Tackling Medical Malpractice in Pakistan – Law, Media And Society

By YLH

Thanks to our ever watchful media,  several serious cases of medical malpractice have come up and have been debated nationwide. For the first time in our history real issues are becoming national issues.  Some of the leading hospitals in Lahore have been accused of gross negligence.   In recent times the cases that have come up and shocked the nation are that of Huma Akram – Waseem Akram’s wife –  and  of young Imane Malik who has touched all of our hearts.

The issue of health care has now come before the National Assembly as well as the provincial assembly.  The News writes:

Acting on a unanimous recommendation made by the National Assembly’s Standing Committee on Health (SCOH) here Thursday, Mir Aijaz Hussain Jakhrani, who was appointed Minister for Sports within hours of attending the said meeting, has left charge of the Ministry of Health after ordering the Pakistan Medical and Dental Council (PMDC) to immediately suspend the registration of all the 19 doctors whose criminal negligence led to the death of Huma Akram, wife of the former captain of the Pakistan cricket team, Wasim Akram.

In another major development, the Ministry of Health has directed the acting Executive Director of the Pakistan Institute of Medical Sciences (PIMS) Dr. Altaf Hussain to immediately relinquish charge of office on account of negligence leading to the death of MNA Faiz Muhammad Khan, and to report back to the ministry until further orders. Some members of the Standing Committee strongly recommended immediate suspension of Dr. Altaf, at which Jakhrani promised to take action within the next 24 hours.

However, within two hours after the meeting, an order was issued for Dr. Altaf to relinquish charge and report back to the Ministry of Health and for Prof. Dr. Ghazala Mehmood to look after the work of the office of the ED in addition to her own responsibilities as professor of gynaecology and dean of Quaid-i-Azam Post-Graduate Medical College.

The former acting ED however, told ‘The News’ that immediately after the SCOH meeting, he submitted to the Secretary Health, a letter requesting an independent inquiry into the death of MNA Faiz Muhammad and communicating his decision to voluntarily relinquish charge of the position. “I voluntarily withdraw from the post of ED PIMS till finalisation of inquiry into the death of MNA Faiz Muhammad Khan and fixing of responsibility of alleged neglect. I may also be permitted to request the Chief Justice to order an independent judicial inquiry to find out the facts and order punishment accordingly,” he claimed to have stated in the letter.

In the Imanae Malik case, the Standing Committee stopped short of recommending closure of Doctors Hospital and asked the Punjab government to give a 10-day deadline to the hospital for establishment of Standard Operating Procedures (SOPs) so that basic standards of care and laboratory services are made available to all patients. An inspection committee will be formed to evaluate the hospital after 10 days; in case of dissatisfaction, further action will be contemplated.

The PMDC has already suspended five doctors whose negligence lead to the Imanae’s death, and has recommended immediate closure of Emergency services at Doctors Hospital so that no more precious human lives are lost at the alter of “butchers running that slaughter house,” in the words of MNA Hanif Abbassi. Furthermore, the child’s parents have already lodged an FIR against those responsible for her death.

All these landmark decisions were taken at a meeting of the SCOH, which was held in the Parliament House under the chairmanship of Dr. Nadeem Ehsan. The committee took up all the three recent cases of medical negligence, namely the Huma Akram case, the Imanae Malik case, and the MNA Faiz Muhammad Khan case.

In addition to Jakhrani, the meeting was attended by Wasim Akram and his brother-in-law, Secretary Health Khushnood Akhtar Lashari, DG Health Dr. Rashid Jooma, then acting ED PIMS Dr. Altaf Hussain, joint executive director PIMS Dr. Jehanzeb Aurakzai, who presented the findings of the inquiry report, and chairman of PMDC Dr. Asim, among others.

In the Huma Akram case, the PMDC has been asked to immediately suspend the following 19 doctors: Kamran Cheema, Abbas Raza, Abeera Mansoor, Somia Qazi, Hammad Nazeer, Javed Asghar, Shahbaz Sarwar, Farhan, Mehmood Ayaz, Javed Iqbal, Mudassir Asghar, Mudassir Sheikh, Noman Tareef, Ziaullah, Shaukat Mirza, Asad Jawad Shahid Sarwar, Anwar A Khan, and Rizwan Ahmed. Furthermore, the SCOH has constituted a 15-member sub-committee that will sit with the disciplinary committee of the PMDC to ascertain the level of negligence committed by these doctors for institution of disciplinary action. The objective behind constituting the sub-committee, which will be led by Dr. Tariq Fazal Chaudhry, is to eliminate the possibility of conflict of interest as the PMDC committee consists of many doctors working in the private sector.

Meanwhile, Wasim Akram is free to lodge an FIR against the said doctors. The SCOH has also asked the Punjab government to share the Punjab Health Care Regulation Bill with its members, the federal government, which has also prepared its own draft bill titled ‘Regulation of Private Hospitals/Clinics/Nursing Homes Bill’ for bringing the private sector under its regulatory framework, as well as the three provinces so that everyone is brought on board for constitution of a unified policy to regulate the private health sector.

“The draft bill that we have prepared recommends constitution of a regulatory body, which would be responsible for annual registration of all health facilities, provided they meet laid down minimum standards. This would regulate quality health care in the private health sector, which up till now is operating uncontrolled. The bill will have national standards and guidelines for all medical facilities, both public and private,” Jakhrani informed the SCOH.

The Secretary Health Punjab shared that the Punjab Health Care Regulation Bill, which seeks to preserve the integrity of the medical profession by taking action against illegal practices, is already facing vehement opposition. Lashari vowed to expedite legislation for regulation of private hospitals, clinics and laboratories.

The findings of the inquiry committees instituted to probe the Huma Akram and Imanae cases were shared with the SCOH, whose members raised intelligent questions on issues ranging from the highly unbecoming and ruthless conduct of doctors to the utter lack of profession acumen among them. All answers and evidences led to the conclusion that both cases wreaked of “gross criminal negligence,” making it imperative for the government to take deterring action. Jakhrani termed lapses in treatment and failure to diagnose both at National Hospital and Doctors Hospital Lahore as contributing to Huma’s death. He referred to “provision of fragmented and uncoordinated care by doctors at both the hospitals, and lack of leadership and imagination on behalf of the two lead physicians namely Dr. Abbas Raza and Dr. Kamran Cheema.”

