License to kill?

From the first baby bump followed by innumerable, unsolicited touches from friends and family alike to feeling it move around the womb; from listening to the first sounds of its heartbeat to sharing the ‘big’ news on live newsfeed amidst preparations of a scrapbook capturing the ever-expanding bump and the unwelcomed queasiness, pregnancy is almost always joyful news.

However, imagine having those nine months of unrestrained excitement and care ripped into shreds of skin, blood and life-altering pain. Imagine having to bury that little bundle of joy, lifeless, or leaving him alone in this boisterous world without the warmth of your arms and your guidance. Simply because of a wrong drug or a fatal incision, an overdose, mismanagement of oxygen or just poor medical precautions taken by the person you trusted to do the job well - the reasons can be many, the feeling, however, still the same - gut-wrenching and dismal.

Doctors have a tough job - one that instantly portrays them as a Messiah after a life is saved. However, the truth is that doctors are also no more than humans: less-than-perfect and increasingly fallible. Why ‘increasingly’? Because it seems doctors in Pakistan have become habitual of making critical mistakes and subsequently burying those blunders deep beneath the surface, quite literally.

Not long ago, in June of this summer to be exact, Pakistani social networking sites were rife with what came across as a lethal combination of ignorance and arrogance - a case of sheer medical negligence. Karachi resident Shaista, mother of two, fell victim to medical malpractice that resulted in the loss of her life, as extensively discussed on a Facebook page titled ‘Medical Negligence in Pakistan’.

According to the information posted, with reference from the deceased’s husband Omer ul Islam, Dr. Shahnaz Hussaini, the consultant doctor on the case, was missing until after 10 hours of the patient being in labour pain and caught amidst mounting complications. The consultant had earlier advised C-section because the patient’s baby had a cord around his neck. Though a common occurrence in pregnancies, the patient still required immediate attention for her pain had apparently become unbearable. However, despite several messages and calls, Dr. Hussaini was a no show and the patient was left at the mercy of junior doctors. After being in ‘severe pain’ since 10 in the morning, she was taken to the O.T. at 8:45pm when perhaps things had already gotten out of hands. Throughout this time, the husband was surprisingly not allowed anywhere near his wife.

 “The patient was taken into the operation theatre at 8:45pm after several hours of pain. The baby boy was delivered at exactly 9:00pm but with complications (exactly within 15 minutes of the patient being taken into the O.T.),” the post revealed. “The husband was busy sorting out the formalities for the ventilator for his new born when Dr. Hussaini called him at around 9:30pm. Please note this is the first time when the husband interacts with the doctor. She told him in person that they will keep the patient in ICU for one day at least due to some complications but did not mention the seriousness of Shaista’s condition. Shaista was unconscious, pale, eyes staring in the upward direction and cotton surrounding her, full of blood, while she was moved from the O.T. to ICU.

“Dr. Shahnaz [preparing to leave at the time] was forced to stay in the ICU [on the family’s insistence] where doctors tried to get Shaista’s heartbeat back. She was put on a ventilator and when Omer went inside the ICU to see her, the scene was unimaginable. He saw profuse quantities of blood everywhere and Shaista’s lower part of the body was dripping with blood. He realised that the case had been mismanaged. He yelled at the doctor and asked her about Shaista’s state where she told him that she was no more,” the post further added concluding that it was negligence at Dr. Hussaini’s part to not respond despite repeated attempts and leave juniors in charge thereby sabotaging the case.

The incident and the doctor’s seemingly blatant disregard for the woman’s immediate need for medical attention sent shockwaves through local web. It was only about that time a widespread discussion paved way for other families to shed light on their experiences putting Dr. Hussaini’s reputation on the line of fire, substantially. A woman by the name of Anusheh Ahmar shared how her sister Bushra too had fallen prey to a similar accident by the same doctor where a prolonged surgery led to obscure complications and eventually her death that still remains a mystery to her family. Her husband has ever since been fighting for justice in a system marked by corruption, incompetency and shoddy or no laws, but in vain.

As cringe-worthy as the incident might be, no story has only one side to it. Hence, You! tried to approach Dr. Hussaini at her clinic for a comment but she was unavailable. Later her daughter Sharmeen Hussaini took to Facebook to reveal that Shaista suffered from a rare case of Amniotic Fluid Embolism (AFE) followed by a cardiac arrest that can happen to just about anybody. AFE is widely recognized as a life-threatening complication caused by an unprecedented allergic reaction during or post childbirth and is usually not iatrogenic. It happens suddenly and rapidly and its causes are still not well understood by gynaecologists around the world. While it is quite possible that the doctor is not directly responsible for the tragedy that unfolded, there is unfortunately no way it can be proven if she is or is not.

