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Issue Editor : Dr. Saurabh Mohite

Executive Editor : Dr. J. Ravindranath

Assistant Editor : Dr. R. Sengupta

Editorial BoardDr. Nitin AbhyankarDr. Shrirang PanditDr. Vijay Natarajan

Dr. Jaydeep Date Dr. Dattatraya DhavaleDr. Mahesh Thombare

Dr. Bharat DikshitDr. P. K. Sharma

Board of TrusteesShri. Mukundas M. Lohia PresidentShri. Hasmukhlal A. Shah Vice PresidentShri. Devichand K. Jain Mg. TrusteeShri. Rajkumar H. Chordia Jt.Mg. TrusteeShri. Rasiklal M. Dhariwal TrusteeShri. Chandmal M. Parmar TrusteeShri. Dahyabhai M. Shah TrusteeDr. Chensukhlal J. Munot TrusteeShri. Amichand K. Sanghvi TrusteeShri. Hemraj D. Katariya TrusteeShri. Kiritbhai R. Shah TrusteeShri. Champaklal V. Suratwala TrusteeShri. Mukunddas M. Kasat TrusteeShri. Bhabutmal P. Jain TrusteeShri. Purushottam M. Lohia TrusteeShri. Prakash R. Dhariwal TrusteeShri. Harinarayan J. Rathi TrusteeShri. Nainesh M. Nandu Trustee

* Views expressed by authors are their own and not necessarily those of the editorial board.

* For Private circulation only.* Copyright reserved.* Registration with Register of News Papers of India

No. - MAHBIL/2000/1809

Publisher, Printer & Editor : Mr. Devichand K. Jain, Managing TrusteeOwner of Bulletin : Rajasthani & Gujarati Charitable Foundation

through Poona Hospital & Research Centre, Pune 411 030.

Place of Publication : 27, Sadashiv Peth, Pune - 30.Name of Printing Press : Typographica Press Services 2181, Sadashiv Peth, Tilak Road, Pune 30.

Contents Page

Editorial 2

Surgical Rounds and Post-Operative Care 3Dr. Mahesh Thombare

Documentation in Medico Legal Cases 10Dr. Vrushali Khadke

Hospital Update 11

Informed Consent and Its Medicolegal 17ImplicationsDr. Sanjeevanee Kelkar

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Vol. 15, Issue No. 2 April-June 2014

PHRCBULLETIN

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Dear Readers,

Greetings from PHRC.

It gives us immense pleasure to congratulate Dr M. P. Desarda, one of our senior surgeons and the pioneer of DESARDA TECHNIQUE OF HERNIA REPAIR, which has been mentioned in the latest edition of Love and Baileys Textbook of Surgery.

This technique was discovered and perfected, over the last many years, at Poona Hospital itself. This achievement just validates Poona Hospital’s position at the forefront of cutting edge research and in-novation.

In this issue, we take a break from covering diseases and treatment protocols and focus instead on the Standard Operating Protocols fol-lowed in the surgical wards and emergency departments. The im-portance of proper documentation, rounds and consents cannot be overemphasized in today’s age and time. We present to you a brief overview of the protocols followed at our institute. The same can be easily replicated and implemented at your clinics and hospitals too. We also welcome any suggestions to improve upon them.

And to conclude, a very pertinent article in Marathi on child abuse and what we can do to safeguard our children.

Hope you enjoy this bulletin and provide us feedback for further is-sues.

With regards,

Dr. Saurabh Mohite Consultant Oncosurgeon Poona Hospital & Research Centre.

EDITORIAL

5*Consultant Gastrointestinal Surgeon, E-mail : maheshthombare787@gmail.com , Cell : 9822045622.

