Tragedy at Varanasi: comparison of multiple healthy deaths due to civic negligence vs one in hospital due to disease


                There is a stark  difference in  the kind of  media  projection, burden of negligence and accountability of preventable multiple healthy deaths by civic negligence   as compared to one hospital death by disease. In fact the burden of   negligence here in healthy deaths is massive and  these deaths are unpardonable. But reality is opposite.  Strangely   “alleged and perceived negligence” ( with no proof and no investigation )  in death of someone already having disease  and death in hospital  during treatment attracts more scrutiny and   stringent  punishment   a naked “negligence  in deaths of healthy people” in such cases  of civic negligence.  

In an unfortunate incident at Varanasi , at least 19 people were crushed to death and more than a dozen injured after two concrete beams fell off 40 foot-high pillars at an under construction flyover in Varanasi on Tuesday evening. Massive civic negligence  again leading to  entirely preventable loss of lives. These incidents bring fore to my mind the misplaced priorities of media and society  which too have  contributed to  some extent to these unabated ongoing preventable   deaths  of  hundreds of  healthy people.

Multiple  Deaths  in healthy people by civic negligence :

Large numbers of death and morbidity happen amongst absolutely healthy population due to preventable causes like open manholes, drains, live electric wires, water contamination, dengue, malaria, recurring floods  etc. These deaths  of people are in thousands, and are almost entirely of healthy people, who otherwise were not at risk of death. In fact the burden of   negligence here is massive and  these deaths are unpardonable.  It’s time media took it upon itself to bring to fore these issues before accidents, so that many innocent lives. Timely action can prevent these deaths. 

       Single  Death in Hospital due to disease:

The  media has always, instead, focused on the stray  and occasional incidents of perceived alleged negligence  in hospital deaths which could have occurred due to critical medical condition of patient. However an impression is created as if the doctors have killed a healthy person. It is assumed without any investigation that it was doctor’s fault.  Media has been responsible for  creating a misunderstanding about the whole process of treatment. They have ignored other important things like civic negligence and has instead trained their entire energy in  blaming the doctors  in an effort  to get something sensational out of nothing.

The whole blame  is cleverly put  on doctors. Even after doing everything possible, doctor may be running for his life, trying to save himself from goons. He may be an object for revenge. He may be running after lawyers, if a medical lawsuit is filed. Even if court give the judgement after decades in favour of doctor, harassment of the doctor is permanent and irreversible damage is  done  to doctor. He is already punished.

Here it will be seen later, whether some one can be punished or not.

Point to ponder-Misplaced priorities:

Who is to be  blamed for  the deaths of healthy people which occur because of civic negligence? Here relatives may be helpless and  the vital questions  may go unanswered or taken as a routine.  There are no punching bags like doctor  for revenge. Any stray incident of death of an already ill patient is blown out of proportion by media forgetting the fact that thousands of patients are saved everyday by  doctors. But media instead chose to defame medical profession by igniting the emotions of people by sensationalising death of diseased and ill,  who probably were already at risk of death and did not give due importance to highlighting prevention of healthy  and absolutely 100% preventable deaths.

Right issues raised at right time will save thousands of healthy preventable deaths. Multiple  healthy deaths should carry more burden of negligence than  one death due to disease.

      

 

Two doctors from Fortis Hospital arrested – How doctors may save themselves by learning from such cases.


Doctor,  do save the patient but save yourself also.

Doctors continue to treat and save  many patients in the years they work. But present law and regulatory system does not take into account those years of  good and hard work. It does  treat doctor as a petty criminal for some single mistake or unfortunate incident. Law just deals with it in a harshest possible manner.  Patient may have died because of disease, but when in side the hospital, it is very easy to relate death with actions or inaction of doctors.  Specially because inquiries are always done  with  retrospective analysis, with wisdom of hindsight. Although there is a feeling among doctors that what is really happening these days, something may not be very appropriate, but there is no room  for leniency here.

News of this kind brings tsunami of fear in minds of doctors all over. It can be anyone in such situation, where  it is just   that a particular doctor did not have that eye for danger in that moment. The  doctor did  not realize or anticipate the gravity of  the consequence and outcome of the patient in real time. It may be difficult to pick up or just not take the situation very seriously. That can simply be poor training or working without good application of mind. But  looking retrospectively, situation becomes clear.

