Hospitals, Please Own Your Own Doctors: Do not treat Doctors as Scapegoats
Health Ministry, Hospitals and Media should not treat doctors as scapegoats. System, policy and guidelines and most importantly 'culture' should be reviewed and changed if needed.
Terminating the doctors is not the solution
In the context of the recent incident, involving preterm babies, at Max hospital in New Delhi, India, we Dr. Munish Kumar Raizada, a Board Certified practicing Neonatologist and Dr. Bharti Raizada will like to bring following points to your attention. We must mention that we studied this coverage in media and also spoke to Dr. AP Mehta, the Neonatologist who handled the twins.
1. These Newborns were born preterm at approximatley 22-23 weeks gestational age. Even in the Western medical community, it is a well established fact that chances of survival are very dim at this gestational age. A fetus between the age of 22-24 gestational age is considered to be of borderline viability. Survival is 2 % in babies born at 22 weeks and such babies carry 85 to 90 % risk of neuro-developmental sequelae.
2.From the very beginning, the family was involved in decision making. Likelihood of survival, long-term sequelae, and treatment options were discussed with the family both before and after delivery. Every time family decided not to go for resuscitation. The family even signed the DNR (Do Not Resuscitate) papers.
According to Dr. AP Mehta: “I reviewed the baby with my associate consultants Dr Vishal and Dr Gaurav at 10,00 AM (about 2 1/2 hours after the delivery) and told the father that the baby had feeble heart beats. The father again said that they do not want any active treatment or intervention.”
3.Comfort care, which is a standard of care, was provided to newborns.
4.As per Neonatologist Dr. A. P. Mehta, he did not declare the newborn dead.
5. Neonate was handed over to the family by nurses, apparently in a plastic bag, without informing the doctors involved in care. We are assuming that this was not the first preterm delivery in Max hospital. The hospital must be having a policy in place regarding discharge and handing over the preterm neonate(s) to the family. If nurses followed the existing hospital policy then it is time for the hospital to change the system and policy.
6.The family reported that newborn was moving after discharge from the hospital. It is not uncommon for such premature babies to show involuntary movements, for hours, after birth at this gestational age. However, baby should not have been handed over to the family before the doctor declaring the baby dead.
However, following can be the medical explanations:
a] It is possible that the baby started moving his body parts after getting rewarmed in the plastic bag.
b] Was it a rare case of Lazarus Syndrome?
7.When this fact was brought to the notice of Max hospital, the physicians, nurses, hospital administration, high-risk committee, and ethics committee should have communicated with one another and should have explained to the family, again, that this even though a traumatic experience, however, does not change the course or management of the baby. Survival chances are still dim and chances of neurological sequelae are very high.
8. There is nothing which suggests negligence and lack of proper communication with family on part of Dr. Mehta.
As per Dr. AP Mehta: “After this interaction and discussion with father, I did not see or clinically examine the baby. Dr Vishal examined the baby at 12-12.30 PM and did not find any heart sounds. He informed the sisters (nurses) about the same and asked them to wait. I did not declare the baby dead. The Babies were handed over without my knowledge and approval.”
9.Media -without looking critically at the case- gave the verdict that doctors are guilty and negligent, before the full investigation.
10. Doctors are not devils. This entire event is traumatic for family as well health care providers. Hospital did not provide any support to the doctors.
Our appeal is:
a. Doctors should come forward in support of Dr. A. P. Mehta and his associate Dr Vishal Gupta who have been terminated.
b. Max hospital should establish a support group for physicians and reinstate the terminated Neonatologists.
c. Ministry of health should act responsibly and not rush to issue statements before the full impartial inquiry and talking to the involved doctors, nurses, family, and the medical facility where new born was re-admitted.
d.. Media should investigate, and present facts. Delivery of judgement is not media’s work.
e. Terminating doctors is not a solution. Analyzing, learning and changing the system and policies/guidelines is.
Dr. Munish Raizada and Dr. Bharti Raizada practice in Chicago.
To read further, how 2 premature borderline viable babies died in Delhi, but the trajectory was different:
In a new development that could spell fresh trouble for the Shalimar Bagh-located Max Hospital, the Delhi Medical Council (DMC) has issued a notice to the hospital seeking details of its qualification and details of the Delhi Nursing Council registration.
The notice was issued on December 20 — the day the hospital resumed its services, soon after its registration was cancelled by the Delhi government and was barred from admitting new patients.
The Delhi government’s action had come after a 22-week-old premature baby was declared dead at the hospital, even though he was alive, and handed over to his parents in a plastic bag, along with his still-born twin.
“Based on the medical reports that a newborn baby was declared dead along with his still-born twin and handed over to his parents at Max Hospital, Shalimar Bagh. In this regard, the DMC has taken suo motu notice of the media reports, alleging medical negligence on the part of doctors of the hospital, and (the case) is being examined by DMC,” reads the notice.
The Council has also directed the hospital to submit a statement of defence, together with any other documents in support of their defence, within 15 days.
“You are directed to submit a copy of your qualification and Delhi Nursing Council registration details,” the notice said.
Girish Tyagi, the DMC Secretary, said the notice issued “is of concern to all the doctors in the hospital related to the case”, and the Council had sought their individual replies.
“We want to check the role of every doctor involved in the case, including the gynaecologist when the baby was delivered. We want to know what exactly happened,” Tyagi told IANS. IANS
New Delhi: The BJP on Wednesday slammed the Arvind Kejriwal-led Delhi government soon after Max Hospital, Shalimar Bagh, resumed its operations, days after its licence was cancelled by the city government for declaring a live newborn baby dead.
