurs in close geographic and temporal relationship to laboratory-confirmed case of JE, in the context of an outbreak.
o Acute encephalitis syndrome (due to agent other than JE): A suspected case in which diagnostic testing is performed and an etiological agent other than JE virus is identified.
o Acute encephalitis syndrome (due to unknown agent ) A suspected case in which no diagnostic testing is performed or in which testing was performed but no etiological agent was identified or in which the test results were indeterminate.
• The incidence is highest among infants <1 year.
• Status epilepticus, cerebral edema, fluid and electrolyte disturbance, and cardiorespiratory failure are some of the complications of AES.
• ICU care is essential for patients with severe encephalitis (i.e., those with seizures, cardiorespiratory compromise, coma, or severe neurologic compromise) with close cardiorespiratory monitoring and careful attention to neurologic status, fluid balance, and electrolyte status.
• Prognosis of viral encephalitis depends upon the age of the patient, neurologic findings at the time of presentation and the etiopathogen.
• The case fatality and morbidity is very high among various viral encephalitis especially in JE or enterovirus encephalitis.
• Survivors of childhood encephalitis should be monitored for long-term sequelae.
• Scrub typhus encephalitis: Curable with doxycycline or erythromycin if diagnosed early. Look for fever, rash, local black eschar in the legs with enlarged, lymph nodes.
• Japanese encephalitis: Mortality is 20% in the best of the centers. Preventable by vaccination.
• Herpes simplex encephalitis: Can be diagnosed due to temporal lobe localization and can be managed with antivirals.
• Lichi encephalitis is manageable with intravenous glucose.
• Enteroviral encephalitis has limited therapeutic options. Intravenous immunoglobulin (IVIG) is often administered despite a lack of convincing evidence for efficacy.
• All children who present with suspected encephalitis should be treated with acyclovir pending viral studies.
• Empiric treatment for bacterial meningitis pending bacterial cultures also may be warranted if bacterial meningitis cannot be excluded.
• Empiric treatment with doxycycline or erythromycin should be given till scrub typhus is ruled out.
• Prevention strategies include hand hygiene, appropriate management of pregnant women with active herpes simplex virus lesions, routine childhood immunizations, JE vaccine, traveling immunizations, and insect control and avoidance measures. Control of culex mosquito.
• All children who are hospitalized with encephalitis should be placed on airborne, droplet, and contact precautions at the time of admission, pending identification of a pathogen.

Disclaimer: The views expressed in this write up are entirely my own.

Dr KK Aggarwal

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