The Judge and the Junior Residents

Sometimes back there was an incident involving a senior neurologist of SGPI Hospital and High Court Judge. This jogged my memory of somewhat similar incidence involving two General surgery junior residents of Kota Medical College.

A little background first. There were only six junior residents in the department of general surgery in Kota Medical College at that time. With two residents going on rotation posting in the neurosurgery and the urology department, there were only two junior residents in First Unit and only one junior resident each in the other two units. 

A married female patient with 60 to 70 % burn was admitted in the Burn Ward under General Surgery department. Due to the high probability of her death and to rule out dowry and marital violence, it is the rule get her dying declaration (statement) recorded by a court judge. But before the judge can record her statement, a doctor has to certify that she is mentally competent and physically fit to give a statement. The junior residents of the concerned unit were usually called to certify this.

When the session court judge reached the Burn ward, in the afternoon, he asked the staff to call the doctor to certify that the patient is fit to give the statement. When the ward staff called the junior resident Dr. Danny (Fictional Name), he happened to be suturing (stitching) a wound of a patient admitted in the early morning in the emergency ward. Once he completed the stitching he checked his phone and found the missed call from the burn ward staff. 

On learning that the session court judge was waiting for him in the burn ward he rushed there, but the damage has already been done. The judge had got quite angry at this delay and scolded him for making him wait before recording the patient’s statement. He threatened to put him in jail for ‘contempt of court’ by making him wait. Efforts to placate his anger by Dr. Danny were of no avail. 

Next day, Dr. Danny received an arrest warrant by a policeman to bring him to the judge’s court. Leaving his work, Dr. Danny went with the policeman to court. The judge made him wait for 2-3 hours, then he called him to his seat. Again the judge expressed his displeasure and threatened to put Dr. Danny jail for ‘contempt of court.’ Dr. Danny pleaded with the judge and was allowed to go after he tendered a written apology.

Dr. Danny shared his experience with his fellow residents who got angry with the judge’s behavior.

Sometimes later, another patient of severe burn got admitted in the burn ward. Again the same session judge came to record her dying declaration. Dr. Vicky Rao (Fictional Name) was the lone junior resident posted in the concerned unit. After being on 24-hour emergency call duty the previous day and after finishing his morning ward work, Dr. Vicky went to the hostel to take a bath and freshen up. Being in bathroom Dr. Vicky did not hear the calls coming on his mobile phone from the burn ward staff to come and certify that the patient is fit to give a statement.

As expected the judge got incensed at Dr. Vicky’s non-appearance and demanded to talk to the Unit Head. On receiving the phone call from the burn ward and learning the matter, Dr. Dev (Fictional Name), the Unit Head rushed to the burn ward from his office. 

Dr. Dev hurriedly certified to the patient’s fitness and apologized profusely to the judge for the inconvenience caused to him. But he also explained to the judge that Dr. Vicky is otherwise a hardworking respectful resident, but due to a shortage of staff he is very overworked and he must be busy in some important work to be so delayed.

Dr. Dev phoned Dr. Vicky, explained the situation to him, including warning that this is the same judge who had dealt with Dr. Danny previously. 

Few minuted later Dr. Vicky reached the burn ward accompanied with 10-15 fellow junior residents. Seeing their angry faces, Dr. Dev got worried. Dr. Dev immediately stopped the group from approaching the judge and said that “If you respect me as your teacher, you will please maintain decorum and not shout any slogan or get physical with the judge.

As expected the judge started scolding Dr. Vicky for his delay in coming and that his action constitutes obstruction of the work of the court and he can be held in contempt of court. But due to the presence of the fellow residents, he was not as vocal as he was with Dr. Danny in the past.

Once the honorable judge had left the hospital, Dr. Dev warned Dr. Vicky that there is still the danger that the judge can summon you with an arrest warrant to court and take action against you.

Forewarned, Dr. Vicky contacted his family friend who was a prominent lawyer of the city. The lawyer informed that the judiciary system expects the judges to have a very high standard and if you have a genuine grievance you can give a written complaint to the honorable District Judge (DJ) and the matter may be forwarded to the High Court (State headquarter) for inquiry and disciplinary action.