“Chief Minister Kejriwal needs to tell Delhi what deal did he strike with the Max Hospital administration for preparing a legally weak case that could not stand for a single date?” Delhi BJP President Manoj Tiwari told reporters.
“The restoration of medical services at Max Hospital in Shalimar Bagh is no surprise for us, in fact, it was expected,” the BJP MP from northeast Delhi said. Tiwari’s remarks came soon after Max Hospital, earlier on Wednesday, said operations were resumed after the Court of Finance Commissioner on Tuesday put on hold the government’s December 8 order.
The hospital had appealed to the appellate authority to revoke the cancellation of the licence. Lashing out at Kejriwal, Tiwari said: “He is master at scripting such gimmicks with which he can emotionally attach to people for political gains. The legally unsubstantiated ban was just aimed to mislead people.”
On December 8, the Aam Aadmi Party (AAP) government cancelled the 250-bed hospital’s licence after its doctors on November 30 declared a premature newborn baby dead. He was found to be alive when his parents took his body for the final rites. The baby died a week later due to “infection and other medical problems”.
Case Number 1: Hospital Safdurjung, New Delhi (Under Central Government)
In June, 2017: Santi Devi – a 28 years pregnant woman delivered a preterm baby at Delhi’s Safdurjung Hospital. As per media reports, with a gestational age of 24 weeks. Birth Weight: 460 Grams. The hospital staff found no movement in the baby, made some attempts to revive and when these attempts failed, handed over the baby to the family to take it home.
At home,they found the baby alive and brought him back to the same hospital (safdurjung). The baby was readmitted.
As per the report published in the HT, father of the baby Rohit Kumar – a daily wage earner- said: “I wouldn’t have opened the polythene if it weren’t for the ladies of the family; they insisted on seeing the boy’s face. When we opened the cover we found he was moving his hands and feet.”
Safdurjung Hospital apparently set up an inquiry in this gross negligence. But, did any heads role in this case? Remember, Safdurjung Hospital does not come under Delhi Government.
Note: What happened to that inquiry that was set up? Details are not available.
Case Number 2: Max Hospital, Shalimar Bagh, N Delhi. A Private Hospital, but comes under jurisdiction of Delhi Government.
November 30,2017: Versha- a pregnant mother- checks into Max Hospital. She is pregnant with triplets (reduction was done, so she has in effect, Twin pregnancy). 23 weeks gestation. She delivered twins- one is still birth, another is live premature baby. According to Dr. AP Mehta- the consultant Neonatologist – the family was involved in the decision making right form beginning. Do Not Resuscitate (DNR) was signed by the family at the time of delivery. Comfort Care was started. The baby was later handed over to the family apparently in a plastic bag. While going to the cremation ground, the family noticed movements of the baby. They admitted the baby in a local Nursing home. (More details can be found at my article written at NewsGram: https://www.newsgram.com/hospitals-please-own-your-own-doctors-do-not-treat-doctors-as-scapegoats/ )
Max Hospital fired the Neonatologists- Dr AP Mehta and Dr Vishal Gupta.
Later on, Delhi Government canceled the license of the hospital
Now, let us look at some medical facts:
1. A fetus less than 22 weeks of gestation is considered Non Viable ( incapable of survival).
A fetus with a gestational age of 22-24 weeks: Borderline Viability. In Western world with advanced medical care, still the decision to resuscitate or not will depend upon many factors. Mortality is 98 % in a 22 weeker baby.
In such premature babies at the borderline of viability, it is not uncommon to see beating of heart (remember, heart has autonomicity), feeble and intermittent respirations and flickering of arms and legs for several minutes to many hours after birth, particularly when comfort care is being provided.
2. Why babies who were apparently dead and cold showed signs of life again? One possible reason is that in polythene bag, the babies get rewarmed and heart starts pumping again. This is just a plausible medical explanation and I can not vouch for the circumstances of the 2 babies cited above.
3. A family discovering the baby alive: This is an absolutely emotional and painful experience for the family. The babies should not be handed over to the family until declared dead by the doctor. However, such situations are equally agonizing for the caretakers too.
These kinds of disastrous situations are not an open and shut case of ‘criminal medical negligence’. Generally speaking, there is not an intent of the doctor to ‘kill’ the baby in such embarrassing medical situatioins . In Safdurjung Hospital case, it seems from media reporting that there was just not enough time spent on the baby to let ‘die’ peacefully and an opportunity for the family to spend and bond with a dying borderline non-viable baby (what we call Comfort Care in medical parlance).
However, by firing his doctors, Max Hospital’s administration shifted the onus on doctors, whereas the fiasco was a collective responsibility.
Why did Delhi Government led by incompetent Chief Minister cancel the license of the hospital based upon this case? The simple answer: Political Opportunism shown by Delhi’s Government on Ventilator.
Because, first Delhi government’s incompetence is well known. It was elected with a heavy mandate, but the govt has lost its sheen and is highly unpopular. It jumped upon this opportunity to score some brownie points and project itself of as a savior of people. Also, canceling a private hopsital’s license shows lack of policy understanding and typical communist mindset of early 1960s. Asking for damages from the hospital would have been a better step: it brings revenue to the sarkari coffer which the government could have spent on improving health standards. Right? Ouch! I am talking of health policy nuances which the CM may not understand! Afterall, its DDC is in absolute despair, just siphoning away tax payer money rather than coming up with some concrete policy suggestions.
Also, this happens because in India, governments are not considered accountable. There must be provision to sue the governing class also (municipality, state, center) and then you will see that Health Ministry in Delhi would have thought 100 times before taking this step. At this point, Health ministry is scoring points to cover up its own incompetence.
The families need healing touch. Doctors and the hospitals need to review their practices and do course correction.
Dr. Munish Raizada is a practicing Neonatologist in Chicago.