Two senior doctors of Fortis Hospital in Haryana’s Gurgaon were arrested on Friday for a “delay in administration of emergency medicines” to a 51-year-old woman, who died of cardiac arrest last year, police said.

 

      Lessons to be learnt:  What options doctors have at present? Because they are at receiving end always. They have to learn from such cases and do something in their routine to prevent disasters. How can they save themselves?

  1. All patients to be seen by primary consultants or someone from concerned unit at the earliest. It is important as emergency doctor may  not be equipped to deal with specialty  problem.  Prompt diagnosis by specialty doctor and written findings are important.
  2. Initial assessment should be quick and with in minimum time.
  3. Good communication and documentation of the problem.
  4. Assess the patient and make a note of treatment to be given.
  5. Document the plan of action, that is investigation and management.
  6. Avoid phone call consultations and leaving treatment loosely. Well thought documented plan should be in place.
  7. Situation may be different for smaller nursing homes. Treatment of an emergency will remain same, whether patient goes to bigger or smaller hospital.   Nursing homes may not be equipped for all the emergencies. So challenge before the smaller hospitals will be to identify the problem and diagnose them quickly  and  if required send them to proper  hospital, rather risking themselves in today’s times.
  8. Aspiring doctors can have a cue about what they are getting into. So as to adapt to prevalent adverse circumstances for doctors, if they aspire to be one.

 

Doctor, do save the patient but save yourself also.

 

‘A doctor who always operated on ear, irrespective of problem’: Role of media in Fortis and Max hospital Delhi incidents


        During my  days as medical student, we laughed at a story wherein a doctor always operated on patient’s  ear for all their ailments. Whatever may be the problem in the body, it was only the ear which received the cut always.  Similar treatment is being given to doctors by media.  Now-a days, for every progression of the disease and for genuine poor prognosis or death of the patient, media  is prompt to start the  blame game of doctor- doctor. Media even does not try to verify the facts. The real medical issues in treatment of these cases are still not emphasized by media, like whether these cases were salvageable or not.  For example why so many preventable disease like dengue, malaria happen every year   to thousands of people every year and are still progressing?  Take the case of foetus at 22 weeks…… how many have survived in India or in  the  world? In this case and that of  the complicated dengue case, the survival chances were quite dismal, even in developed world medicine.  Inability of media people to analyze the difficulty on scientific parameters, unwillingness of people to accept the real poor prognosis and political class to flow with populist opinion has done irreparable damage to medical profession. Just a blame game and the word ‘negligence’ are in the air.

    Outcome in these cases is not uncommon or unanticipated by any yardstick in the world. But no one is concerned about that. And in the end, what are the losses?

    Discouraged medical fraternity, low morale of doctors, and talk of leaving this profession have become smaller issues and do not affect anybody in media or Government. 

   But larger issues remain: how to prevent thousands of death due to poor control of communicable and preventable diseases. Proper delivery of health care will not improve by playing the blame game on doctor.  Media bashing of doctors may divert attention from the real issues and  media people   will earn money and fame. Doctors will be punished  as a result of  populist revenge.  But this approach of media is not going to save patients or provide better health care to masses in future.

Max Hospital Delhi handed over dead baby : Is “ Lazarus syndrome” a possibility?


 

        There are lot of discussion going on about live  baby handed over to parents by Max Hospital  Delhi, as dead.  Every one including  media has as usual  jumped on to the favorite  topic of  doctor bashing.  Facts are still under investigation. But as a doctor, I can not reach conclusions without scientific discussion, least possible by media  talking superfluously. There can be number of possibilities, which we will  know with time after proper investigation. But whatever the result, doctors bashing had already been done by media , with or without knowing facts.

Life and death are still far beyond the reach of science and obviously  of doctors as well. There are still a lot more unknown than known story about human life. I just wish to draw the attention of my readers about an entity, which is quite mysterious.  Condition is  called     “ Lazarus syndrome”. Also known as auto resuscitation after failed cardiopulmonary resuscitation, is the spontaneous return of circulation after failed attempts at resuscitation.