Dr. Vicky with the help of the lawyer wrote a complaint letter against the judge and gave to the District Judge. The District judge called the Hospital Superintend and Dr. Dev to explain the matter to him. They went to the DJ court, explained the matter to him including the difficulties faced by everyone due to the shortage of doctors. 

After listening to the grievance of everyone concerned an agreement was reached. Dr. Vicky apologized to the judge for any inconvenience caused to him and in return, the session judge apologized to Dr. Vicky for any hurt caused by him. On apology by the judge, Dr. Vicky withdrew his written complaint against the judge.

(Based on allegedly true incidents)

— ND
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 DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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The Eczema Side-Effect

One afternoon, Dr. Dev (Fictional Name) received a registered letter from a lawyer. The lawyer claimed to represent a patient Dr. Dev had operated, three months ago in the government hospital for fissure-in-ano. The lawyer had written, as a side-effect of the wrongly done operation, his client had developed intractable eczema which had made his life horrible.

The lawyer instructed Dr. Dev to pay his client INR 50,000/- as compensation for the cost of treatment and the mental agony the patient is facing because of eczema developed due to the faulty operation. In comparison, Dr. Dev’s entire pay for one month was INR 35,000/- at that time. Also as the operation is done in the government hospital free of cost, Dr. Dev did not receive any extra money for doing any operation there. Dr. Dev was also surprised by the allegation of developing eczema after fissure-in-ano.

For Non-Medicos:  In fissure-in-ano, a small cut develops in the sensitive inner lining of the anus. This is very painful at the time of passing stools. In the operation for the anal fissure, the anus is generally dilated manually or by dividing the muscle surrounding it, making the anus wide which helps in healing of the cut. The side-effect of the operation is generally incontinence, i.e. the patient is not able to voluntarily control his act of defecation or passage of stools. There is also the chance that the cut may not heal in few patients, who may then require further treatment. Eczema developing as a side effect of the operation for fissure-in-ano was not possible.

Dr. Dev tried to remember if he had operated on any patient with fissure-in-ano and eczema. He recalled that he indeed had seen and operated on a patient with fissure- in-ano who was suffering from chronic eczema long before the fissure developed. With the patient’s name from the letter, Dr. Dev searched the hospital record and got a certified copy of the patient’s entire case-record from the hospital.

On-going through the record to his dismay he found that in the inpatient case-sheet the ward in-charge junior resident had only written; Diagnosis: Fissure in ano; History: Painful defecation x 2 months, no bleeding per-rectally; On Examination: Fissure in ano at 6’ O’clock position; Operation done: Anal Dilatation under spinal anaesthesia. The junior resident had not recorded the presence of the previous eczema in either the history or the examination of the patient.

Not losing hope, he went further through the hospital record. Going further, he found attached the patient’s consultation slip when he had consulted Dr. Dev at his clinic. In Dr. Dev’s personal note made at the time of consultation at his clinic, it was clearly mentioned that on examination of the patient Dr. Dev had found that along with fissure-in-ano, the patient was also having perianal and buttock region eczema skin disorder. On enquiring the patient told that he is having the eczema for many years which cause itching and occasional bleeding and pain, which was also recorded in the OPD slip. 

Dr. Dev asked the patient to first consult a skin specialist before the operation of the anal fissure. He also recorded the fact in the patient’s OPD slip that the person is suffering from chronic (long-standing) eczema for which skin reference had been advised. In meanwhile he advised some medicines for temporary relief for the fissure.

Sometime later, the patient again consulted Dr. Dev. He showed a skin specialist consultation sheet in which the dermatologist had given clearance for surgery, as the eczema was allergic and not infective. This fact was also recorded in the OPD slip.

Armed with this evidence, Dr. Dev consulted his lawyer. The lawyer sent an official reply to the patient’s lawyer that the patient is misrepresenting facts. He was suffering from eczema long before the operation. This fact has been recorded in the OPD slip. The patient will not get any money from Dr. Dev. In fact, Dr. Dev is considering a defamation case against the patient.

A meeting between the two lawyers was done at which Dr. Dev’s lawyer produced the copy of Dr. Dev’s OPD slips as a proof. Faced with this evidence the lawyer decided to withdraw the case against Dr. Dev. Instead of going in further litigations and wasting his time and money in court, Dr. Dev also agreed to not file a defamation suit against the patient.