The meeting started with a statement by Wasim Akram. “I am here to seek justice. Justice has got to be served. If this can happen to a resourceful and known person like me, you can well image the plight of an ordinary Pakistani,” he stated. In spite of the strong-nerved man that Wasim appears to be, tears kept flowing from his eyes throughout the course of the meeting. “More than 17 physicians examined Huma, and all of them were being paid; yet, they all failed to diagnose her ailment. I tell you, that hospital is a slaughter house,” he stated, like Hanif Abbasi. Wasim painfully recollected the “arrogant and negligent attitude of the doctors in Pakistan,” and compared it with the compassion that he received at the Apollo Hospital in India, where Huma was eventually shifted. “Huma, my brother-in-law, and I entered India without a visa; when I asked doctors about the charges, they said, let your wife be okay, then we will talk about money matters.” Wasim charged Dr. Abeera for being “unavailable and un-contactable” at a time when she was most needed. The cricket hero was also debarred from leaving the hospital until he cleared all bills. “I only had Rs40,000 on me; it was 1:00 a.m. at that time, and I told them I would clear the bill in the morning, but they firmly told me that I would not get the gate pass until I had made the payment in full,” he stated.

Wasim stated having repeatedly asked Dr. Cheema whether Huma was fit to be flown to India, and he replied in the affirmative even though she should not have embarked on the journey in view of her deteriorating condition. “I have handled many pressures in life; cricketing pressures and controversies; but never have I found myself so helpless,” he said, with tears rolling down. As far as Huma’s diagnosis was concerned, Dr. Azra Talpur wondered how so many doctors could have missed a bicuspid aortic valve with fungal vegetation, that too when the whole scenario wreaked of fungal infection, given that the patient was also not responding to the excessively high doses of antibiotics given to her.

MNAs Hanif Abbassi and Shahnaz Shaikh expressed strong dissatisfaction over the working of PIMS and demanded immediate suspension of Dr. Altaf. “Our colleague remained unattended at PIMS for one and a half hour. Be it an MNA or an ordinary person, how can a patient requiring emergency care be shifted to a ward, rather than the ICU,” Hanif questioned. “Why was a ventilator not available? Why should the top administrator not be suspended, in addition to the two doctors and a nurse against whom action has been taken,” he further asked. Shahnaz Shaikh also emphasised that nothing short of the ED’s removal would be acceptable to colleagues of the MNA. She also demanded that the inquiry into the MNA’s death be expedited. “The ambulances of your hospital are being used for transportation of doctors; only today, one of your vehicles has been stolen from the ‘sabzi mandi’ (vegetable market),” she said while addressing Dr. Altaf, who did not say anything in his defence. He did raise his arm half-way in the air several times to seek permission to speak, but the manner in which he did so remained unnoticed by the chair

A committee ruled similarly on the tragic events that unfolded on day 2 of Eid last month in Doctors’ Hospital

LAHORE: Three-year-old Imanae Malik was taken to the Doctor’s Hospital, Lahore, for treatment for minor burns. According to reports, Imanae was repeatedly injected with anaesthesia, and the accumulated dosage caused her death within minutes of administration.  As the investigations into Imanae Maliks death continue to surface, the Pakistan Medical Association probe committee finds out that the death of the three-year-old was a result of the negligence.

In response to Wasim Akram’s allegations impugning the doctors he holds responsible for his wife’s death,    Mr. Salman Chima – the partner at Chima And Ibrahim – and  Dr. Kamran Chima’s counsel sent me this comprehensive and very informative legal noticewhich should be of considerable interest to everyone – as the other side of the story:

Chima & Ibrahim

Advocates

Corporate Counsel

1-A/245 Tufail Road                                                                                 Telephones : (9242) 36681265-7                    

Lahore Cantt, Pakistan                                                                                         Telefax : (9242) 36687790                    

WITHOUT PREJUDICE

December 15, 2009

Mr. Waseem Akram

64/2, Z Block

DHA, Lahore

Subject : Legal Notice

Dear Sir :

We have instructions from our client, Dr. Kamran Chima of 10-A Upper Mall, Lahore, to address you as under :

  1. Our client is an American Board certified pulmonologist and critical care specialist, presently associated with the Services Hospital Lahore, and the Doctors Hospital Lahore. It may also be mentioned that he was the best graduate of King Edward Medical College (from where he graduated in 1986) and completed his specialized training from the Yale University, USA.

 

  1. Our client has been practicing in Lahore since 1994. The love and affection extended by his patients is not only touching, but also sufficient to establish the immaculate reputation our client enjoys.

 

  1. Your late wife (Mrs. Huma Akram) was admitted to the National Hospital Defense Lahore (“National Hospital”) on 6 October 2009, on account of multiple ailments. She was attended to by a team of doctors associated with the National Hospital, who looked after her ably and with all requisite attention. However, it is worth noting that our client (not being associated with the National Hospital) was not among them.

 

  1. Our client was asked to see Mrs. Akram, by way of special request extended by Dr. Nauman Tareef. The request was made at 23.43 hrs on 14.10.09. Our client was well within his rights to decline the request, considering how late in the evening it was made, and the fact that he was not even associated with the National Hospital (and was not therefore obligated to accept the request). However, our client virtually immediately rushed to the National Hospital and saw Mrs. Akram for the first time at the rather unearthly hour of 00:45 AM (i.e. in the early hours of 15.10.09). After thorough examination of the patient (and all her medical records made available to our client), our client’s assessment/diagnosis was that she was suffering from ‘endovascular infection/infective endocarditis’. Incidentally, that diagnosis remains correct (though the actual organism suspected of causing the infection was identified after the patient’s death).

 

  1. Our client was then kept advised of the patient’s progress throughout the day, by Dr. Nauman Tareef. There are no less than 5 calls between our client and Dr. Tareef on 15.10.09.

 

  1. During the course of 16.10.09, the doctors treating Mrs. Akram at National Hospital felt that due to possible infection in her heart valve it may need to be replaced and it could not be done in the National Hospital (which does not have facilities for such valve replacement). Our client (who specializes in critical care treatment) was requested by Dr. Nauman Tareef to assist the move to the Doctors Hospital as well as the requisite procedure.