Surgical Rounds and Post-Operative CareDr. Mahesh Thombare*

Surgical rounds are taken by surgeons in patients and own interest. The aim is to learn about the patient’s physical and mental well being, any deviation from the pathway of recovery to enable to take necessary corrective steps. The phrase may have different meaning in context of different levels of surgeons, e.g. surgical resident versus the professor of surgery. The concept of multidisciplinary round involves several key members of the team coming together & offer expertise in patient care e.g. a cancer patient requires a surgeon, medical oncologist, radiotherapist, pathologist, radiologist, social worker for comprehensive care. Multidisciplinary rounds increase patient volume, shorten hospital stay, improve satisfaction with care and benefit to the participant (medical professional). Grand rounds are taken to apply theory knowledge in context with the given patient in most comprehensive way.

Eyes do not see what mind does not know. The doctor taking a round has to read the theory part of the patient’s disease and its evaluation and treatment. Unfortunately there are no shortcuts in surgery. The most important aspect of a round is communication which is usually not taught in the medical curriculum. How to present your patient in minimal words or sentences without missing an important finding is an art in itself and can be mastered by repeatedly doing it in a structured manner. Thus a surgeon at any level of competence (junior, senior, consultant etc) has to communicate, present, evaluate, treat or carry out orders from the seniors or simply put has an

afferent arm (input) and effectors arm (output / action).

Documentation of patient’s progress is an equally important aspect of the surgical round. It is the surgeon’s best defense against a litigation. This is probably the most poorly maintained aspect of the patient care. In legality what is not mentioned is what is not seen and much time argues against the medical professional.

Most surgical teams round twice a day. Most of the surgeons in the private practice are all in one, eg.like a junior resident taking history, ordering a investigation, doing pre-operative work-up, as a consultant doing a surgery and taking post-operative round till discharge. It is most important to be structured to decrease the strain and stress and build a team to be efficient and accurate.

From the patients perspective the whole business of the treatment can be summed up as a service, the quality of which decides the satisfaction quotient.

Pre-operative care though important is not considered here for lack of space and only operative & peri-operative care will be discussed in a broader sense than specifics about any particular disease.

What is my role in the patient care ? What are the expectations ?

• Try to know more about your patient and his illness than anyone else.

• Prepare before you go to the operation room – anatomy, type of procedure, surgical plan and post-operative orders

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• Develop critical thinking skills – why is the patient is presenting in such a way? What is the underlying disease? Why a particular procedure is preferred for this patient?

• Are you worthy of assuming responsibility?• Be punctual, honest, enthusiastic, aggressive in

taking responsibility, respectful of others

The goal is to learn and learn and learn• Manage clinical problems. You should be able

to do ward procedures, dressing• Prepare rounds• Prepare for examination if you are a student

What are your ward responsibilities ?• Taking detailed history and examination of a

new patient• Give time to evaluate the nursing charts

especially for vitals, intake and output chart, bowel movements

• For patients demanding ICU care, the organ system approach is good

• The round presentation should be succinct in SOAP format.

• Documenting the round in real time• Discuss the orders with the consultant or senior

resident• Discuss the results of the imaging modalities

with the concerned consultant• Do not lie or deceive or suppress the facts• Inform seniors about the finding , the significance

of which you do not know or which are important

• Communicate without hesitation with the seniors

• Do not give orders over the telephone without seeing the patient

• Do not waste a presentation opportunity.• Maintain and respect the hierarchy• Know to whom you are responsible.• Maintain a positive attitude – be enthusiastic,

punctual, aggressive in accepting responsibility.

• Always keep a diary in your pocket to jot down questions raised during the day and find out the answers for the same

• Try to learn from others mistake and try to avoid them

SOAP formatS- Subjective assessmentü Patients nameü Post-operative dayü Procedure doneü Events overnight- talk to the sister or resident

doing night dutyü How patient feel this morning

O- Objectiveü Vitals such as pulse, blood pressure, respiratory

rate, temperatureü Physical examination – quality of the wound,

drain output and character and other pertinent finding, fluid balance

ü Laboratory values, recent imaging, consultations

A-Assessmentü Very short recap of the general overall status

of the patient e.g. patient is doing well or recovering well

P-Planü Offer plan for each pertinent body system o Neurology – pain control o Gut – feeding o Genitor-urinary-Foleys catheter use or

removal o Respiratory-ventilation, oxygen supplement,

nebulisation, chest physiotherapy o CVS - CVP pressure, fluid balance,

antihypertensive, fluids o Discharge plans

Exampleü Subjective - Mr. Daniel is a 65 yr male on

post –op day 2 after an inguinal hernia repair. Pain is minimal and tolerable. Patient walked today. He has passed flatus, stools and urine. On full diet.

