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--------------- Print Magazine --------------
  May 2016
  April 2016
CASE STUDY - By Anoop K. Kaushal
Res Ipsa Loquitur and Standard Texts
Tagore Heart Care and Research Centre Pvt. Ltd.
Mrs. Kanta

First Appeal No. 426 of 2006, decided by National Consumer Disputes Redressal, Commission, New Delhi on 27 th May, 2011.

Facts: Complainant Smt. Kanta, 55 years at the relevant time, at the end of August 1999, suffered acute chest pain, consulted a medical practitioner at Amritsar who examined her and found that the symptoms could be of a heart attack. She was advised to obtain opinion and treatment of a cardiologist and cardio surgeon. Appellant examined the complainant and advised admission for conducting Angiography. The complainant was allergic to almost all the antibiotics except few of them like Pelox, analgesic, Voveran etc. Angiogram showed LAD artery blockage, to the extent of 95%. It was alleged that though the appellants took permission of her son for performance of PTCA or angioplasty for removal of the blockage, yet it was given up in the midway after 15 - 20 minutes on the ground that she was allergic to many drugs and she was shifted to the ICU. She suffered severe pains throughout the night, yet nobody attended her. Later she was admitted at Escorts Heart Institute, Delhi.

Another Angiography was conducted at the Escort Heart Institute through radial artery of the right arm with a view to locate the extension of dissection of Aorta. Dr. Trehan of Escorts expressed opinion that the Aorta dissection has taken place during the Angiography procedure done by the appellants and that was iatrogenic in nature. However, she was given due treatment by a Senior Cardiologist, subjected to angioplasty and was discharged after the hospitalisation of ten days. The complainant alleged medical negligence on the part of the appellants while conducting the Angiography which resulted into dissection of Aorta and claimed compensation of Rs.11 lakhs from the appellants. The State Commission considered the rival contentions and affidavits of the parties and held that the complainant suffered the dissection of Aorta during the Angiography conducted by the appellants and the aortic dissection took place when the appellant No. 2 forced the catheter through artery in negligent manner, that it was a case of res ipsa loquitur in as much as without due care and caution, the catheter was pushed through iliac artery and the appellants were directed to pay compensation of Rs.5 lakh to the complainant.

Medical Text relied upon : From a reference book captioned 'Cardiac Surgery in the Adult' by L. Henery Edmunds, JR., some useful passages may be quoted as below:-

"In the absence of a connective tissue disorder, arterial hypertension is the most important pre-disposing factor for aortic dissection."

"Iatrogenic trauma occasionally causes aortic dissection. Radiological diagnostic procedures coronary Angiography, and therapeutic balloon catheter manipulation all have produced dissections."

"Direct iatrogenic trauma to the aorta that is inflicted during arterial cannulation for cardiac surgery or during catheter-based diagnostic and therapeutic interventions accounts for about 5% cases of aortic dissection. The majority of iatrogenic dissections have been reported in the descending thoracic and abdominal aorta. Reports suggest a relationship between the severity of atherosclerosis and the risk of developing an iatrogenic dissection. In these cases, dissection may be initated by catheter related injury to the intima, which may previously have been weakened by atherosclerosis. "

The medical literature further shows that 'aortic dissection' is differentiated from the spontaneous rupture of the aortic wall or laceration of the intima and media without or with only limited separation of wall layers.