 

Since you have wantonly suggested in your statements to the press (including on 10.12.2009) that doctors were not available as and when necessary, it is relevant to set out the chronology of calls/events in this behalf (all substantiated by telephone records attached as Annex A to this legal notice) :

  1. Our client receives call from Dr. Nauman Tareef on 16.10.09 at 20:48 (through this call Dr. Tareef requested that the patient be shifted from National Hospital to Doctors Hospital).
  2. Our client immediately (at 20:54) calls Dr. Sobia Kazi at Doctors Hospital to alert her of the patient’s anticipated admission.
  3. A follow up call is made to Dr. Sobia Kazi at 20:59.
  4. Two calls are then made to Dr. Tareef (at 21:02 and 21:09) to confirm that arrangements have been made.
  5. Incoming SMS is received from yourself (Waseem Akram) at 21:44 on 16.10.09.
  6. Our client calls you (Waseem Akram) at 23:17. In this call our client also makes it very clear to you that if you decide to shift Mrs. Akram to Doctors Hospital, her dialysis would be supervised by Dr. Abeera Mansur. (It may also be mentioned here that our client has full confidence in the professional capabilities of Dr. Abeera)
  7. A call is received from Dr. Tareef at 23:37, in which arrangements are discussed and confirmed.
  8. An SMS is received from yourself (Waseem Akram) at 00:47 on 17.10.09, informing our client that Mrs. Akram has arrived at the Doctors Hospital.
  9. Our client, who was already on his way, reaches the hospital minutes later and remains with the patient for 60 minutes.
  10. Our client sends an SMS to Dr. Asad Jawad at 02:01 hours (regarding the procedure Mrs. Akram may need to undergo later in the morning). This SMS was sent while our client was at the Doctors Hospital.
  11. Our client then calls Dr. Asad Jawad at 07:56. Considering that our client was in Doctors Hospital at least until 02:30 or so (his last message to Dr. Asad Jawad is recorded at 02:01 hours), you can well imagine that he could not have had more than 4 ½ hours of sleep before he was back on the case. All this, incidentally, on Friday night/Saturday morning – when most people would be enjoying their weekend.
  12. 11 further calls are then recorded between 7:56 and 11:44, in a period of less than 4 hours (which were made by our client to various doctors seeing Mrs. Akram, including Dr. Asad Jawad, Dr. Sobia Qazi, Dr. Abeera Mansur, Dr. Sarwar and Dr. Nauman Tareef).
  13. At 11:49, a call was then made by our client to you (Waseem Akram), informing you of the doctors’ consensus that before executing heart valve replacement, it was advisable to get further testing from the Punjab Institute of Cardiology (“PIC”). The TEE test at PIC in fact showed that valve replacement was not necessary (CD of the test is available with you), and the patient was shifted to Heart and Body Scan for further testing.
  14. While the patient was undergoing testing at PIC, and thereafter ‘total body scanning and CT angiography of kidneys and abdomen’ at Heart and Body Scan (during the latter phase our client was personally present with the patient), and during the rest of the day, our client made 6 further calls to various doctors seeing Mrs. Akram (including Dr. Sobia Qazi, Dr. Faisal Sultan CEO SKMT, Dr. Nauman Tareef, Dr. Arifeen and Dr. Abeera Mansur). This is in addition to being personally present with the patient during most of that time.
  15. It is also noteworthy that despite spending most of the day with the patient on 17 October 2009 (which was a Saturday), our client sent an SMS to Mrs. Bakhtiar Wain at 21:09, regretting that he would not be able to make it to the dinner she was hosting, though he had earlier confirmed participation. Why? Because he was working on stabilizing Mrs. Akram (no favor to you, as our client has done this on countless other occasions as well).
  16. In fact, our client did not leave the patient until her condition was stabilized. Once that had been done (and she in fact remained stable during the rest of her stay in Doctors Hospital) most of our client’s work (as critical care specialist) had been accomplished. However, he regularly kept seeing the patient during subsequent days as well, as noted below.

 

7.         In the afternoon of 17.10.09, you informed our client that (on the insistence of your in-laws) you had made arrangements to shift the patient to Mount Elizabeth Hospital in Singapore. Our client, as well as Dr. Faisal Sultan (CEO SKMT), Dr. Abeera Mansur and Dr. Sobia Qazi advised you that in their reckoning NUS Hospital was the best hospital in Singapore. However, you indicated that arrangement had been made by ESPN.

It was in the aforesaid context that our client mentioned to you in passing, that one of his patients was taken to the world renowned Cromwell Hospital in 2008, and to our client’s recollection the air ambulance charged approximately USD 125,000. This was meant to inform you of your options, and nothing more. The issue was never discussed or mentioned thereafter (though one would have thought that most people in your situation would pay the extra amount to ensure their wife was taken to the hospital which is amongst the very best reputed in the world – it perplexes one that you did not consider the option).

Be that as it may, it may be noted that the other patient’s family who arranged the aforesaid air ambulance service, has kindly permitted our client to disclose the invoice, which is attached as Annex B. It shows a charge of EURO 86,500 (which in US Dollar terms would come to what our client roughly indicated).

In your recent and entirely unfounded outpouring, you have alleged that our client asked for USD 150,000 to arrange air ambulance service for Mrs. Akram. The allegation is absolutely incorrect. Our client also fails to understand the relevance of this allegation, considering that you arranged the ambulance service entirely on your own. It may though be noted that neither our client nor Doctors Hospital is in any manner involved in arranging air ambulance service. They have never done this before, and do not intend to go into this business for the future either. On the one previous occasion when this was done in our client’s  knowledge, this was entirely arranged by the patient’s family. It would also be rather stupid of anyone to ask for a commission in this regard, considering that air ambulance can be booked directly from the internet.

8.         Coming back to the chronology of events, the next day, which was 18.10.2009 (and a Sunday), our client received an SMS from yourself at 13:50, and then immediately thereafter a call from you at 13:54. Our client proceeded to the hospital to see Mrs. Akram and spent most of the day in Doctors Hospital, seeing Mrs. Akram as well as other patients.