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Know your operating room responsibilityAlways try to read the anatomy of the area to be involved in the surgery and operative steps from a surgical atlas. Please also read what can go wrong in this procedure and in this patient and the ways to manage the complications. Please remember eyes do not see what mind does not know. This should be possible in each and every elective surgery. The similar exercise can be done in emergency surgery after the surgery is done.

Every human being has 24 hrs a day It is not must to read the chapter from 1 st line only. Try to find time gaps which are plenty to read such as waiting for the case to start, before consultant arrives for the round. Try to carry a reading material in your pocket either few copied pages or pocket book or even newer gadgets. Develop a plan about what to read, when to read and where to read. One method is to learn common things first then going in to specific diseases. Every trainee is not the same and can have different methods to read and learn. Anything which is read but not learned is a waste of time. At the end of reading a chapter, determine have you met the objectives of the chapter? e.g., can you list 3 signs and symptoms of acute appendicitis. Always try to organize the knowledge, make a synopsis in your mind, ways to revise the same and adding new information to the previous knowledge. Evaluate you reading retention by way of self testing questions, multiple choice objective questions.

Feedback Feedback is a good tool to improve upon you

and collectively as a team too. Feedback should be descriptive ( not judgmental ), timely and specific. Feedback reinforces what is known and point out mistakes before they become habitual. It should be a periodical exercise. Try to seek feedback especially in areas in which you lack confidence. The surgical trainee could ask more details about the feedback. It also shows interest and willingness to learn from your mistakes.

• Respond but do not react. Try to keep emotions out of the response.

• Do not be defensive. Choose your word correctly.

• If you make a mistake, acknowledge, accept, take a vow not to repeat it, commit to improve and move on. Do not enter in to an argument.

• Do not take criticism personally unless you have committed normative errors. E.g., lack of diligence, honesty, suppression of facts.

• Keep your tone down.• Judge the situation and then act

Stress management Do not give up on other aspects of your life to do well in surgery. You will perform better if you do not give up on everything else. Balancing patient related responsibilities with your personal needs and those of others takes conscious efforts.• Eat sensibly• Take time out for family and friends• Do exercise• Have a space for yourself• Have a confidant.• Self evaluation is equally important

IMMEDIATE POST-OPERATIVE CAREPost-operative patients are at risk of clinical deterioration & should be monitored & assessed closely to minimize them. If the patient is restless, something is wrong. Trends are more important than isolated or single abnormal values.

Physiological parameters include

ü Objective – pt is afebrile and stable. Operative site is clean and dry. There is no drain. Urine-1600 ml, No lab ordered.

ü Assessment / plan – pt is doing well, plan to discharge today. Stitch removal planned on post-op day 7. Advised gentle laxative. Advised not to strain excessively and to increase ambulation.

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ü Respiratory rateü Oxygen saturationü Temperatureü Pulse rateü Systolic blood pressureü Level of consciousness

When patient’s condition is deteriorating, this should be informed verbally to the senior consultant using situation, background, assessment and recommendation (SBAR) tool.

SBAR toolSituation ü Identify where you are calling from ü Identify the patient and reason for report ü Identify what you are concerned about Background ü Significant medical history ü Information from charts and notesAssessment ü Vital signs ü ConcernsRecommendation ü Explain what you need ü Clarify expectations

Wound care and observationCheck the wound for excessive bleeding which may be an indicator of hemorrhage.

Transferring the patient from recovery area to wardRecovery area should be accessible to the surgeon or surgical resident. Patient should only be transferred out of recovery after following checks are done with satisfactory findings.

