Appeared at the time of arguments

For the Petitioner     : Nemo

For the Respondents : Mr. Gaichangpou Gangmei, Advocate

Pronounced on: 15^th December  2021

ORDER

The concept of interventional cardiology should expand beyond mechanical revascularization to encompass preventive interventions that forestall future events. There is need for uniform reporting system for Angiography reports to avoid confusion and unwanted litigations. 

1. The Petitioner Nizam’s Institute of Medical Sciences filed this Revision Petition under Section 21 (b) of the Consumer Protection Act, 1986 against the impugned Order dated 17.01.2011, passed by the Andhra Pradesh State Consumer Disputes Redressal Commission (hereinafter referred to as the “State Commission”) in First Appeal No. 1125/2008, wherein the appeal was allowed and the Petitioner as well as the Respondent No. 2 (Dr. Anil Kumar) were directed to pay an amount of Rs.1,95,969/- together with compensation of Rs.25,000/- towards mental agony and costs of Rs.5000/-  to the Complainant/Respondent-1).
2. The brief facts are that on 11.02.2004, the Complainant (hereinafter referred to as the ‘patient’) underwent Coronary Angiogram for his Cardiac check-up at the Opposite Party - Nizam’s Institute of Medical Sciences (hereinafter referred to as the “NIMS”). The doctors at NIMS issued the Angiography report with films. The patient was advised for medical management. The Complainant again on 31.07.2004 suffered heart attack and his doctor at Rajahmundry reviewed the Angiogram film and report issued by NIMS and expressed that as per report the patient should not have suffered a heart stroke. The patient on 21.08.2004 approached Care Hospital at Hyderabad and consulted the Cardiologist who reviewed the previous Angiogram report and opined that there was presence of 75% critical lesion and LV dysfunction also. Again at 2^nd Coronary Angiogram was performed which revealed   99% critical lesion in proximal segment as well as two more lesions.  Therefore, the patient was treated by Coronary Artery Bypass Graft (CABG) surgery. The Complainant/Patient incurred heavy expenses and also suffered mental agony.  The Complainant being aggrieved due to  alleged gross medical negligence of the doctors at NIMS who failed to report critical lesion correctly from 1^st Angiography procedure the Consumer Complaint was filed  in the District Forum, Hyderabad.
3. The written version was filed by the Opposite Parties and denied the allegations of negligence.
4. The District Forum after hearing the averments of the parties dismissed the complaint. The Complainant then appealed in the State Commission, it was allowed and the dismissal Order of the District Forum was set aside. The Opposite Parties (the doctor & hospital jointly) were directed to pay   Rs.1,95,969/- as compensation, Rs.25,000/- towards mental agony and Rs.5000/- as costs.
5. Being aggrieved by the Order of the State Commission, the NIMS - Opposite Party filed the instant Revision Petition.
6. I have heard the learned Counsel for the Parties and perused the material on record inter alia the Orders of both the fora below, two Angiography reports and the affidavit of Dr. M. Srinivas Rao (PW-3) filed before the District Forum.
7. The case of the Complainant is that on 11.02.2004 the doctors at NIMS failed to diagnose the lesion of 75% stenosis (block) and the LV dysfunction during Angiography which further led to deterioration in the health of the patient and subsequently he had to undergo Coronary Angiography Bypass Graft surgery (CABG) at Care Hospital.
8. I have perused both Angiography reports one from NIMS dated 11.02.2004 and another done at Care Hospital on 21.08.2004.