9.         On 19.10.09 (which was a working day, and our client was in Services Hospital during the first half), he not only kept in touch with doctors at Doctors Hospital, but also personally visited the patient in the afternoon. You had already, on your own initiative, made arrangements to shift the patient to Singapore, which you confirmed to our client. Even though neither the hospital in Singapore nor the air ambulance service had requested our client in this behalf, he prepared a rather detailed summary of her medical history – which was handed over to you in the evening on 19.10.09. This shows the commitment with which our client was ensuring the well being of his patient. Incidentally, the same day another of our client’s patients (the mother of his very dear friend, and sister of Justice (R) Naseem Hassan Shah) became critically ill, and died despite efforts to revive her – so the aforesaid summary was prepared despite other claims on our client’s time.

10.       Our client’s last call to you was at 22:18 on 19.10.2009 – incidentally the record establishes that this was not in response to an SMS from yourself. During this call, you profusely thanked our client for all the help extended to you and your family. You also confirmed receipt of the medical summary prepared by our client and thanked him for it. You confirmed that the team from Singapore had arrived to assess the patient, and that you would be flying out at 2 AM. Our client later found out that you did not in fact fly out at 2 AM, but at 10 AM.

11.       With this record of commitment and service, it is surely laughable for anyone to suggest that our client was not available when required. The record would show that there is not a single SMS by you to our client which was not instantly responded (either by personal visit or telephone call or both). It may just be worth mentioning that our client’s wife was in the USA at the relevant time, and our client was also entrusted with the care of their 9 year old son – which our client totally compromised during those days.

            Our client would like to record the fact that he was impressed by your devotion to Mrs. Akram. Every time our client visited her (even at odd hours) he always found you to be there. Perhaps you feel that our client should also have devoted as much time to Mrs. Akram as yourself – if so, the expectation is unrealistic.

12.       Our client understands the subsequent events to be as follows (these are gleaned from the Brief Report issued by the Inquiry Commission – though it has to be said that our client has not formally received a copy; moreover our client disagrees with some of the findings and reserves the right to challenge the same) :

“HOPE AIR AMBULANCE: She developed serious distress and restlessness in the air, most likely due to low oxygen at high altitude. In order to treat her restlessness she was given intravenous diazepam. This might have been the last straw. She immediately developed cardiopulmonary arrest. She underwent a long resuscitation effort lasting ½ an hour. Her heartbeat recovered but she had by then suffered irreversible brainstem injury. The plane landed in emergency at Chennai, India, and she was admitted to the Apollo Hospital.

APOLLO HOSPITAL, CHENNAI : At the time of admission she required breathing support, and had severe brainstem damage. She developed skin blisters on 23rd October 2009 for which deep biopsies of skin and subcutaneous tissue were obtained from thigh next day. She died on 25th October without a firm diagnosis. She was however put on empirical antifungal treatment as a part of protocol for treating fungal infections. A report of the skin biopsy which was issued two days after her death which revealed extensive fungal infection ie Mucormycosis that had blocked all her blood vessels in the subcutaneous tissue.”

The inquiry report also records :

“Ironically even the ambulance team apparently did not have senior consultant to adequately evaluate the status of the patient.”

13.       Before one proceeds further, it needs to be noted that according to the Indian test reports Mrs. Akram died due to the “Mucormycosis” infection. According to Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases (7th Edition) (Annex C) :

Disseminated mucormycosis is rarely apparent before death …. Blood cultures are nearly always negative … biopsy of the suspected site is critical for diagnosis of the infection.

As noted in the inquiry report, biopsy was only possible once the patient developed skin blisters on 23 October (which was after she left Pakistan).

This establishes that no one can be blamed for not diagnosing this particular infection – and least of all, our client, who is not an Infectious Diseases expert, and whose only job was to stabilize the patient (as a critical care specialist) which he did.

It may also be pertinent to quote from the conclusion recorded by the Inquiry Team :

“CONCLUSION : Systemic Mucormycosis is a deadly disease and can occur in bicuspid aortic valve with very high mortality.”

As you know, your late wife also had a congenital heart defect (noted above), which placed her in the category with particularly poor prognosis in respect of such disease.

14.       Ever since the tragic death of your wife (for which no blame can attach to any doctor who saw her in Pakistan), our client and all other doctors involved in her treatment have been subjected to baseless and ridiculous defamatory and scurrilous allegations. Our client has resisted the urge to set the record straight, attributing your lack of reason to an understandable grief which may have caused you to be emotionally disturbed. Understanding your grief, our client did not want to aggravate it by confronting you – notwithstanding that your baseless and entirely unfounded utterances (which have received vast coverage in the print and electronic media, as well as on the internet, both in Pakistan and abroad) were impacting our client’s good name and reputation. However, our client considers that this has gone on too far and long, and the record needs to be corrected!

15.       The irresponsible allegations made by you include the following :

i.        Doctors were not available, even on the phone.

ii.       Our client asked you for USD 150,000/- to arrange air ambulance.

iii.      Our client was negligent in allowing Mrs. Akram to be shifted to Singapore by air ambulance.

iv.      Mrs. Akram died on account of negligence by the doctors in Pakistan.

16.       While the first (at least so far as it is applicable to our client) and the second have been sufficiently addressed above, it is also important to counter the remaining two, which as well are equally baseless.

17.       Whether our client was negligent in allowing Mrs. Akram to be shifted to Singapore by air ambulance?

This allegation is best answered in light of the following questions.

17.1         What was the prognosis if she stayed in Pakistan?

The fact is that there was no clear ascertainment of the organism that caused the infection. There was a suggestion made by Dr. Faisal Sultan (who is Lahore’s senior most Infectious Diseases expert, and CEO of SKMT) that she was possibly suffering from ‘Hanta’ virus, which cannot be diagnosed or treated in Pakistan. It thus seemed that her best chance was to go to a place where such diagnosis and treatment could take place.

As noted by the inquiry committee report, even the hospital in India was not able to identify the organism until two days after her death.

17.2         Would the outcome have been any different had she stayed in Pakistan?

For reasons noted in paragraph 13 above, the answer to this question quite categorically is that the outcome would have been no different.

In fact, our client finds it very strange that on the one hand, you are accusing doctors in Pakistan of negligence for not being able to fully diagnose and treat your late wife (the charge of course is baseless), and on the other hand and in the same breath, you are accusing our client for not stopping her from leaving these very doctors that you are otherwise accusing!