A little bit about  this rare phenomenon.      

 

Lazarus syndrome, also known as auto resuscitation after failed cardiopulmonary resuscitation, is the spontaneous return of circulation after failed attempts at resuscitation. Its occurrence has been noted in medical literature at least 38 times since 1982. It takes its name from Lazarus who, as described in the New Testament of The Bible, was raised from the dead by Jesus.

Occurrences of the syndrome are extremely rare and the causes are not well understood. One hypothesis for the phenomenon is that a chief factor (though not the only one) is the buildup of pressure in the chest as a result of cardiopulmonary resuscitation (CPR). The relaxation of pressure after resuscitation efforts have ended is thought to allow the heart to expand, triggering the heart’s electrical impulses and restarting the heartbeat. Other possible factors are hyperkalemia or high doses of epinephrine.

Cases

-A 27-year-old man in the UK collapsed after overdosing on heroin and cocaine. Paramedics gave him an injection, and he recovered enough to walk to the ambulance. He went into cardiac arrest in transit. After 25 minutes of resuscitation efforts, the patient was verbally declared dead. About a minute after resuscitation ended, a nurse noticed a rhythm on the heart monitor and resuscitation was resumed. The patient recovered fully.

-A 66-year-old man suffering from a suspected abdominal aneurysm who, during treatment for this condition, suffered cardiac arrest and received chest compressions and defibrillation shocks for 17 minutes. Vital signs did not return; the patient was declared dead and resuscitation efforts ended. Ten minutes later, the surgeon felt a pulse. The aneurysm was successfully treated and the patient fully recovered with no lasting physical or neurological problems.

-According to a 2002 article in the journal Forensic Science International, a 65-year-old  deaf Japanese male was found unconscious in the foster home he lived in. Cardiopulmonary resuscitation was attempted on the scene by home staff, emergency medical personnel and also in the emergency department of the hospital and included appropriate medications and defibrillation. He was declared dead after attempted resuscitation. However, a policeman found the person moving in the mortuary after 20 minutes. The patient survived for 4 more days.

-Judith Johnson, 61, went into cardiac arrest at Beebe Medical Center in Lewes, Delaware, United States, in May 2007. She was given “multiple medicines and synchronized shocks”, but never regained a pulse. She was declared dead at 8:34 p.m. but was discovered in the morgue to be alive and breathing. She sued the medical center where it happened for damages due to physical and neurological problems stemming from the event.

-A 45-year-old woman in Colombia was pronounced dead, as there were no vital signs showing she was alive. Later, a funeral worker noticed the woman moving and alerted his co-worker that the woman should go back to the hospital. A 65-year-old man in Malaysia came back to life two-and-a-half hours after doctors at Seberang Jaya Hospital, Penang, pronounced him dead. He died three weeks later.

-Anthony Yahle, 37, in Bellbrook, Ohio, USA, was breathing abnormally at 4 a.m. on 5 August 2013, and could not be woken. He was given CPR, and first responders shocked him several times and found a heartbeat. That afternoon, he coded for 45 minutes at Kettering Medical Center and was pronounced dead. When his son arrived at the hospital, he noticed a heartbeat on the monitor that was still attached. Resuscitation efforts resumed, and the patient was revived.

-Walter Williams, 78, from Lexington, Mississippi, United States, was at home when his hospice nurse called a coroner who arrived and declared him dead at 9 p.m. on 26 February 2014. Once at a funeral home, he was found to be moving, possibly resuscitated by a defibrillator implanted in his chest. The next day he was well enough to be talking with family, but died fifteen days later.

Implications  The Lazarus phenomenon raises ethical issues for physicians, who must determine when medical death has occurred, resuscitation efforts should end, and postmortem procedures such as autopsies and organ harvesting may take place.

Medical literature has recommended observation of a patient’s vital signs for five to ten minutes after cessation of resuscitation before certifying death.

In Popular Culture

In the TV show Grey’s Anatomy, a patient had a heart attack and after 42 minutes of resuscitation efforts they declared her dead. And 20 minutes after death has been declared, the patient vital signs returned and regained consciousness.

