Lessons from the tragedy
How to prevent these deaths
DR ABDUL MAJID SIRAJ
In the panorama of media hype, many promises were made following the tragic events in G.B Panth Hospital. This episode must be looked at holistically on the health services of J&K that in itself is a huge undertaking. Nevertheless having worked in children’s hospitals of world repute, I will try to make a few facts known. No doctor will contribute to a death of a patient unless he is a psychopath. The G.B Panth saga is a culmination of vagaries of systemic failure. And deaths will not stop, no matter how many incubators and doctors are recruited to service.
Doctors have to be made aware of legal obligations in duty of care towards fetus. There is no liability until damnum and injuria concur. During delivery of a foetus a duty of care arises for the doctor to avoid injury to the emerging baby. As soon as the baby is born and ceases to be a foetus and becomes a person, there is a concurrence between damnum and injuria and the baby has a right to sue for negligence. A new born becomes a plaintiff for ‘Wrongful life’ being born with disability. The law did not make the doctor liable for not helping the child not to be born.
The new born babies always pose a challenge for the doctors after the mother completes her period of gestation. The baby is examined at birth for any congenital abnormalities for signs of respiratory Distress Syndrome (RDS) or Fibrocystic Disease or Congenital Displacement of Hips (CDH) and heart problems like septal defects (ASD or VSD) or combined defects like Fallot’s Tetrology or Patent Ductus Arteriosus (PDA) or Spina Bifida. Some babies may go home with disability and some do not make it.
A recent study (See, Brazier & Cave Medicine, Patients and The Law 4rth edn. 2007 Penguin) has shown that just 16% of babies born at 23 weeks and only 44 % born at 24 weeks survive. Babies born at 23 weeks who survived to 6th birthday 25% had severe disability. These figures make a useful reading to explain Panth saga of deaths. Premature babies referred from other hospitals and nursing homes have a lesser chance to live in Kashmir because the routine neonatal screening is not done. In this study only two babies born at 22 weeks survived. Severe disability like hydro-cephalous or duodenal atresia can be corrected but anancephaly or Babies with Edward Syndrome can only survive with intensive care treatment and die in short time. Respiratory Distress Syndrome (RDS) is investigated and unless conditions like diaphragmatic hernia are not operated, the child will die. The arduous task for the doctor is to face the agonizing decisions parents have to take and keep them fully informed.
Normal babies born are not referred to Panth Hospital. They go home and enjoy maternal milk and love with imminent head shave and circumcision in males. However in India the incidence of congenital abnormalities of the babies is as high a 2-5% of births. A family history of neural tube defects in the mother or both parents that carry sex linked or autosomal defects in chromosomes are indicative of investigations like amniocentesis to detect alpha-feto-proteins, ultrasound or foetoscopy, chorionic villous biopsy or chodocentesis while the mother is still waiting. No nursing home in Kashmir is equipped to perform these tests. In later stages of pregnancy abnormalities are visible in radiological studies. Abnormalities to look for would be duodenal atresia, TOF (Tracheo-oesopageal fistula) or diaphragmatic hernia, meningocele, extropy of bladder, hydrops. These anomalies need immediate treatment after birth and some a long term management like Congenital Dislocation of Hips (CDH). A baby will not survive if CHD like Fallot’s tetrology are not operated on. In Panth hospital they will add to the statistics.
Infections take a toll. Meningitis, enteric fever, gastro-enteritis and septicaemia are some of killer infections. A baby should not die with kernictterus. The newborn is a person and has rights but a life of disability is all she will know. Resuscitating a 22 week baby to live for 3 days is a difficult question to confront. A baby born without intestine can be kept living with IV feeds, but for how long? The incubators remain a scarce commodity all over the developing world. Amniocentesis offers a chance to diagnose Cystic Fibrosis or Down’s Syndrome and laws in UK allow termination to the end of pregnancy. Philosophers contend in variance saying that you kill a foetus at 38 weeks but save a premature baby of 24 weeks. What moral difference does the journey through the birth canal make?
In most cases of ill children it is the fault of mothers. The child’s rights are derivative only. For instance a blood transfusion in one case had rendered the couple rhesus incompatible creating a danger to the baby. It is common for doctors to be prescribing drugs to the women of child bearing age and not watch for or warn about the risks to the baby. The drug thalidomide, tetracycline benzodiazapines etc are examples. The mother could be affected by drugs, smoking, radiation or infections.
Hospitals are held negligent for want of facilities. In Premnath Hospital v Poonam Mangla 11 (1998 ) CPJ (Haryana) case the hospital the District Forum ( Consumer Protection Act 1986) held the hospital negligent in not providing incubator for the treatment of the premature baby. It is essential to give all supportive facilities for a modern Children’s hospital to save the fragile babies who are at the thin edge of their lives. That may be a dream for our State but possible contingency measures are listed.
1. All private nursing homes where babies are born must have a basic intensive care facility with an incubator and monitoring system and graduated oxygen supply. They must have expertise for venupuncture to draw blood and setup an IV lines. Transporting critical babies is dangerous.
2. The maternity hospitals must be equipped to diagnose and administer first line of treatment for the neonates.
3 A Children’s surgical hospital must be started with immediate effect. The Kashmir Nursing Home is the most appropriate building and can be used with minimal effort. That will not only save many thousands of lives but also take the burden of the existing beds for children.
4. The infrastructure of the Panth Children’s hospital has to be redone with a fresh look at the drawings that created it. A project report can be drafted and work started forthwith.
Lastupdate on : Tue, 22 May 2012 21:30:00 Makkah time
Lastupdate on : Tue, 22 May 2012 18:30:00 GMT
Lastupdate on : Wed, 23 May 2012 00:00:00 IST
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