17.3    Would it have been proper for our client and/or The Doctors Hospital to stop her?

Considering that (i) there was no clear identification of the infecting organism; (ii) there was a plausible diagnosis which recommended that she be shifted without delay; and (iii) you and the patient herself wanted to shift to Singapore (all arrangements in this behalf were made by yourself), it would have been unethical to detain her in The Doctors Hospital.

17.4     Was she stable to travel?

It may be noted that she was not only conscious and breathing on her own but was also able to walk around on her own, and there was no circumstance that would have suggested she was not stable to travel in an air ambulance equipped with all necessary equipment and accompanied by highly trained physician(s) and nurse(s). Her condition from this perspective had improved since she was shifted to the Doctors Hospital, though of course she continued to suffer from (as yet undetected organism, but nevertheless) lethal infection. It may be noted in this behalf that throughout her stay in Doctors Hospital, Mrs. Akram was in a private room (and not in the ICU) – which itself establishes that she was fit to travel under specialized care as noted above. In fact such travel would have meant that she would be shifted to an ICU (which is what the air ambulance was meant to be) instead of a private room.

Also, this needs to be noted in light of the following representations issued by most air ambulance services, including the one that you actually engaged (in fact the following statements are taken from website of Hope Air Ambulance service – Annex D) :

–                      Inside the air ambulance are life support systems, oxygen, monitors and emergency drugs. A highly trained physician and nurse escort team will accompany and treat the patient throughout the flight [Highlighting is theirs]

–                      However, when a patient is critically ill or requires round the clock medical care .. the options for travel become limited to traveling with specially equipped and qualified doctor and nurse escorts. This is what Hope Air Ambulance specializes in.

–                      Advance Life Support medical equipping

  • Ventilator (critical care, multi mode)
  • Multi-parameter monitoring (including invasive line and EtCO2)
  • Defibrillator
  • Pacing (TCP)
  • Airway management (including emergency surgical airway)
  • Drug (cardiac, resuscitation, anaesthetic, analgesia, etc.)
  • Vaccum immobilization
  • Suction
  • Syringe and infusion pumps
  • Special pediatric, trauma, burns, kits, etc.

–                      Infectious Disease Transfers

Hope Air Ambulance has an extensive array of equipment  and drugs that allows us to handle the entire spectrum of critically ill patients … from major trauma to heart attacks and patients on full life support etc.

–                      Our medical professionals are experienced, calm and versatile individuals

  • Specialist physicians (emergency physicians, intenservists and anaesthetists)
  • Physician escorts (ICU, flight and emergency trained)
  • Nurses (Critical care and emergency qualified)
  • Paramedics

The vast experience of our teams includes hundreds of flights ….

–                      Management : Theresa Yeap, Josephine Ham and Charles Johnson together run Hope Air Ambulance Pte Ltd. Charles is an emergency physician and a fellow of the Royal College of Surgeons (Edinburgh) and Theresa and Josephine are critical care registered nurses. They each have more than 15 years hospital, ICU, emergency and flight experience.

–                      Quality Assurance : Hope Medflight has a firm commitment to quality assurance and is Singapore’s only private ambulance organization that is ISO (9001/2000) certified in road ambulance, air ambulance, home healthcare and emergency medical training.

–                      Our Promise of Care : Hope ambulance stands behind and guarantees the quality of service we provide.

–                      Success Stories :

  • Hope Medflight team transferred an elderly patient from San Francisco to Jakarta. The patient was on life support (ventilator). To prepare for the flight, our physicians had to liaise with the US treating physician ………. Our doctor and nurse team flew to the US 24 hours earlier to assess and prepare the patient for long flight. The oxygen and power requirements had to be calculated and confirmed. Finally, family members were briefed on all eventualities. The flight was smooth and the patient stable. He was continually monitored. The flight included a transit stop at Korea and a change of aircraft at Singapore.
  • Hope transfers by Learjet a severely ill teenage boy with dengue fever and respiratory and renal failure. His blood pressure was unstable and required multiple drug infusion inflight. He required a ventilator and dialysis, with long stay in ICU. The determined young man recovered to return to Indonesia completely well.
  • In Oct 2009, we do a commercial medical repatriation from Brazil to Manila. The patient requires full ICU like set up inside the commercial airliner.
  • A young lady on a cycling expedition in Vietnam has an accident and sustains severe head injury. … the van is converted to an ambulance with our portable life support equipment. We fly back to Singapore with the cabin pressurized to sea level.

 

This establishes that if the aforesaid representations are indeed correct (and of course if they are not, only Hope Air Ambulance Service would need to answer), there was no risk to the patient from such travel – as she would have traveled ‘with cabin pressurized to sea level’, with all the possible equipment that may have been required (including ventilators, oxygen, etc. – it is specifically noted that “Hope Air Ambulance has an extensive array of equipment and drugs that allows us to handle the entire spectrum of critically ill patients … from major trauma to heart attacks and patients on full life support”) and ‘highly trained physician and nurse escort team’. Moreover, the physician is stated (on the website) to be qualified for critical care, so there was going to be no reduction in coverage.

17.5         What was the responsibility of the air ambulance?

As noted above, there was every reason to believe that Mrs. Akram was fit and stable to travel, particularly under specialized medical care. However, it is also important to note the following representation made by Hope Air Ambulance Service :

–                      “However, when a patient is critically ill or requires round the clock medical care .. the options for travel become limited to traveling with specially equipped and qualified doctor and nurse escorts. This is what Hope Air Ambulance specializes in.”

–                      Hope Air Ambulance has an extensive array of equipment and drugs that allows us to handle the entire spectrum of critically ill patients … from major trauma to heart attacks and patients on full life support etc.

–                      “Our doctor and nurse team flew to the US 24 H earlier to assess and prepare the patient for the long flight. The oxygen and power requirements had to be calculated and confirmed. Finally, family members were briefed on all eventualities”.

Moreover, and even otherwise (according to established medical practices), it is the responsibility of the accepting physician (in this case the physician attached to the air ambulance) to ensure that the patient is fit and stable to travel to the next facility. Because only he is best able to evaluate the patient in light of the specific facilities available to him in the ambulance.

17.6     Did the air ambulance service comply with the aforesaid representations?

Before one considers this question, it is of course axiomatic that if they did not, only they are answerable for the lapse. Unless you consciously negotiated a lesser (discounted) service which did not entail some of their promised and essential features. In this behalf, one learns from the inquiry committee report that :

“Ironically even the ambulance team apparently did not have senior consultant to adequately evaluate the status of the patient”.