ü Ability to maintain airwayü Respiratory rate and chest movements ü pallor and cyanosis ü oxygen saturation on pulse oximetry ü pulse rate, pulse volume ü blood pressure

ü body temperature ü response to verbal commands and pain

stimuli ü ability to move limbs ü ability to cough ü patent intravenous line and fluid progress ü urine output, drain output and character ü stoma colour if any ü wound bleeding ü analgesia ü medication chart, operation notes, post-

operative instructions, antibiotics, deep vein thrombosis prophylaxis, blood sugar level in diabetics

ü relative visit in the recovery bay

Patients with the following risk factors foe deterioration should be reassessed with in 2 hrs of the first post-operative assessment.ü ASA grade ≥ 3ü Emergency or high risk surgeryü Operation out of hours

Pain controlPatient should be observed for signs of bleeding, shock, sepsis, effects of analgesics and anesthesia. Check the patient level of consciousness and vital parameters if opiate analgesia is given by infusion. The patient should be pain free and awake in order to communicate with hospital staff in the post-operative period. The type of surgery and individual sensitivity decides the level and type of pain control. Most common methods used to control post-operative pain include intravenous, epidural, patient controlled intravenous analgesia. Pain management is our job. The indicators of pain should be observed.

ü Restlessness ü Immobility ü Grimacing ü Increased perspiration ü Pallor

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ü Anxiety ü Tachycardia ü Hypertension

Ideal way of giving analgesia is to give small intravenous bolus of about a quarter or a third of the maximum dose, wait for 5-10 minutes to observe the effect. Estimate the correct dose and give the remaining dose intramuscularly. If opiate analgesia is needed in the ward, give an intramuscular regimen.Airway and respiration It is the first vital sign to be affected if there is change in cardiac or neurological state. This observation is needed to perform accurately. Observe and record the followingü airwayü respiratory rate – regular, effortless,

symmetrical movementü respiratory depression – bradypnoea,

hypoventilationü Location of trachea – central or not?ü Breathing sounds ü Percussion notePatient should be encouraged to take deep breaths & cough actively with support to abdominal wall (splinting). Nebulisation with normal saline or medicated nebulization is administered to loosen the secretions and cause bronchodilation. Patient in whom there is a suspicion of pulmonary complication should have an arterial blood gas analysis, chest x-ray, sputum culture and ECG. Oxygen should be given to patients with hypoxemia to achieve necessary SpO2. Failure

to achieve SpO2 > 90% or PaO2 > 60 mm Of Hg is an indication for assisted ventilation. Patients developing respiratory failure should be referred to critical care specialist for possible ventilation. Timely intervention is important as hypoxia or hypercapnoea may lead rapidly to cardiorespiratory arrest. Diagnosis of chest infection is made if any 2 of the following is present for more than 2 or more days. ü Fever > 380 C ü Positive sputum culture ü Positive clinical finding ü Abnormal chest X-ray–atelectasis /

infiltrates.

Oxygen therapyPrescribe oxygen to patients who have epidural, patient controlled analgesia or morphine infusion. There is nothing called as oxygen toxicity. Oxygen helps to remove anaesthetic gases from the body. Ensure proper rate of administration and humidification. Face mask are better than binasal prongs in ensuring the delivery.

Pulse oximetryOxygen saturation on room air should be more than 95% in patient with normal lungs. Administer oxygen when the saturation on room air is less than 95% or when patient has asthma or COPD or has pallor or cyanosis.

Heart rate and blood pressureAssessment of hypotension should be done as lowered systolic blood pressure with tachycardia may indicate hemorrhage and /or shock.