Source

Lazarus syndrome. (2017, September 2). In Wikipedia, The Free Encyclopedia. Retrieved 16:51, December 4, 2017, from https://en.wikipedia.org/w/index.php?title=Lazarus_syndrome&oldid=798456668

https://en.wikipedia.org/w/index.php?title=Lazarus_syndrome&oldid=798456668

Death declaration by doctor: complex communication skill. “No negligence in alive baby declared dead: hospital “


The death pronouncement is one of the most sensitive and complex part of communication in and out of hospital, intensive care. It comprises more than the actual declaration of death. It may be a relatively straight forward when the death is expected and the family is mentally prepared and accepting the outcome. However, when the doctor is interacting with a grief-stricken family, dealing with the death of a child, or coming to terms with the death of a personal patient, a death pronouncement becomes complex. Problem is compounded often in presence of violent relatives, non acceptance of death, medico legal cases and   especially in cases of unnatural causes for the death. Relatives often refuse to accept death and within no time mobs swell in number, threatening of physical and verbal assaults and revenge against the doctor in various forms. Although there can be specific protocols and hospital policies, it will still depend upon the timely thoughts and skills of the doctor, how to handle the situation. Doctors should be better trained for handling of death as it can put them in risky situation, because of following reasons.

  1. Death itself is a complex issue. Even today modern science has not reached scientifically at the bottom of life and death.
  2. Communication of death is complex. It varies with each patient, type of relatives, place, country and every situation in same hospital is different.
  3. Declaration of death is a legal matter. How a doctor verifies death, communicates and documents death, it can create legal and other problems for doctor.

Any problem related to declaration of death is immediately picked by media and the initial reaction is to blame the doctors. The doctors in such cases are projected as incompetent and callous, and that makes a media news. Invariably one stray incidence is used as to project whole medical community in negative manner. Later inquiries and further inquiring continue, and even later truth emerges, that is not enough to bring back the lost prestige for medical profession.

Take for example the latest news of “ Alive Baby declared dead.”

http://timesofindia.indiatimes.com/city/delhi/alive-newborn-declared-dead/articleshow/59208765.cms

Later after two days, news was “ hospital enquiry claims No negligence in alive baby declared dead”

link   http://www.dnaindia.com/india/report-no-medical-negligence-in-case-where-newborn-was-declared-dead-2479826

Above news just conveys the complexity of situation, doctors often face. My aim here is to convey  that communication of death is a very complex subject. Ironically no structured training of emotional, communicative and legal issues is imparted to medical students. But they are supposed to face the situation everyday, when they function as doctors.

 

Most legal determinations of death are certified by medical professionals who pronounce death when specific criteria are met. Two categories of legal death are death determined by irreversible cessation of heartbeat and breathing (cardiopulmonary death), and death determined by irreversible cessation of functions of the brain (brain death).

Especially new doctors need to realize that the structure of modern society is to make life and death, medical and then legal matters, and to subject the most basic elements of our existence to professional authority. The birth certificate and the death certificate are signed by doctors, and then registered by the civil authorities.  Because of all  these sensitive issues, emotional aspects and legal dimensions of death being  huge, so need more attention. .

In remote areas doctors are totally alone and helpless, so security issues will remain. There is no solution in sight for these problems. Already I have written about a “real story of female doctor assault”.

Problem is that doctors during training days or residency are not trained in such kind of communication. Although while doing their duties they observe seniors and learn how they are communicating. But still when actual situations arise, which can be diverse, complex and challenging, and everyday getting more demanding. In view of current scenario against doctors, they need better training on these issues. Basic question is, if doctor needs help, where can he turn to for help or information. The resources, other staff and the setup is not of much help in difficult scenarios.  It is not uncommon that doctors are left to themselves, if a difficult situation arises. Medical education and Hospital systems need to be better equipped to provide more support to doctors in present era. For doctors, if they make a mistake, there is no one to support them or save them from verbal, physical assaults, law and medico legal cases.

Harassment is tremendous. Therefore   doctors, be careful – save the patient, but save yourself also.

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