Observations: Aortic dissection is a rare but recognised phenomenon of Angiography. Perusal of the medical literature shows that word 'dissection' is a condition in which there is bleeding into and along the wall of the aorta (the major artery reaching and connecting the heart). This condition may also involve abnormal widening or ballooning of the aorta (aneurysm). It is further explicit that acute dissection of the aorta is a vascular surgical emergency. From the relevant entries and the discharge summary of the medical papers concerning the treatment given to the complainant by the appellants, there was no emergency to treat the aortic dissection, the complainant was not required to be immediately operated after noticing the dissection of aorta and it is only in case of acute aortic dissection that may require an emergency open-heart surgery. However, in case of sub-acute aortic dissection treatment with medication may be sufficient. The very fact that the complainant was found stable after third day of the Angiography and till the date of discharge, i.e., on 8-9-1999, would be sufficient to infer that she suffered sub-acute aortic dissection. The aortic dissection begins with a tear in the inner layer of aortic wall. It appears that aortic dissection may be result of hypertension, continuing disorder, and feeble condition of the aortic wall and like causes. In the present case, the complainant failed to adduce any evidence of expert to show that the aortic dissection was the direct result of any negligent or rash act committed by the appellant No. 2 while conducting the Angiography. There is only allegation in her complaint of abdominal pains during the process of Angiography. As stated before, she was aged about 55 years and was suffering from hypertension as well as there was family history of ischeaemia when the Angiography procedure was conducted on her. It is probable that due to such associated causes the passage of the catheter through aortic space was not smooth. There appears no tangible material to infer that the appellant No. 2 had undertaken any adventurous procedure, knowing the risk that it would result into aortic dissection. The tearing of the portion of aortic wall may be a result of weakness of the wall itself or hypertensive condition of the complainant.

There is no substantial reason to say that the appellant No. 2 used any brutal force to push the catheter ahead through the aorta blood vessel. The medical record shows that Angiography was completed and resulted in the finding that there was LAD artery blockage to the extent of 95%. Obviously, the mere fact that aortic dissection did occur during the process by itself, cannot give rise to assumption that the appellant No. 2 was negligent or rash in conducting the procedure. There is no dispute about the fact that such finding of dissection was reached not only by the Escorts Heart Institute, New Delhi but the CT scan and the MRI conducted at the hospital of appellants also confirmed this fact. The conduct of appellants go to show that they did not try to tamper with the medical record. They came out with clean hands. They had nothing to hide. Their medical papers show the complaints of abdominal pains as made by the complainant. Their conduct does not reflect mind of a negligent medical professional. One cannot be oblivious of the fact that the complainant became stable and was, therefore, discharged on 8-9-1999. She had further undertaken journey to Delhi in order to consult Dr. Trehan of Escorts Heart Institute. The complainant underwent coronary with stenting LAD on 19-10-1999. Affidavit of Dr. R.P. Singh was filed by the appellants after the arguments were advanced who stated in the affidavit that arotic dissection can occur spontaneously in a hypertensive manner and that in case of abdominal aorta dissection, it is not possible to complete the coronary Angiography. The statement is limited to 'abdominal dissection', yet the complainant did not challenge the said affidavit. No interrogatories were addressed to Dr. R.P. Singh. The mere completion of the Angiography does not rule out aorta dissection during the procedure. It was not a serious aorta dissection but was a sub-aortic dissection, the complainant was subjected to clinical management, i.e ., wait and watch procedure for a few days. The very fact that the appellant No. 2 did not rashly proceed to conduct the Angioplasty is indicative of his bona fides , he took wise decision to wait until the tear caused to the aortic wall was properly healed. This aspect is totally overlooked by the State Commission. The complainant did not file affidavit of any expert in the field of cardiology to show that the aorta dissection was on account of negligence committed by the appellant No. 2 during the procedure of Angiogram. At times accident may occur or causes like hypertensive condition of the patient may result into aorta dissection and subsequently the medical practitioner may be blamed by the patient or his / her relatives. In each case the expert's opinion may not be required and the complaint can be considered on its merits without such an expert's opinion. Still, however, where the complexities of the medical treatment as well as surgical procedures are required to be examined, it is desirable to have an expert's opinion. Mere fact that the patient suffers some adverse effect during or after the surgery is not enough to take a frog-leap and say that it is a case of " Res Ipsa Loquitur ".

Held : In the result, the appeal is allowed. The impugned judgement and order passed by the State Commission is set aside. The complaint filed by the respondent shall be deemed as dismissed.

Anoop K. Kaushal, Advocate - kaushal@justice.com
(Print Version)
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