Tip: Always record any pre-existing illness or condition in the patient’s case-sheet; however it appears unrelated to the patient’s present illness. This is valid even in non-medical situations. When you join some organization or project, do an active ‘witch-hunting’ and report all pre-existing problems at beginning so that later you may not get blamed for them.

For example, when a new CEO of a nationalized bank joined as head, in the next quarterly report there was a sudden jump in the non-paying borrowers and bad loan reported by the Bank. What happened was that the CEO setting strict standard declared the entire previous borderline or under review borrowers and loans given during the previous CEO’s period as non-paying borrowers and bad loans at the onset of her tenure. This will prevent these bad loans and borrowers from showing in her tenure if declared later on. So the first quarter result declared under her was very bad, but she did not got any blame for it.

Tip: Even though it may be work of your junior to complete the case sheet or basic workup, do keep a check on them and make a complete record yourself if necessary. In the above-mentioned case, it is Dr. Dev’s comprehensive notes which saved him. The junior resident had treated the case as only a simple minor case and wrote only a minimal basic record.

Tip: When confronted with any legal notice or litigation, it is better to let your lawyer work as a mediator and not deal directly with the opposite party even in a case clearly in your favor. This may increase your cost but creates an atmosphere that you are serious about confronting the opposite party in court if necessary. There is also a lot of legal jargon that which we are not familiar with.

Tip: Have a personal insurance cover even when working in government sector, as the court or patient may hold you personally responsible for any compensation.

(Based on true incident)

— ND
© Author. All rights reserved. 

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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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The Female Chaperone

Please Note: This article is intended only for Doctors and medical undergraduate and post-graduate students. Non-Medicos please do not read this article.

Dr. Dev was sitting with his friend, a fellow surgeon, in his consultation chamber. A young lady came to consult his friend with the complaint of a lump or swelling in her right breast. She was accompanied by her mother.

After taking the history, Dr. Dev’s friend asked the mother to wait, while he asked the female staff nurse sitting outside to come inside. It is one of the guidelines that a female patient should be examined by a male doctor in presence of another female only. With the female staff nurse acting as chaperone he examined the female patient in the separate private examination area. Dr. Dev also noticed that his friend also made a small notation afterward on the side of the patient’s consultation slip, Chprn: S/N Margarita.

Once the patient had left, Dr. Dev asked his friend why he troubled the female staff nurse to come and act as female chaperone, when the patient’s mother was already present. Secondly, what is the meaning of the notation he made in the patient’s consultation slip?

His friend explained, I always examine any female patient in presence of my female staff members only and never in the presence of the patient’s female relative. The patient herself may be shy in exposing in front of her relatives.  The relative may not understand what is a necessary part of the examination and what is inappropriate action. In case of some controversy, the female attendant may side with the patient even if you are right. Also, how will you be able to trace and get the female relative to come and give evidence in your favor if necessary?

The note in the patient’s consultation slip was that I had examined the patient in the presence of Staff Nurse Mrs. Margarita acting as chaperone. A similar notation is made against the patient’s name in the registration register at the reception. This acts as a record, so that if any controversy arises even days later, I have the record of which female staff member was present while examining the patient.

Tip: Male doctors should always examine the female patient in presence of your female staff member.

Tip: Avoid examining the patient in presence of female relatives.

Tip: Make a small note of the name of the female staff member in both the patient’s and your record.

(Based on true incident)

— ND
© Author. All rights reserved. 

If viewing from Mobile, switch to Webpage view to see a list of popular posts and index of topics of previous posts.

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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The Referral Controversy

Please Note: This article is intended only for Doctors and medical undergraduate and post-graduate students. Non-Medicos please do not read this article.

At midnight, Dr. Anil Kumar (Fictional Name) Medical Officer-In-Charge of the Community Health Centre (CHC), a government hospital at sub-district level, was woken up by a patient. His hand had got injured by Thresher (a farming equipment).

Without bothering about the late night hour, the blood dripping from the patient's in his house's consultation chamber, he attended the patient. As he was having a severe injury, after preliminary care, he referred the patient to Government M.B.S. hospital, Kota.