Unverified, uninvestigated

Dozens of women across Pakistan lose the battle of life during pregnancy, often if not always due to negligence, on a daily basis. On average five new cases of medical negligence are filed in Sindh High Court alone every year; not to mention the numerous that go unreported. According to a recent report by Save The Children titled ‘The urban disadvantage’, Pakistan’s maternal mortality ratio was calculated to be a startling 149 that means Pakistan witnesses 276 deaths per 100,000 live births on an average. As of 2014, the infant mortality rate in the country spiked to 8.6% with 52.35 female infant deaths per 1000 live births.

Yet there is no system or roadmap in place to investigate why, or hold doctors accountable for the ones that were an outcome of their glaring mistakes. Even in the cases mentioned above, despite constant pestering over an investigation, each of the families were handed a mere one-page reply, summed up in four bullet points, by the hospital authorities that declared the doctor innocent and not liable for the loss of life, leaving many a question unanswered.

Can all this be tied up to the government’s lack of willingness to take the issue of medical malpractice seriously and offer a neutral platform of inquiry for both doctors and patients alike? Dr. Idris Adhi of the Pakistan Medical Association reveals that the association has been working diligently to put a procedure in place for relevant investigations and subsequent actions but the government has failed to implement a law, time and again.

“The PMA formulated a document laying out the rules and regulations relating to cases of negligence after countless meetings with various medical boards and organisations. We even took it to the assembly where a health care commission was passed but there has been no implementation of the law whatsoever. The local government has been continuously neglecting it,” he shares. 

According to Dr. Adhi, it was imperative that inquiries are undertaken in such cases for there are times “when patients have high expectations to the extent that they may intrinsically refuse to recognize the complications they may have been informed of. One cannot prove medical negligence without thorough investigation. However, if any doctor has failed to exercise their knowledge and has shown incompetency in communicating the risks prior to treatment, then they must be held accountable for it.”

The missing three ‘Cs’

Communication, counselling and compensation - the three Cs of significance in relation to medical negligence and the three Cs that are repeatedly ignored. Communication is key to a doctor-patient relationship and crucial to a doctor’s competency. Medical negligence is perceived to be so more as a result of poor prior communication with the patient and her family regarding possible complications and risks. 

If, however, the victim has her fate sealed and has suffered through the painstaking consequences of malpractice, especially ones that include losing a child, counselling becomes of utmost importance. This is where health care NGOs step in. And while many of them have been making a conscious effort to offer support systems, they are often restricted and challenged due to lack of resources and awareness among people.

“In relation to women health problems, majority of the cases we receive are due to medical negligence or delays,” informs Dr Abida Khan of HOPE foundation. “The cases are mostly associated with obstetrics for instance complications during pregnancy or child birth. The women come with bleeding, shock, high blood pressure, severe deficiency of blood or with fulminating infections. The first step is to give prompt treatment in order to reduce further complications and save her life. The second step is advocacy, explanation of how early referral saves life and reduces complications in the future.”

However, despite their best efforts, they fall short of providing psychological counselling to the sufferer. “We do not have psychiatric counselling but we do console the mother who has lost her baby at home or within the hospital premises. The death may be of a new born, an intrauterine death or the death of child up to 5 years. She is explained the precautions that are to be taken to prevent any mishap in future. Sometimes they may even require antidepressant medications,” she adds.

While such counselling may help the mother suffering from physical trauma, there are no places to counsel families or husbands who lose their loved ones because of such negligence and may experience mental trauma. Hospitals and the general medical system are found apathetic to the responsibilities they have towards them and indicative apologies are non-existent, let alone compensation. In contrast, over 20 hospitals in the UK are reported to have paid over £1.1 billion in compensation for even the slightest of medical blunders in the past five years.

Just this week, however, a landmark decision was passed by the Lahore consumer court where Dr. Tahir Masood, whose negligence resulted in permanent liver damage of a new-born, was asked to compensate the baby’s parents with Rs33 million that were spent on a liver transplant abroad as well as litigation. While this is a milestone achievement of its kind in case of medical malpractice, the doctor’s license has not been cancelled allowing him to continue his practice without dire consequences for his career. Nevertheless it’s a step in the right direction that needs to be embraced by the system at large.

It’s about time doctors start owning up their mistakes and the system shifts focus to offering more recourse for patients and families who have been victims of medical negligence as well as keeping stringent checks on possible quacks. Doctors will not feel liable for neglecting unless it becomes a legal duty to be more careful, one that comes with a heavy price tag if not fulfilled to standards. If meaningful actions do not govern medical practices in Pakistan, then there is no doubt that the country’s health care system will be nothing more than a meaningless, crumbling edifice that it is fast becoming.