Observe if : Seek further advice if :Awake and easily arousable Drowsy or unarousableComfortable DistressedNormal preoperative B.P. Hypertensive preoperativelyWarm Cold Well perfused ( capillary refill < 2 seconds) Capillary refill > 2 secondsHeart rate – 50-100/min Heart rate - > 100 or < 50/ minPassing urine – more than 0.5 ml/Kg/hr Oliguric - < 0.5 ml/Kg/hrNo obvious bleeding Signs of bleeding – drains, wounds, hematoma

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Increased blood pressure is due to inadequate analgesia or is due to anaesthetics. Postoperative blood pressure should always be reviewed with reference with preoperative and intraoperative blood pressure. Further assessment is required for patients with heart rate < 50 or > 100/ min with systolic pressure of < 100 mm of Hg. Continue antihypertensive medications perioperatively unless patient becomes hypotensive postoperatively then it may be appropriate to discontinue some drugs. Beta blockers and IV nitrates can be used safely in postoperative hypertension. Beta blockers should be continued perioperatively in patients previously taking these drugs for coronary disease, congestive heart failure, hypertension or arrhythmias. Seek cardiologists help early in the management of serious arrhythmias or suspected myocardial infarct. Search for the potentially correctable causes of supraventricular arrhythmias such as hypoxia, hypovolaemia, electrolyte abnormality, sepsis or drug toxicity.

Temperature All patients especially old aged patients, children & those with long duration surgery are at risk of hypothermia. The good way to prevent hypothermia is to use temperature controlled water bed along with use of warm air blankets during surgery and patient warmers postoperatively. If temperature is elevated use antipyretics , fanning or tepid sponging to normalize it. Fever could be due to infection and hypothermia due to sepsis. In a surgical patient there are many causes for fever such as plate atelectasis, ventilator associated pneumonia, thrombophlebitis, central line colonization, wound collection, intravenous fluids.

Level of consciousnessA change in level of consciousness can be a sign of shock. Also do blood sugar level especially in diabetics, alcoholics, liver cirrhotic. The AVPU scale is used for assessing level of consciousness in adults, children unless they had neurosurgery

AVPU scaleü Alertü responds to Voiceü responds to Painü Unconscious

Fluid balance, electrolyte balance and renal managementAccurate assessment of fluid & electrolyte status can be difficult & should be individualized for the patient needs & requirements & reviewed frequently. Volume depletion & volume overload are equally bad for the wound healing. Diuretics should be used only for fluid overload. Hyponatremia is more commonly due to volume overload than due to sodium deficiency. Hypernatremia most commonly indicates total body water deficiency and should be treated promptly. Hypokalemia can delay postoperative recovery. Hyperkalemia is a medical emergency, seek senior help. Metabolic acidosis is usually due to poor tissue perfusion but can also be caused by excessive administration of saline.

Record post-operative fluid balance.ü IV fluidsü Oral intakeü Urine output. Low urine output can be a sign

of inadequate resuscitation, shock or renal failure. Also check that the urinary catheter is not kinked or compressed below the patient body. Avoid indiscriminate and blind use of diuretics, a common practice with stressed residents. Central venous pressure is a useful adjunct to decide the end point of IV infusion volume.

ü Stoma outputü Nasogastric drainage or vomits ü Wound discharge if anyü Drain output and character ü Watery stools if any, it’s frequency

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ü Assessment of volume status o Hands – warm or cool, pink or pale? o Capillary return, 2 s or not? o Conjuctival pallor o Jugular venous pressure o Urine colour and rate of production

SepsisIntravenous catheter insertion site dressing and checking should be done every 24 hrs and peripheral venous access changed every 72 hours. Hand washing with the soap and water or alcoholic cleansing agents should be done before and after patient contact. Early identification of and appropriate treatment of sepsis improves outcomes. If the cause of sepsis is not known, then treat it with broad spectrum antibiotics guided by local or hospital antibiotic policy. The duration of antibiotics should usually be limited to 5-7 days. Check for fungal and atypical bacterial infections by cultures and treat accordingly. When systemic inflammatory response (SIRS) is present an infective cause should be sought first.

