Doctor vs. Patient

A few weeks ago the Court of Appeal af-firmed that Professor Priyani Soysa, former Professor of Paediatrics was guilty of Negligence in causing the death of Suhani Arsecularatne.

The verdict was treated as a landmark case in that it was the first case of medical negligence in this country where a doctor - an eminent professor at that - was found guilty.

But, does this verdict, in any way, change the "treatment" - literally and metaphorically - meted out to patients by doctors. Will it open the floodgates of litigation? What are the possible consequences of this verdict? Or, will this decision, in a few months time, gather dust in the records of law libraries?

To examine such matters, it is important to realise why Professor Soysa was found guilty. It is significant that the law of Medical Negligence, as it operates in this country, recognises that doctors, though they play God, are only human. So, they make mistakes. A mistake in diagnosis is not necessarily Medical Negligence.

But in this case, Professor Priyani Soysa was found guilty of negligence for having erred and not diagnosed a Brain Stem Glioma (BSG), a rare brain tumour. The Professor had only diagnosed it as Rheumatic Chorea, but was still found guilty; why?

Both courts, first the District Court of Colombo and then the Court of Appeal held that the wrong diagnosis was due more to callousness and indifference to advice and detail rather than wrong judgment per se.

This is what the Court of Appeal said, in their judgment: "By the Defendant apparently coming to a hasty conclusion without recording or considering many symptoms and characteristics observable in the patient, presumably due to her confidence in her ability to come to a conclusion, she had allowed herself to gloss over many features...."

The Court of Appeal also admonished Prof. Soysa for her practice of not making notes on the Bed Head Ticket herself: "A doctor who considers herself too important not to condescend to write history on a BHT or make referral notes herself cannot be expected to have treated the child or the parents with camaraderie and respect nor given herself sufficient time to investigate and reconsider her initial diagnosis...."

Those in the medical profession no doubt will take these observations with a pinch of salt. For instance, it is the practice among most medical specialists to get junior doctors to record their (the Specialist's) observations on the patients' Bed Head Tickets. That is a "system" devised to save time. If this judgment is to be heeded, this practice must be stopped, at least in the private sector. It is also an open secret in the medical profession that specialist doctors rarely take a full and detailed history and make a complete physical examination of every patient and this practice is not due to negligence either. They couldn't do so even it they wanted to because, in the state sector they are expected to see hundreds of patients a day. So, an internal "referral" system has evolved, where junior doctors are expected to do complete assessments of patients and refer the "difficult" cases to the specialist.

But of course, it is an entirely different ball game in the private sector where no one is compelled to see a given number of patients within a limited time period, and doctors are expected to examine and treat patients, thoroughly and properly.

It is indeed naive to expect doctors to limit their private practice because of this judgment. In fact, at channeling centres, the practice of seeing about fifteen patients per hour - at four minutes per patient for a thorough history, examination, diagnosis and treatment - continues to thrive judgment of medical negligence not- withstanding!

Why, one may ask, do most doctors regard this case an exception, rather than the rule. They are alive to what most in the medical profession realise and acknowledge privately - the chances of a patient suing for medical negligence and succeeding are very remote in Sri Lanka at present. To put it simply, the cost is too high.

In this case it is known that President's Counsel Romesh de Silva appeared without a fee for the prosecution.

Another factor is what a newspaper called "clannishness among professionals". When allegations of negligence are tested in a court of law, questions about the degree of care given by the doctor are often of a medical nature. Opinions about these are given by other doctors - who are almost always, colleagues of the accused, and sometimes their students, for the medical "circle" is a small one in this country.

This writer is aware of a case of apparently obvious negligence by a senior neurosurgeon. The victim's family approached many doctors, requesting their advice. When the name of the surgeon was mentioned, they declined to co-operate. Finally, faced with the prospect - and cost - of getting down doctors from overseas, the family stopped proceedings!

Even with the Priyani Soysa case, when the District court of Colombo first gave a guilty verdict, it will be recalled that many medical organizations rushed to issue statements expressing "confidence" in the doctor. The Medical Council - that is supposed to act against doctors guilty of ethical or legal misdeeds - did nothing. Certainly, there was no "Mea Culpa" forthcoming from the medical profession.

To be fair by Prof. Soysa, she has appealed against the decision and we recognise her contributions in her specialty which includes obtaining three months of maternity leave for working women - for which every mother in this country must be grateful to her. But what we question here is not the personality involved but whether it was ethical for responsible medical bodies to express confidence in her when she had just been found guilty by a court of law.