It also then appears from the inquiry report that the air ambulance staff was not able to efficiently manage the patient (by administering intravenous diazepam in the first place, and/or thereafter once she suffered cardiopulmonary arrest).

This raises some questions about the actual service that was ordered. For instance :

  1. Did the air ambulance have the facility to ensure adequate oxygen pressure during the flight – as represented on the website? If not, why not?
  2. Did the air ambulance come with senior consultant/critical care specialist, as represented on the website? If not, why not?

 

You are best able to answer these in light of your actual communication with the air ambulance service. One trusts that you would not deliberately have ordered a ‘discounted service’ – and that it is ultimately for the air ambulance service to answer these issues.

However, our client certainly is not to blame in this regard.

18.       Was there any negligence by doctors in Pakistan?

Whether one looks at the immediate cause that resulted in Mrs. Akram’s death (which evidently is mishandling by the air ambulance staff), or one looks at the fundamental underlying cause (which was a rare fungal infection), in either scenario it is more than clear that there is absolutely no negligence by the doctors in Pakistan. Least of all by our client who is not an expert on Infectious Diseases. Even still, the question may be addressed as follows.

18.1         Immediate Cause

The immediate cause recorded by the inquiry committee is as follows :

“She developed serious distress and restlessness in the air, most likely due to low oxygen at high altitude. In order to treat her restlessness she was given intravenous diazepam. This might have been the last straw. She immediately developed cardiopulmonary arrest. She underwent a long resuscitation effort lasting ½ an hour. Her heartbeat recovered but she had by then suffered irreversible brainstem injury. The plane landed in emergency at Chennai, India, and she was admitted to the Apollo Hospital.”

The immediate cause of death therefore was the entirely unnecessary administration of intravenous diazepam (just because she was in distress and restless, there was no justification to administer this), which caused respiratory arrest and ultimately led to cardiopulmonary arrest. It may be noted that the patient was in ‘severe distress’, from time to time, even prior to the flight (as also noted in the summary prepared by our client), and the ambulance staff should therefore have been prepared for this (unless of course, you omitted to provide the summary to them – for which you alone would be liable).

Needless to add, administration of intravenous diazepam (which in fact got the ball rolling in a certain direction) was an independent action by the ambulance team, which cannot at all be attributed to the doctors in Pakistan.

It is further recorded by the Inquiry Team that : “Ironically even the ambulance team apparently did not have senior consultant to adequately evaluate the status of the patient”. How can the doctors in Pakistan be liable for such lapse, particularly when you yourself had made arrangement with this particular service!

18.2         Underlying/ultimate cause

Regardless of the immediate cause (which appears to be negligence by the ambulance team), the ultimate/underlying cause was Systemic Mucormycosis. The question then is : did she have any realistic chance of survival with this infection? Consider what the Inquiry Committee has recorded :

“CONCLUSION : Systemic Mucormycosis is a deadly disease and can occur in bicuspid aortic valve with very high mortality.”

Were miracles then to be expected from doctors in Pakistan!

In any case, in order to get a definitive finding on this issue, one needs to perform an autopsy with toxic tests of Mrs. Akram’s body. Without such detailed analysis, it is wholly unfair and scandalous to accuse anyone of negligence.

18.3         Why were the Infectious Diseases experts in Pakistan unable to detect the fungal infection?

 

Although our client is not an expert on Infectious Diseases, and this question is best addressed by them, the following points need to be noted in this behalf :

–                      According to Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases (7th Edition) : “Disseminated mucormycosis is rarely apparent before death …. Blood cultures are nearly always negative … biopsy of the suspected site is critical for diagnosis of the infection

Pakistani doctors can hardly be blamed for failing to identify an organism that rarely becomes apparent before death, and even the Indian hospital only identified the organism after Mrs. Akram’s death.

–                      It now transpires that Mrs. Akram may not have revealed her entire and accurate history to the doctors. For instance (and there may well be other aspects as well which require further investigation) the patient withheld the information that she underwent botox injections. It is speculated by the Inquiry Committee that this may have been the cause for the infection. Her own failure to disclose this aspect may therefore have been responsible for the Infectious Diseases experts not being alerted towards this possibility.

–                      Moreover, disseminated mucormycosis with endocarditis has never been reported in the world without prior history of certain risk factors, which your wife denied. The fact that she was diagnosed with this infection, may well suggest that true history was not presented to the doctors.

19.       The above facts notwithstanding, which have been most fully in your knowledge at all material times, you have persisted in generating a media frenzy about the death of Mrs. Akram, and have accused each and every doctor who saw her (our client not excepted) of negligence and malpractice. Additionally you have made some charges, as noted above, specifically against our client as well. All this has not only caused great loss of name and reputation to our client (as also other doctors), but needless distress and anxiety to our client as well.

20.       You have also influenced the course of the inquiry proceedings, not least by making entirely inaccurate and unsubstantiated allegations against the doctors, as well as the proceedings before the Standing Committee of the National Assembly (which incidentally took place, and unprecedented decisions taken without our client or any of the other doctors even being invited to attend the proceedings – had that been done, the committee would surely have seen the shallowness of your allegations).

You are accordingly required through this legal notice to forthwith tender an unconditional apology to our client, and to withdraw all the non-sensical and baseless allegations leveled by you including as noted above. You are further required to pay damages to our client in the amount of Rs. 100,000,000/- (Rupees One Hundred Million). Should you fail to tender the apology, the amount of damages to be claimed by our client shall be Rs. 500,000,000/- (Rupees Five Hundred Million). In such event, our client would also proceed to file criminal charges for your entirely irresponsible conduct. Needless to add, the aforesaid damages (which upon recovery shall be contributed to the Shaukat Khanum Memorial Trust Hospital) are on account of loss suffered by our client alone, and other doctors may of course be pursuing their own remedies in this behalf.