1. Angiography report  done on 11.02.2004  at NIMS:

          “LMCA: NORMAL

          LAD: TYPE III VESSEL, PROXIMAL IRRULARITY GOOD DISTAL VESSEL NORMAL

          DIAGONAL: TWO, NORMAL

          RAMUS: - -

          LCX: NON DOMINANT, NORMAL

          OMS: TWO, OM NORMAL, OM2 MID SEGMENT MINIMAL DISEASE

          RCA: DOMINANT, PROXIMAL MILD DISEASE, GOOD DISTAL VESSEL PDA MILD           IRRGULARITY, PLVB NORMAL

          LV ANGIO: NOT DONE               

          CATH DIAGNOSIS: CORONARY ARTERY DISEASE, LMCA NORMAL, MINIMAL TRIPLE VESSEL DISEASE, RWMA+, DISTAL IVS & APEX HYPOKINETIC MODERATE LEFT VENTRICULAR SYSTOLIC DYSFUNCTION,NO LV CLOT & NO MR

          ADVICE: MEDICAL MANAGEMENT

2. Angiography report done on 21.08.2004 at Care Hospital:

          “LMCA: Normal

          LAD: Type III vessel, there is a discrete, concentric 99% lesion in the   proximal segment followed by mild irregularity. Distal vessel shows good         flow and is graftable.

          DIAGONAL: D1 is a large vessel, normal

          LCX: Non dominant system, normal

          OMs: Large OM1 has a critical lesion at bifurcation, graftable.

          RCA: Right dominant system, proximal total occlusion with thrombus. Distal vessel is filling retrogradely from LCA, graftable.

          LV ANGIO: Dilated LV, Global Hypokinesia with akinetic apical and    anterolateral segments. Severe LV dysfunction, No MR, clot.

          CATH DIAGNOSIS: #CAD Triple Vessel Disease

                                       # Severe LV dysfunction

          CATH ADVICE:         #CABGs

9.     Adverting to the controversy in the instant case that whether the doctor at NIMS wrongly reported the first Angiography dated 11.02.2004 and the ‘medical management’ advised by him constitute medical negligence.

10.    It is pertinent to note that NIMS is a medical teaching institute and having different super specialities including Cardiology. The Angiography was performed and reported by the senior resident in Cardiology. He mentioned that “RCA: DOMINANT, PROXIMAL MILD DISEASE, GOOD DISTAL VESSEL PDA.” The same Angiography film / report was reviewed and interpreted by Dr. M. Srinivas Rao, the Cardiologist of Care Hospital. According to him, previously there was 75% stenosis and LV dysfunction. He further stated that the NIMS report and the ‘medical management’ advice was wrong. His submission on affidavit is reproduced as below:

          “7.     I respectfully submit that at the time of complainant’s visit to the opposite parties, his health condition was in such a state where proper treatment and medicines could have cured him and no surgery was required. But the improper diagnosis from the opposite parties has led to further deterioration of the complainant’s health and it went to a stage where he had no other option except to undergo Coronary Artery Bypass Grafting Surgery.”

11.    According to Dr. M. Srinivas Rao, in the instant case, initially there was 75% stenosis and medical management was wrongly advised at NIMS. It is pertinent to note that at the time of admission to NIMS, the patient was asymptomatic, BP 130/80, pulse 78 per minute and the chest was clear. Therefore, based on clinical assessment & Angiography findings, the Doctor at NIMS took a conscious decision of medical management and prescribed proper medication. The patient was called for review on Tuesday, Thursday and Saturday.

12.    From the medical literature, Atherosclerosis of coronary arteries is a progressive disease.  In my view, there is no straight jacket formula for management of CAD cases. The medical management or surgical intervention (Angioplasty/CABG) depends upon several factors like symptoms and co-morbidities of the patient. The treating doctor has to decide which treatment is more beneficial for the patient. Admittedly, on 11.02.2004, the patient was Asymptomatic and no major signs of cardiac ailment. In the instant case the patient suffered MI on 31.07.2004 i.e. after 5 - 6 months, which may be due to progression of pre-existing atherosclerosis despite the patient, was under proper medication. The treatment initially advised by the NIMS was not deviation from the reasonable standard of practice. I do not find any deviation from the reasonable standard of care at NIMS. Moreover, it is evident from the past history that, on 20.12.2003, the patient suffered Coronary Artery Disease (CAD) - Anterior wall Myocardial Infarction (AMI) and was treated with thrombolysation i.e. medical management.

13.    I have gone through standard textbook on Cardiology namely Eric Topols textbook of Interventional Cardiology and Braunwald’s Heart Disease. Also perused few research articles on Interventional Cardiology.  

