CASE 1

A general practitioner, Dr. A treated a patient B for a metal foreign body in his left eye by irrigating the eye under topical anaesthesia using a 26G x ¼” needle (non-LUERLOCK) attached to a syringe. This was successfully done.

Patient B felt discomfort in the right eye and he requested for similar irrigation. Dr. A obliged. The needle “slipped” and “hit” the right eye. Dr. A immediately referred the patient to an ophthalmologist, Dr. C.

Dr. C’s findings
i) right eye vision 6/9, left eye vision 6/9
ii) right eye – penetrating injury; entry wound at limbus at 3 o’clock extending to the iris and lens obliquely with exit wound at posterior lens capsule at 9 o’clock.
iii) mild lens opacity posteriorly
iv) mild anterior chamber reaction with cell 2+
v) Fundus examination was normal; no retinal involvement

Diagnosis : penetrating injury right eye with uveitis

Dr. C’s treatment

i)Moxifloxacin and tobranycin eye drops every hour
ii)Ciprofloxacin tablets 500 mg b.d.
iii)Moxifloxacin and tobranycin eye drops to left eye 4 hourly

Progress

A. Reviewed three days later
i) right eye vision 6/24; pin hole 6/9
ii) right eye was white; no eye pain
iii)minimal anterior chamber reaction
iv)to continue antibiotic eye drops every 3 hours
v)review in one month!

B. Reviewed twenty four days later
i) right eye vision 6/24; pinhole 6/18
ii) right eye was white with no anterior chamber reaction
iii)part of the lens was cataractous
iv)advised review in 2 months. K.I.V. cataract operation with intraocular lens implant

C. Patient returned three weeks later
i) right eye pain and reduced vision for 4 days
ii) right eye vision – hand movement
iii)fibrin and hypopyon seen in anterior chamber
iv)intraocular pressure 19mmHG
v)hazy fundus

Diagnosis : endophthalmitis right eye

vi)started on antibiotic eye drops and Ciprofloxacin tablets

D. Patient reviewed 1 day later
i) right eye vision – hand movement
ii) hypopyon level was less than previous day
iii)patient referred to General Hospital

COMMENTS

DOCTOR A

he has caused a penetrating eye injury.
he should not have used a needle attached to a syringe to irrigate – it is a potential projectile
use a syringe only to irrigate
correctly referred the patient to an ophthalmologist

DOCTOR C

he should have monitored patient B daily for at least two weeks, when an early intervention would have saved the vision of the right eye – removal of the injured lens with or without the implantation of an intraocular lens
endophthalmitis may not have resulted if Dr. C has been vigilant in his management
Dr. A was directly responsible for the penetrating injury but the end result, endophthalmitis, could be attributed to delay on the part Dr. C.

CONCLUSION

In view of the above, the opinions by the ophthalmic experts in this case was that the case could not be defended. The claim was settled for a substantial sum.

CASE 2

1½ months old boy admitted under the care of Doctor A for:

a.Acute gastroenteritis
b.Failure to thrive

The patient was treated accordingly and was discharged on the fourth day of admission and reviewed ten days later for a tender, swollen left leg. X-rays confirmed that the left leg bones were normal.

Provisional diagnosis : Cellulitis left leg.
Two days later patient was admitted to a University Hospital.
It was reported in the newspaper two months after the first admission to Doctor A’s hospital that there was dry gangrene of the left leg which required an amputation.

A solicitor acting for the father of the patient wrote to the medical centre for a medical report. Because the response was ‘slow’ the solicitor lodged a complaint with the Malaysian Medical Council, quoting the Private Healthcare Facilities & Services Act 2006.

Doctor A, who is also the Medical Director of the Hospital, had to attend an Inquiry of M.M.C’s Preliminary Investigative Committee. The complainant subsequently withdrew the complaint.

COMMENTS

1.The public is now more aware of their rights and will not hesitate to seek ‘justice’. Complaints to M.M.C. are increasing.

2.In this case Doctor A should have responded in a timely manner to provide a comprehensive report.

3.Attending an Inquiry will interfere with your practice schedule especially if you are from outstation, cause mental stress, cause unnecessary expenditure – meeting up with solicitors to prepare the case. Hearing usually takes more than one sitting.