Very truly yours,

Chima & Ibrahim

 

PTH has presented above both sides of the picture and takes no sides whatsoever beyond noting that the development of mass torts and class action law  in Pakistan is essential for it to function as a democratic and a civil society.  People need to see the system working for them.  These issues are the real issues in Pakistan and a democratic society is only good if it can deliver.  We are not taking sides but these tragic events have underscored a crucial new development in Pakistani society.   Today we are more aware of our rights and a very real and genuine process of accountability is being put in place with the Media which we all love to criticise.   It is thanks to the media that ordinary people have found a voice and are asking the concerned and responsible people for justice and for their rights.

These developments are all interlinked –  a free media, courts striking down bad laws,  legislature taking up the allegations of negligence and the real prospect of due process in Pakistan.

As the immortal Faiz said : “Umeed -e- Sahar ki Baat suno.”

13 Comments

Filed under Jinnah's Pakistan, Law, Pakistan

13 responses to “Tackling Medical Malpractice in Pakistan – Law, Media And Society

  1. As heart breaking as all these affairs are, I totally agree with PTH that “people need to see the system working for them”. This will not only keep those in position of responsibility on their toes when conducting their affairs, but will also ensure that the general public gets the entire picture and makes an informed decision.

    Well done PTH.

    Just my 2 cents!

  2. Arif

    The Untold Story
    To lose a dear one is a dreadful tragedy. Expressing one’s anger and frustration on this loss is a natural reaction. Blaming others for this loss is reactionary. However when this reaction leads to distortion of facts, sanity has to prevail and justice has to be served. In the domain of professional accountability, professional misconduct investigations in a civilized society are conducted confidentially respecting the position these individuals occupy in the society and their contributions. Our system of accountability is deficient in so many ways that if it ever comes into action, distorted facts and desire to exploit the situation for self-projection results in abuse of power and violation of individuals’ rights.
    We as doctors serving your community have been patiently watching the endless media trial of our colleagues involved in this case. Professionalism of our colleagues has prevented them so far from any mud-slinging and breach of confidentiality of this matter. A respect for the legal system has stopped us from giving statements in their defence as in the midst of this chaos we still hope that justice will prevail. We do not intend to inflict any suffering on the bereaving family in spite of their undue aggression towards the entire medical community. While we fully sympathize with the grieving family of Mr. Wasim Akram, we do resent his efforts to malign the doctors and the hospitals who took care of his critically ill wife in the most professional manner. We feel compelled to narrate the facts for our patients who have had any doubts about the competence of our colleagues and the safety of this healthcare system.
    The doctors involved in this case have a great repute and have always remained committed to your welfare. Several of them have given up their lucrative jobs abroad to be in this country to serve their fellow countrymen. They have braved the lawlessness, terrorist threats, bomb blasts and other uncertainties of this society to help you. They are not only excellent clinicians trying to provide you with quality healthcare but also leading academicians and researchers who have trained hundreds of junior colleagues. In their desire to help the patient in question, all of them had spent hours pouring their mind over this difficult patient. They knew little that the more they got involved, the more they were exposing themselves to a never ending tirade of baseless accusations of negligence from the family, authorities, media and the public. As a result of their interventions, the patient had improved to the point that her spouse stated “Huma was fine on the day we left for abroad” (Associated press of Pakistan). They however could have never imagined what was in store for them. To appease the bereaving spouse the system had “decided” that they were negligent, reckless and responsible for the loss of life that occurred a thousand miles away. The system had “decided” without listening to their point of view that they were guilty of professional misconduct and did not deserve to practice in this country.
    Has anyone asked what is the fault of these 25 doctors? The fault of these doctors is that they took care of a critically ill patient who was suffering from a rare disease that they never saw and probably will never see again in their lifetime. Few if any of these 18 patients ever reported have ever survived in spite of the best efforts of physicians in the best of healthcare facilities. The records showed that they continued to provide excellent clinical care individually as well as collectively. Their efforts were definitely hampered by the desire and ability of the family to continuously shun or change consultants if they were felt to be “inadequate”. It was not the will of the coordinating physician but the desire of the family that 25 physicians gave their input in into the care of this patient. Not a single physician called by the family was able to make a breaktrough in this case although their recommendations were adhered to. Are they also going to be held accountable??? These include people practicing in the major medical centers of Pakistan as well as abroad.
    What happened after the patient’s departure from the hospital in the air ambulance will remain a mystery. Did she receive sedatives that caused her demise or was it some infection that resulted in her death. This could have only been determined with an autopsy. However what is very clear is that this patient did leave the hospital “fit” as per her spouse and the professional medical team responsible for transporting her abroad (one would definitely assume that these professionals would have never transported an unfit patient who could not survive the journey). The doctors in charge of her care were not involved in this transfer; they never arranged or even offered to arrange this ambulance for $150,000 as alleged repeatedly.
    Professional misconduct and criminal negligence are serious accusations and never thrust upon professionals without due process. This arbitrary process of accountability, as in this case, if not stopped, will continue to peril our society. It will result in doctors shunning high profile, acutely ill patients. The escalating healthcare cost will prevent an increasing segment of the population from obtaining essential medical services in the private sector while the government facilities struggle to absorb this increasing workload (70% of the healthcare currently being provided in this country is in the private sector). Demoralized practitioners will rightfully become overly cautious and abstain from providing services that expose them to any such persecution. Who then is going to fill this vacuum?
    The point of view of those involved in this tragedy has to be listened to without any prejudice or bureaucratic pressure. Investigation reports cannot be “adjusted” or repeated inspections carried out to make a case against these professionals. If they were felt not to be at fault the first time around, they cannot be made liable after a “review” of this report by the higher authorities. Saying that ALL Pakistani doctors are unethical or negligent is unfair to a lot of us who have struggled to proved the best possible care to our patients in the most ethical manners. Pakistan is one of the few countries where practically every doctor spends a large portion of his/ her day taking care of indigent population and teaching students/ junior doctors. The society needs to recognize this fact and reward us accordingly.
    We hope the readers will all support the doctors of Pakistan in these tough times and help them to continue to provide the best possible healthcare. May Allah Almighty bless the soul of the deceased, and give strength to the family to bear this loss. Justice has to be served but sanity has to prevail.

  3. yasserlatifhamdani

    Arif mian…

    What is wrong with doctors being accountable for their actions… there should be a fair process to determine whether a doctor was guilty of negligence or not.

    I hope the doctors themselves will support a regulatory policy for the medical industry.