The patient on his own initiative went to a private hospital and got treated there. He was not satisfied with the outcome. He filed a court case on the private hospital and also dragged Dr. Anil Kumar’s name in it. He complained that Dr. Anil Kumar had referred him to that private hospital; therefore he is also to be blamed for his poor outcome.

As, Dr. Anil Kumar was very clear about his policy of referring only to the government hospital, as he was in government service, he did not come under their pressure. On searching the hospital record, he found a clear mention of referring the case only to Government MBS Hospital, Kota. On producing this record in court, the charges against him were dropped. Maintaining and preserving clear records, with a policy of referral only to the government hospital, helped save Dr. Anil Kumar from undue harassment.

Tip: If you are referring the patient to some other hospital, mention in the patient’s record and in your own hospital’s record maintained separately, the date and time of referral, the place where referred and the reason for referral.

Tip: Also keep a record with you on the condition of the patient at the time of referral.

Tip: Refer only in accordance with your hospital’s policy whether working in private or government sector.

(Based on true incident)
— ND
© Author. All rights reserved. 

If viewing from Mobile, switch to Webpage view to see a list of popular posts and index of topics of previous posts.

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 
DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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The Axillary Block

One patient suffering from infection of hand came to AIIMS, New Delhi, for treatment. He was seen by Professor Tarun Kumar Chaturji (fictional name) and advised I & D operation.

For Non-Medicos: I = Incision / cut in the skin over the site of infection and D = Drainage / letting out of the pus / infected material.

The infection was in advanced stage and normally require general anesthesia (G.A.) for adequate drainage / operation.

In G.A., the patient is made fully unconscious. For G.A. the patient normally requires blood investigations, a chest X-ray, E.C.G., etc. He has to be absolute fasting for 4 to 6 hours before general anesthesia, i.e. he has to stop taking even take water for at least 4 hour before the operation. He also needs to be admitted and monitored after operation. There is also the slight but definite risk of general anesthesia.

Dr. RG (fictional name) was junior resident at that time in AIIMS, New Delhi. Dr. RG was very dynamic and enthusiastic resident doctor. He was always looking for new ways to serve the patients. He thought of operating on the patient using only regional anesthesia, i. e. axillary block.

For Non-Medicos: In axillary block, a local anaesthetic injection is given near the axillary artery in the axilla (armpit) blocking the pain sensation in hand, forearm and arm.

At that time the concept of regional nerve block was in nascent stage in India. Even most of the anesthetist had not done many of the regional blocks such as axillary blocks. Dr. RG had not done this procedure before although he had studied the theory of the block in great detail and practiced mentally the entire procedure many times.

The patient was bought in the Emergency O.T. (Operation Theater) in the AIIMS, New Delhi and positioned on the operating table.

Dr. RG had especially purchased a book on anesthesia for its detail instructions on nerve blocks meant for non-anesthetist. To make sure the block will work perfectly, Dr. RG decided to follow word to word the instructions given in the book.

Since he had don sterile gloves and was doing the block, Dr. RG asked the nursing staff to read aloud the steps from the anesthesia book, so that he could follow them exactly word to word without any margin for errors.

Following the instructions, Dr. RG gave an excellent block. The patient had excellent anesthesia and did not feel any pain during the otherwise very painful procedure.

Two days later, Professor Tarun Kumar Chaturji called all the residents doctors to his office.

Professor TK Chaturji asked, “Have any of you operated on the patient with hand infection two days ago?” “Yes sir, I did the I & D in that patient”’ replied Dr. RG.

“What anesthesia did you used in the operation?” inquired the Professor.

“Axillary block sir,” proudly Dr. RG replied. His sense of pride was justified as perhaps he was the only surgeon in AIIMS, New Delhi at that time who had given such an excellent axillary block.

“Well the patient’s relatives have complained that you are doing operations while reading from books”. informed Dr. TK Chaturji. “You are treating the patients as experimental guinea pigs.”

While the patient was being operated in the Emergency OT, the patient's relatives were standing just outside the operation theater door had overheard the staff nurse reading from the book. They found that Dr. RG was doing the block for the very first time that too from reading a book.

They were shocked that even at a premier institute like AIIMS, New Delhi, doctors were learning while doing operations and had complained to Professor TK Chaturji for entrusting the operation of their patient to such a novice surgeon.