4.Only a medical defence organisation will provide you legal service. If indemnity is with insurance company one has to bear the legal expenses which can be substantial if the Inquiry involves more than one hearing.

CASE 3

A female patient presented with sudden onset of epigastric pain. Patient was examined and investigated.

Ultrasound confirmed gall bladder stones; the common bile duct was not dilated.

Laparoscopic cholecystectomy was performed by Doctor A the next day. Uneventful recovery. Discharged on first post op day.

Returned on second post-up day with inability to pass urine – a urinary catheter was inserted. Patient was admitted.

On 3rd post op day the urinary catheter was removed. Patient was able to pass urine on her own. She was discharged.

Doctor A was on leave from third post op day for seven days.

At 1.15pm on the third post op day, Doctor A, whilst on the way to the airport, received a call from M.O. of A&E Dept of Doctor A’s hospital. Patient has returned for epigastric pain. Doctor A instructed M.O. to treat –

a.I.V controloc for the epigastric pain
b.Observe and call surgeon on call if necessary

At 2pm, the patient left the A&E Dept.

She went to another medical centre where she was admitted. Ultrasound was done followed by E.R.C.P by Doctor B. Dr. B confirmed that he found residual stone/sludge on the clip but the common bile duct was clear. Dr. B felt that the stone/sludge at the clip could not have caused the epigastric pain. A sphincterotomy was done. Patient was discharged four days later.

The patient subsequently demanded compensation from Dr. A.

Subsequently the patient filed a claim in the Session Court.

COMMENTS

1.Dr. A should not have done the laparoscopic cholecystectomy if she was going on leave three days later. Dr. A should be available for at least one week post op to manage the patient.

2.Whilst she was on leave she could not personally attend to the patient. By giving treatment over the telephone, Dr. A is liable. The latter sought treatment at another centre. Dr. A gave instructions over the telephone which the patient may have perceived that Dr. A was not concerned.

3.Patient demanding compensation – indemnity with a defence organisation or insurance company provides for legal costs and court awards only.

4.Dr. A did not subscribe to Therapeutic Laparoscopic Surgery in her indemnity. Hence, Dr. A has to defend the claim at her own costs.

It is imperative that doctors should have adequate indemnity coverage for their scope of practice.

CASE 4

44 year old male, victim of assault, sustained multiple lacerations on the scalp.

Seen at A&E Dept at 2215hrs; the wounds were cleaned and dressed by medical officer.

X-ray and C.T. Scan skull : nad

Admitted to ward at 2353 hrs. He had a full meal, hence T&S could not be done immediately.

Meanwhile patient was fasted, I.V. drip set set, inj A.T.T. given and I.V. antibiotics started; head chart started.

Surgeon A was informed. He scheduled the patient for T&S at 0800hrs the next day. At 0800hrs next day, Surgeon A saw the patient. He could not do the T&S as scheduled because the insurance company has not approved the admission.

Surgeon A started his elective list.

By 1025hrs the approval was still not obtained. Surgeon A continued with his elective list.

At 1200hrs, insurance approval was finally given.

At 1230hrs the T&S was done.

Post operative recovery uneventful.

Wife of the patient lodged a complaint with M.M.C. on “unsatisfactory treatment” and the expensive charges for a stay of three days and two nights.

Member had to attend Inquiry by the Preliminary Investigative Committee. P.I.C. decided not to refer the member to M.M.C.

COMMENTS

1.Surgeon should have seen the patient on the night of admission although he was satisfied with the treatment instituted by the Medical Officer.

2.The delay in the operation was due to
a.the patient was not fasted
b.the insurance company did not give approval till 1200hrs the following day

Surgeon A is not responsible for the above two factors. The anaesthetist could explain the reason for not giving anaesthesia on patient with a “full” stomach.

Surgeon A is not responsible for the insurance approval. This is an arrangement between the hospital and the insurance company.

Surgeon A’s fees were within the Private Healthcare Facilities & Services Act’s schedule.

The hospital is liable in event any complication that may arise from the delay in the operation.

The insurance company should be reported to the Ministry of Health, as well as to Bank Negara.