So, at least for now, it appears that doctors are unrepentant, even defiant about this "incident". In fact, in the immediate afterglow of publicity following the District Court verdict, several insurance companies floated insurance schemes for doctors to protect themselves against malpractice suits and many doctors subscribed. They, no doubt, raised their fees to cover the premium. Otherwise, little else has changed.

And that leaves the general public with some perennial question: what are their rights when they see a doctor? If they feel they have a grievance against a doctor or a hospital, to whom should they complain? And, what are the legal remedies available?

It is pertinent to answer these queries here. A patient seeing a doctor has a right to a reasonable degree of care and skill. He also has a right to know what his ailment is, what his treatment options are and the costs and after effects of those options.

If a patient feels he has been deprived of these he could complain, in writing, to the Sri Lanka Medical Council which then conducts an inquiry. If found guilty at this inquiry, a doctor could be warned, suspended or de-listed from the medical register.

Apart from this, the patient could also file a civil action in courts for the recovery of damages and that is what the Arsecularatnes did. But all this is easier said than done, which is why court cases of medical negligence in this country have been few and far between.

The fact remains, then, that the Arsecularatne vs. Soysa case, though a landmark event, has done little to remedy doctors' attitudes towards patients. This case also will not mean that the man-on-the-street will have a fair chance of pitting himself - against the might of the medical profession. Sad though this may be, it is the truth.

But this case may have achieved something in that now, more and more people in this country are aware of the concept of medical negligence and that something could be done about it. If this prompts doctors to now be that bit more careful, that bit more diligent, Suhani Arsecularatne's death may not be in vain.

In this context, it is only appropriate to record the poignant words of Justice Weerasekera who was one of the Judges in Professor Soysa's appeal hearing: "I am not insensitive to the cries of anguish, pain and suffering of a vast array of patients...., if it did occur in the private sector I could quite imagine what it could be in the sector of non-paying patients. I am also not insensitive to the tribulations of medical personnel. Even so it is my view that a body which has statutory control over the conduct of these professionals (and they themselves) should examine, question and activate themselves..., it is a duty they owe the public and a duty they are bound to themselves if the good name and reputation of the profession which was known for its noble traditions, is to be maintained..."

Medical Faculty News

The Faculty of Medical Sciences, University of Sri Jayewardenepura will hold its second annual scientific sessions on Saturday August1 and Sunday August 2, at the Faculty.

These sessions follow the success of the Faculty's inaugural lecture and scientific sessions held last year on the initiative of the Dean of the Faculty, Prof. M. T. M. Jiffry.

This year, the Faculty Lecture will be delivered by Prof. R. Arsaekularatne and is titled, "What is education? What is a university? The Chief Guest will be Prof. Lakshman Jayatilake and the Guests of Honour will be Vice-Chancellor of the University, Prof. P. Wilson and Dr. V. Mohan of the Diabetes Specialties Center, Chennai, India.

The sessions will also include a workshop on medical research and lectures by eminent medical specialists, Dr. Anula Wijesundera (on Japanese B Encephalitis), Dr. Kolitha Sellaheva (on Snake Bite) Dr. V. Mohan (on Epidemiology of Heart disease, Hyperlipidemia and Diabetes), Prof. Tissa Vitarana (on Dengue Fever) and Prof. Dayasiri Fernando, and also a seminar in - paediatrics.

The first batch of students of the Faculty are due to graduate in November - December this year. Over 700 medical students are now undergoing training at the Faculty at present.

The modest beginnings of anaesthesia

By Dr. V. P. H. Rajapakse (FRCA, FFARCSI)

Anaesthesia means the temporary loss of all sensations including pain. Pain usually performs an important function. Pain enables people to avoid serious injury and helps their survival. However in man there is a fundamental situation where pain is counterproductive. This is in disorders that can be cured or substantially improved by surgery.

The discovery of anaesthesia is one of the most important milestones in medicine, comparable to the introduction of antibiotics. Today complicated operations like organ transplants and heart surgery are being performed. None of these would have been possible without general anaesthesia.

History records that medicine was practised and even surgery was performed in ancient times, even during the time of Hippocrates in the 4th and 5th century BC. Remains of an ancient hospital are seen today at Mihintale. Instruments resembling modern surgical scalpels have been found among the ruins of the Anuradhapura period. Unfortunately there is no record of anaesthesia during this period.