This raises some important ethical, moral and medico-legal questions. Any doctor has to do all his procedure or operation for the first time some time in his lifetime. Should we expressly tell the patient that we are doing the procedure for the first time? If a doctor does only those procedure / operation that he has done before how will his surgical repertoire improve. 

But why only the doctors? There must be a first time when a taxi driver takes his first passenger on a ride, bus driver drives the bus independently or pilot flies a commercial flight independently. Do we ask or do they tell their experience before getting in a taxi, bus, or airplane.

 

Clear practical guidelines should be made so that doctors doing or learning new procedure does not get unnecessary victimized or criticized depending on the complexity of the procedure and / or the potential for complications.

Tip: Following word to word instruction when doing any new procedure can reduce your chance of committing an error.

Tip: At that time better keep the patients relatives away from the operation theater while doing any operation for the first time (Just Joking).

(Based on true incident)

— ND

© Author. All rights reserved. 

If viewing from Mobile, switch to Webpage view to see a list of popular posts and index of topics of previous posts.

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

 DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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The Medicine Sample

This happened to my good friend, Dr. S. M. Meena. He had gone to Baran, Rajasthan for giving expert medical evidence in a medico-legal case, in the District Judge (DJ) Court. The District Judge had become friendly with Dr. S. M. Meena as he had gone many times previously to the same court for giving evidences in medico-legal cases.

After his evidence was over, the Judge asked Dr. S. M. Meena to please give him some medicines for his ear-ache. He was having the ear-ache for some time, but due to his busy schedule, could not find time to go and consult some ENT specialist for it.

As, Dr. S. M. Meena was posted and living outside Baran at that time, he did not have any medicines with him. He remembered his senior, Dr. Prithviraj (fictional name) was having a roaring general medicine practice in the same town.

So, Dr. S. M. Meena, went to Dr. Prithviraj’s clinic and asked him to give some medicines from the samples provided by the Pharma companies’ representatives. Dr. Prithviraj searched through the samples to find some higher generation antibiotics, ear-drops and some pain-killer for the Judge Saab. Finally, finding some suitable medicines, Dr. Prithviraj gave them to Dr. S. M. Meena,

Dr. S. M. Meena immediately took the medicines to the Court and gave them to the Judge Saab with a feeling of mission completed successfully. The Judge took the medicines, thanked Dr. S. M. Meena profusely and looked at the medicines.

Suddenly with a stern look on his face the Judge demanded, ‘Dr. Meena, do you want to cure me or kill me?’ On hearing this, Dr. S. M. Meena was shocked. With a crest-fallen face he asked, ‘Sir, what is the problem?’ ‘What have I done to make you say such a thing?’

Pointing at the medicines, the Judge explained, ‘Look at the expiry date on these medicines. Both the antibiotics and ear-drops have passed the expiry dates months ago!’ Dr. S. M. Meena looked closely and indeed found this to be true.

The judge further enquired. ‘Where have you got this medicines?’ Dr. S. M. Meena replied, ‘I have got them from my senior Dr. Prithviraj.’ The judge ordered, ‘Call Dr. Prithviraj here immediately. I am registering a case against both of you for negligence and attempt to cause bodily harm by your action.’

Dr. S. M. Meena phoned Dr. Prithviraj, explained the goof-up which had occurred, and immediately called him to the Court. Rushing to the court, Dr. Prithviraj along with Dr. S. M. Meena, explained to the Judge that the mistake has occurred unintentionally, they had the best intentions in mind and such an error will not ever occur in future.

Suddenly with a smile the Judge said, ‘I understand that giving this expiry date passed medicines to me was unintentional mistake on your part. I just want to impress in your mind the problem which can occur if you had given these medicines to someone other than me. They may have not checked the expiry date on the medicines and used them and then blame any subsequent problems on you. Be vigilant in future and make sure such a thing never occurs in future.’

Dr. S. M. Meena and Dr. Prithviraj thanked the Judge Saab for letting them off the hook and departed the Court.

Dr. S. M. Meena and Dr. Prithviraj learned their lesson that day. Sometimes actions done with best intention can back-fire due to some small over-sight. They now very carefully check the expiry date before giving or receiving any medicines or samples.

(Based on true incident)

— NKD

© Author. All rights reserved. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 


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