  4. Arif

    Sure, we are all for a “fair” process of accountability and self-policing as you said. Emphasis is on fair where both sides of the story are heard. THe case of Imanae Malik is indefensible and “appropriate” punishment is in order. However thie case of the cricketer’s wife has no relevance or commonality with it. The decision makers have lumped them together unfortunately. The point of view of the effected doctors has not been heard to date. Do you know that amongst the 7 doctors involved there are some who NEVER saw the patient or if they did, they did so in a very remote role- like putting an I/V.

  5. nayyar

    Doctor Arif
    You should not defend your colleagues, I am also a practicing USA physician . The doctors in lahore belong to a MAFIA system. WE are trained to provide compassion and save lives not destroy them. If u look at all the facts from Mrs. Akrams case one would like to know why all the doctors failed to start her on anti fungal medication early on. As in cases of suspected endocarditis or sepsis it is a standard procedure to start patients on wide range of antibiotics and anti viral agents and antifungal agents as well. Even if we agree that disseminated mucormycosis had poor prognosis Dr. Chemma who I had personal experience with, when he dealt with my mother as a patient seems to be an incompitent physician. I agree with his lawyer that he was not ID specalist but as an ICU specialist should have communicated well with the family of patient and had shown some compassion. It is shameful for us as Pakistanis that Mr. Wasim Akram found Indian doctors more compassionate and less money minded and for this you dont need any special technology or tests. I have had experienced this personally when the Doctor’s hospital refused to rlease my mother’s dead body when my family had paid several Lakhs for unnecessary treatment which they dragged and I know this for a fact because I have medical knowledge my friend and intrestingly in the same field as Dr. Cheema. My brother had to borrow money to clear the bill as just like Mr. Wasim he was only under 500o RS short. An unstable patient is only transferred from one hospital to another if there is a clear benefit and a life saving procedure can be done and as mentioned above by the lawyer that she was supposedly diagnosed by Dr. Faisal Sultan with Hanta Virus which is very rare and was suggesting that it can not be treated and diagnosed in Pakistan then my friend I have some news it could not have been treated anywhere either. If Dr. Faisal knows the hospital or placewhere this Hanta Virus could be treated effectively then the entire world would be gratified if he can tell us the place where it can be treated. Dr. Cheema rather than recommending which hospital Mrs Akram should be taken he should have focused on patient care and so WHAT if he missed a dinner and only got 4 hrs of sleep, as doctors we do it all the time and I just want to ask the lawyer if his wife, mother ,son or daughter died at the hands of Dr. Cheema would he still be so concerned about Dr. Cheema’s sleep. I DONT THINK SO…………..
    There is nothing wrong with being accountable for your actions especially when we are dealing with human lives. Dr. Cheema was trained in USA but unfortunately pakistani system and corruption has polluted him. I am talking from personal experience that he is highly arrogant and full of himself. The way he treated my mother in 2004 it still haunts me and ALLAH is great and will never let injustice pervail. Dr. Cheema’s lawyer stated that he is board certified in USA has any one checked if he has maintained his certification and plus who cares if he stood first in class when he is incompassionate and arrogant doctor.

  6. A Haranwalla

    It seems the good, doctor Cheema a thorough professional, did allow his American board certification in Internal Medicine to lapse for about 4 years. Question is did he continue to represent himself as board certified during this period?

  7. My father was a professor at GCU Lahore. He died of malpractice. Read about his details at

    http://buildpakistantogether.blogspot.com/2009/12/how-pakistan-killed-my-father.html

  8. A. Haranwalla

    Saeed Sheikh Sb may the Almighty grant your father eternal rest in paradise. The doctors are butchers and interested only in their fees and leisure. The two institutes you mention Doctors Hosp and Services Hosp have the worst, most arrogant doctors working for them with degrees from the best universities in the world yet they have lost the compassion and respect for human life and will think nothing of manufactureing false evidence labeling a patient as responsible for their condition. It happend to a young innocent girl in lahore who was branded a drug addict by the treating doctors. It really isnt that difficult to say sorry and empathize sometimes that is all that the relatives are looking for.

  9. Arif

    Dear all,
    Just a piece of information. Wasim Akram has formally apologized for his unsubstantiated allegations against the doctors. The standing committee of the National Assembly of Pakistan also met the same doctors and after listening to all the facts, decided not to proceed with any disciplinary hearings against them. What all of these doctors went through (including some who NEVER took part in the care of Huma Wasim Akram) was very traumatic and not based on any facts.
    For our honorable professional colleagues who think that antifungals will treat mucormycosis, please get your facts straight; it needs debridement and removal of the effected tissues !!!! How do you do this in a disseminated infection?
    For the physicians working in USA- please try and develop an understanding of the healthcare system in Pakistan and the financial constraints- I can assure you that you will find plenty of doctors who have sacrificed their lucrative jobs in USA (that all of you are enjoying!!) and opted to be in their homeland for their parents and countrymen. They are excellent clinicians and work hard to take care of their patients and train junior doctors. Calling them ALL “butchers” is unfair.
    Instead of this polarization, I would like to invite you all to initiate a movement and dialogue that develops a full understanding of the healthcare system and starts the process of fixing this system. Sacrifice some of your precious time to help reform the system and that will be much more productive. We are not afraid of accountability but accountability in the form of baseless allegations of “premeditated murder” (302) is unheard of; particularly when you later retract your allegations.

  10. Muhammad Amjad

    A doctor that I know reuses syringes (in fact he only keeps on in his clinic) on multiple patients.

  11. Muhammad Amjad

    A doctor that I know reuses syringes (in fact he only keeps one in his clinic) on multiple patients. This could potentially be deadly dangerous for his patients!

  12. A Doctor Who Was Sick of Healthcare System in Pakistan

    First do something about quack doctors in your Galli/Mohallas who are spreading Hep B&C.

    Do something about postgraduate training of doctors.There is medical college in every Galli/Mohalla and no postgrad training opportunities at all.

    Then you expect doctors to be good. They cannot be good unless you do take healthcare of the nation seriously and train them….Otherwise these incidents will keep happening

  13. Muhammad Amjad

    Where does one go about reporting such malpractice? This particular doctor’s excuse is this is how is the modus operandi he was taught. He’s a highly qualified and senior doctor. I don’t really swallow that excuse. The only plausible reason for him doing this that occurs to me is merely to save on cost!