Anaesthesia as we know it today was introduced in the mid-19th century. Like some other great discoveries anaesthesia was discovered by serendipity. This does not mean that it was necessarily discovered in ancient Sri Lanka but that it was discovered by chance. During this time it was customary in Western countries to inhale a nitrous oxide or laughing gas for fun. People used to collect in halls and inhale this gas in order to enjoy it's effects.During one of these performances a dentist, Horace Wells noticed that someone in the audience hurt his leg against a table. The wound started to bleed but this person did not feel any pain until the inhalation of nitrous oxide was stopped and his attention drawn to the wound.

Wells then started using nitrous oxide for dental extractions and painlessly extracted teeth in about fifteen patients. However when Wells attempted to give a public demonstration of the anaesthetic effects of nitrous oxide the attempt ended in failure. The patient complained of pain and Wells was hissed out of the room as a fraud. (This may have been due to a defect in the apparatus used. We also now know it is difficult to anaesthetise patients using nitrous oxide alone)

Another dentist, William Thomas Greene Morton who saw this failed demonstration experimented with another drug, diethyl ether. On October 16th 1847 he gave the first successful public demonstration of anaesthesia using diethyl ether at the Massachusetts General Hospital. During this demonstration the surgeon removed a tumor from the neck of a patient who said he felt no pain. Morton is generally recognized as the discoverer of anaesthesia.

The other early anaesthetic used was chloroform. Ether made people cough and struggle. It was difficult to anaethetise patients with nitrous oxide alone. Chloroform was easy to use but was harmful to the heart and liver.

During the early days of anaesthesia when patients had to be anaesthetised doctors would place a mask on his or her face. The mask had a metal frame that was covered with gauze. The anaesthetic agent, chloroform or ether was dropped on to it. The patient breathed the anaesthetic in and out of the atmosphere.

Today anaesthesia has developed into an independent medical speciality. The anaesthetist puts the patient to sleep, keeps him asleep and looks after his general condition like monitoring blood pressure and heart beat while the surgeon does the operation. Now lots of money is spent on development of new anaesthetic drugs. Drugs are first tested on animals before they are used on human beings. Sophisticated equipment is used with improved patient care. It is interesting to remember that anaesthesia or relief of pain during surgery had very modest practical beginnings based on practical observations.

The author was formerly a consultant Anaesthetist attached to the Matara and Kandy hospitals and is now a senior lecturer attached to the Department of Anaesthesia, University of Peradeniya.

Understanding Mad Cow Disease

Mad Cow Disease is a term that caused some panic even in Sri Lanka some time ago. What is this disease? How is it caused? And is it found in Sri Lanka? Eminent Neurologist Dr. J.B. Peiris discusses some of these issues:

Mad cow disease can occur in cattle and humans - the human form is the variant Creutzfeldt Jakob Disease (vCJD), while in cows it is Bovine Spongiform Encephalopathy (BSE). In both conditions the brain shows a massive loss of neurons and resembles a sponge.

There are 3 forms of CJD - genetic, sporadic and iatrogenic. In addition there is the vCJD described below. The genetic form behaves like an autosomal dominant disease. The iatrogenic forms are due to 'infected' corneal grafts or contaminated Growth hormone therapy. The cause of sporadic cases is unknown and only a very few belong to the vCJD.

It is important to stress that none of these forms are spread from human to human by direct contact, even intimate, or by indirect contact, such as droplet infection or use of common items, and it is perfectly alright to nurse a patient with loving care.

It would be useful for the reader to be provided with more factual information to prevent panic and for the proper understanding of this emerging disease.

Human CJD and BSE are two members of a family of related fatal disease of the brain, which are caused when the individual is exposed to an infectious protein called a prion. This protein is a mutated form of a natural protein that is found on the surface of many cells in the body.

Neither CJD nor BSE is a viral disease, but unique diseases caused by a variant of a normal protein. The reason these proteins are so dangerous is that they are very resistant to normal sterilisation methods. They are called prion diseases. Other prion diseases are Scrapie, a disease of sheep and Kuru, seen earlier in a particular Tribe in Papua New Guinea which seemed to have arisen as a result of the practice of cannibalisation of deceased relatives as an act of veneration.

In many countries, post World War II animal carcases were processed and fed back to animals, converting herbivores such as cattle into carnivores. However, initially, the rendering process using high temperatures and solvent extraction to remove fat also inactivated the prion protein.

Deregulation of the industry coupled with greed of the farming industry, resulted in cheap rendering processes that did not inactivate the prion protein. The upshot of this was that within a couple of years, cows fed with this modified feed developed symptoms of BSE or Mad Cow disease as dubbed by the media.

