CASE STUDY
Tolerance of illegal
practices
Rajesh Malhotra
This case study is, unfortunately, not uncommon in
our set-up and is a fallout of the societal attitude that accepts that those
working in government organisations are going to work elsewhere to make extra
money. This tolerance accords legitimacy to this illegal practice where the
person involved can even afford to be defiant rather than defensive or guilty
and may justify his actions.
A poor patient gets injured and is taken to a
hospital where he is entitled to get free treatment including the implant but
gets restless because he is not being told when and what operation is going to
be done. This raises several questions:
(i) Is it not the duty of
surgeons to inform patients about their injuries, the proposed method of
treatment, alternate methods of treatment, the expected period of recovery and
the prognosis? The fact that once the patient became restless, he was suggested
another place for treatment, certainly raises the suspicion whether this sort of
practice was a routine to coerce patients to take treatment in private
hospitals.
(ii) Did the Employees State Insurance (ESI) hospital have an
orthopaedic surgeon but 'no facilities to operate such injuries'? In that case
what is the protocol for such patients? There would be some referral centre
where such patients would be referred. Was a suggestion made to the patient that
he could take treatment at another government hospital? I doubt it, given the
fact that the doctor himself judged that 'in another hospital he will have to
wait months for surgery'.
(iii)Was the doctor, out of ignorance or
intentionally, unaware of the conservative method of treatment using traction
since the facilities for operative treatment were not available in the
government hospital? Did he suggest this alternative to the
patient?
Given the serious nature of orthopaedic infections,
especially with implants in situ, it is imperative that orthopaedic surgeries be
done in the best and the cleanest operation theatre (OT) of the hospital. It was
probably the only theatre in the nursing home, forcing one to presume that all
other infected cases were also being operated upon in the same theatre.
Infection is not surprising in these circumstances; but the infection was
apparantly not treated by irrigation and debridements. Was the nursing home was
not accredited? I suggest that it should be obligatory for all hospitals to be
certified as fit for undertaking orthopaedic operations by a competent
regulatory body. Even if the patient had too little money (Rs 70,000/- is not
too little for the treatment of these injuries), aggressive treatment could have
been done at the ESI hospital where the patient was entitled for treatment.
Perhaps his infection was neglected because he had run out of money and his
doctor had lost interest in him now. The surgeon admitted to implanting inferior
implants in a small nursing home and justified it as 'you cannot get five-star
treatment at two-star rates'. He was pushed into accepting the option
which, to him, was probably the only choice available.
The treating
surgeon has also overlooked a few principles of good medicine: (i) that the
treatment should not harm the patient and should not be more harmful than the
disease, even if at the worst it can do no good to him; (ii) that once you
operate on a patient, he becomes your lifelong responsibility and you have to
look after his interest whether or not he has any money left.
There is, however, another aspect of the case. It
is not uncommon for contractors to promise the best treatment to labourers
injured in industrial accidents, either out of empathy or to avoid medicolegal
repercussions. Injured persons are often unable to resist the temptation of
treatment in private hospitals where they presume they will get better
facilities and more comforts. However, the minute they refuse a medicolegal case
or the expenditure exceeds the estimate, or a few days pass they face the harsh
realities of life and have to fend for themselves.
While it is easy to put the entire blame on the
doctor in the ESI hospital or on the nursing home, one must realise that it the
system which breeds these types of ills. Inability to provide the facilities for
quality care in public hospitals, lack of accountability and discipline among
physicians working in these organisations and, at times, the patronage of the
high and mighty to the dishonest care providers-all make such incidents possible
while the guilty remain arrogantly apathetic.
RAJESH MALHOTRA, Consultant Orthopaedic Surgeon,
All India Institute of Medical Sciences, New Delhi 110029, India. e-mail:rmalhotra62@hotmail.com