14.    The Cardiologist often confronted with CAD. Due to the pathophysiology of coronary atherosclerosis its clinical aspects have changed radically. At first, the decreased coronary blood flow may not cause any symptoms. As plaque continues to build up in coronary arteries, the patient may develop the signs and symptoms coronary artery disease.It is needed to individualize therapy on the basis of specific patient characteristics. The growing field of biomarkers, the genetic risk stratification and pharmaco-genetics will prove fruitful in this regard. Thus it will help to target preventive therapy in a more efficient and cost-effective manner for reducing the risk of atherosclerotic complications.

15.    The purpose of coronary angiography is to know the coronary anatomy and the degree of luminal obstruction of the coronary arteries. It is most commonly used to determine the presence and extent of obstructive CAD and to assess the feasibility and appropriateness of various forms of therapy, either medical management or revascularization by percutaneous (PTCA) or surgical interventions (CABG).  In my view, in the Cardiology Centres in India, the Angiography reporting varies from individual to individual Cardiologist. Few centres reports the stenosis as ‘mild, moderate or severe’ whereas few centres report it in percentage (%) and the type of lesion. The report ‘mild/moderate/severe’ is an individual perception which leads to misinterpretation or confusion. 

16.    In my view, the doctor at NIMS has not deviated from the standard of practice, he adopted accepted mode of treatment.  This view dovetails from the decision of Hon'ble Supreme Court in the case of Achutrao Haribhau Khodwa vs. State of Maharashtra, (1996) 2 SCC 634, wherein it was held as below:-

"the very nature of the profession is such that there may be more than one course of treatment which may be advisable for treating a patient. Courts would indeed be slow in attributing negligence on the part of a doctor if he has performed his duties to the best of his ability and with due care and caution. Medical opinion may differ with regard to the course of action to be taken by a doctor treating a patient, but as long as a doctor acts in a manner which is acceptable to the medical profession and the court finds that he has attended on the patient with due care, skill and diligence and if the patient still does not survive or suffers a permanent ailment, it would be difficult to hold the doctor to be guilty of negligence."

        Recently, in the case of Harish Kumar Khurana v. Joginder Singh, 2021 SCC Online SC 673 summarising  on the subject, including the decision in Jacob Mathew v. State of Punjab, (2005) 6 SCC 1, which laid down the ‘test’ for establishing medical negligence, the Hon’ble Supreme Court observed that:

“[It] is clear that in every case where the treatment is not successful or the patient dies during surgery, it cannot be automatically assumed that the medical professional was negligent.”

17.    I do not readily accept the comments of the Cardiologist, Dr. M. Srinivas Rao that “the coronary angiogram report dated 11.02.2004 issued by the NIMS was ‘absolutely wrong’ and the report was not proper and they have not properly gone through the film.” In my view after going through the NIMS Angiography films Dr. M. Srinivas Rao should have made his own speaking report. Giving mere unreasoned, unelaborated value judgement (“absolutely wrong”) or making remarks of this nature on other similarly / equally qualified consultant(s) is unethical and not viewed favourably. It appears to be ‘sponsored litigation’. 

18.    In the larger interest of patients in our country the Angiography reporting should be uniform. Many times it was noticed that findings in CAG reported as “Mild / Moderate or Severe stenosis” which is an individual Cardiologist’s perception and it varies from person to person. Thus, to decide for better patient care and management, it would be proper to report the CAG as type (A,B,C) and grading the percentage (%) for coronary occlusion/block as many institutes follow the American College of Cardiology / American Heart Association (ACC / AHA) Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures who developed a classification scheme to characterize the complexity of coronary stenosis.

19.    Based on the foregoing discussion, in the given facts and relying upon the precedents from the Hon’ble Supreme Court and the text material from Cardiology, it is not feasible to attribute negligence / deficiency on the NIMS and the doctor therein.

20.    Accordingly, the Order passed by the State Commission is set aside and the Revision Petition is allowed. Consequently, the Complaint is dismissed.