However, it was only in 1989 that most potentially infective parts of the animal such as the brain and spinal cord which usually ended up in a cheap mince and beefburgers were banned from human consumption.

A new clinico-pathological phenotype of CJD has recently been identified which may be unique to the United Kingdom. This has raised the possibility of a causative link between BSE and CJD, which now has been confirmed. This is called variant CJD or vCJD. The identification of vCJD caused great public concern because of the suspicion that it resulted from exposure to BSE inadvertently introduced into the human food chain. Although none of the 10 initial cases of vCJD had consumed brain, it must be remembered that hamburgers, sausages etc may contain brain derivatives that are used in the industrial process.

The new variant CJD (caused presumably by eating BSE contaminated nervous tissue) has a distinctive clinical picture that is distinct from that previously seen in CJD. It is possible to differentiate with some accuracy, clinically, by EEG and brain biopsy, the classical CDJ from the vCJD presumably caused by eating BSE contaminated nervous tissue. Scanning procedures including MRI, PET does not seem to be helpful in early diagnosis.

A few cases of classical CJD have been seen in Sri Lanka but none which appear belonging to the category of vCJD or human mad cow disease. While there is no risk of vCJD by consuming meat of cattle fed entirely on a herbivorous diet, there may be a risk in consumption of meat or meat products containing nervous tissue fed on synthetic feeds produced without proper control.

Prion diseases are still enigmatic disorders. The causative agent is still the subject of considerable debate. At present, no clues are available regarding the therapy of these fatal diseases, which requires further understanding of the molecular mechanisms of these diseases

Courtesy: Pulse

Glue in the ear

Your Health

By Dr. Sanjiva Wijesinha

Probably the commonest cause of childhood deafness is a condition known by the intriguing name of "Glue ear".

To understand how it occurs, it is necessary to have an idea of the structure of the ear. The outer ear is that part of the ear which we can see - the auricle which sticks out and the ear canal which is the hole about an inch long that extends inwards to reach the ear drum. The outer ear is like a trumpet that collects external sounds and focuses them on the ear drum - which is an elastic membrane (rather like the skin of a drum) that vibrates freely when sound waves strike it.

This drum forms the outer surface of the middle ear, which is an air filled cavity, rather like a box, containing the ossicles - tiny bones that, connected to one another, form a chain extending from the inside of the ear drum to the outer surface of the inner ear. Their job is to amplify the sound waves reaching the ear drum and carry them to the inner ear.

The inner ear is really a bony cavity (somewhat like a snail shell) filled with liquid and containing thousands of minute nerve endings.

Now the middle ear is connected to the inside of the nose by a tube (known as the Eustachian tube). The function of this tube is to ensure that the air pressure inside the middle ear (the box containing the tiny bones) is the same as atmospheric pressure. Every time one swallows, the tube opens up and equalises the pressure.

Now if the tube gets blocked and cannot function (as happens when infection causes swelling of the tissues around its opening) air cannot move freely between the middle ear and the atmosphere. It gets gradually absorbed by cells lining the middle ear - creating a negative pressure, or vacuum, inside the "box''. This allows fluid to be gradually sucked into the cavity.

Initially this fluid is thin and watery, but if the middle ear remains continuously blocked, it becomes as viscous as glue - which is why the term "glue ear" is so appropriate.

Glue ear affects children because their Eustachian tubes are narrower and shorter than in adults - and so are more easily obstructed by repeated upper respiratory infections.

Recognising glue ear in a child isn't easy unless one is aware that such a condition exists! The only objective finding is partial deafness of a varying nature - so often the condition remains undetected.

Once the problem is recognised, the child should be helped in a practical way. Teachers can be requested that these children be seated in the front of the class till the condition clears. If hearing loss is considerable and recovery prolonged, temporary use of a hearing aid will help.

In most cases, the tube returns to normal function in about three weeks as the infection clears. The usual treatment is antibiotics for the infection and decongestants to dry up the fluid, the latter in the form of nose drops.

If glue ear does not clear in about six weeks, surgical treatment may be necessary - usually an operation to insert tiny tubes (grommets) in the ear drum to drain the fluid inside the middle ear. These tubes stay in for two to six months and fall out naturally as the drum heals.

If glue ear is not treated properly, the fluid inside the middle ear gradually becomes thicker and thicker, causing permanent deafness due to changes in the ear drum and ossicles.

Glue ear however is sufficiently common for you to get your doctor to check your child's hearing if you have the slightest suspicion about it.

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