Systemic inflammatory response syndrome is defined as presence of 2 or more of the following

ü Temperature >380C or < 360Cü Heart rate > 90/minü Respiratory rate > 20 / min or PaCO2 < 32

mm of Hgü WBC count > 12,000/cmm or < 4,000/cmm

or > 10% immature forms

Enteral nutritionUnless contraindicated every patient should receive enteral nutrition with in 24 hrs of surgery. The volume of the enteral nutrition given should be increased from 30 ml per hour to 90 ml per hour with in 12 hrs. If patient is unable to tolerate enteral nutrition or full caloric requirement cannot be fulfilled in 72 hrs, consider parenteral nutrition.

Ambulation It should start within 24 hours. Patient is encouraged to move limbs, hands, change posture as early as possible. He is also given assistance to move out of bed and walk. Patient with increased risk for deep vein thrombosis should receive either heparin or low molecular weight heparin or anti DVT stocking. Patient unlikely to move should be placed on air mattress to avoid risk of pressure ulcer. Remove Foleys catheter as early as possible.

Make a discharge planü Which is the best time to dischargeü Clear instructions about medicationü Time of follow upü Date of dressing / stitch removalü Collection of pending reports especially

histopathologyü Diet charting to avoid constipationü Giving contact details for any emergencyü Duration of rest or physical activities

permittedü Further consultation or need of treatment ü Proper documentation of the surgical procedure

& important investigations, patient’s progress, medication received.

References :1. Implement multidisciplinary rounds. Institute

for healthcare improvement.2. WHO surgical care at the district hospital 2003.3. How to reduce the risk of deterioration after

surgery. Nursing Times 12.06.13/Vol 109 No. 23 principles of monitoring post-operative patients. Nursing Times 05.06.13/Vol 109 No 22

4. How to present a patient on your surgery rotation, American Medical Student Association.

5. Postoperative management in adults, by Scottish Intercollegiate Guidelines Network.

q q q

12*Interventional Pulmonologist and Intensivist, E-mail : vgkhadke@gmail.com , Cell : 9822407783.

Documentation in Medico Legal CasesDr. Vrushali Khadke *

Medical record serves as a central repository for planning patient care and documenting communication among the patient and health care provider and professionals contributing to the patient's care.

While patient care precedes everything, a doctor has to fulfil certain legal requirements in service by compulsion or voluntarily as defined under law. Medicolegal case examination and reporting is one of the legal responsibilities of all doctors working in government or private hospitals.

A good working knowledge of the law in this regard, coupled with precise documentation helps over riding the fear of MLC.

Medicolegal case (MLC) can be defined as a case of injury or ailment , in which investigation by the law-enforcing agencies is essential to fix the responsibility regarding the causation of the said injury or ailment.

Situations in which MLC is recorded are :

● Medical examination of a person brought by the police or on order of the court.

● A person attended to and MLC registered at another hospital, is now referred for specialist care.

● A patient himself expressing a desire to register a case against an alleged accused.

● Where the attending doctor after eliciting history and examination feels so, i.e when the history is not completely revealed.

Who ?The MLC will be registered by the attending medical doctor.

* In case of sexual assault on a female, a lady doctor will examine the case *.

When ?The first priority of a doctor is to resuscitate the patient and all legal formalities may be suspended till then.

After due treatment, register and inform the police in writing or on phone. Note down the name, buckle no. of the MLC recipient and the police station informed. The details should be entered in a medicolegal register, preferably in duplicate.

Avoid re-registering a MLC if already done at another hospital. Note down the MLC number there. If during the course of treatment of a case not registered as MLC initially, foul play is suspected, one may register the MLC then. Do not delay registration of the MLC unnecessarily.

Section 176 IPC (Indian Penal Code) : provides for prosecution of the doctor for failure to inform. Reinform police when the patient dies or is discharged. Note down the recipients details again.

Which cases?Cases considered medico-legal:● Trauma or burns ● Electrocution ● Poisoning

Continued on Page 15....

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Hospital UpdateCONGRATULATIONS –• Dr. Farhazhusen Bohari has been awarded DR. SAM G. P MOSES Gold Medal for Gen. Medicine for

the session June 2012 at the 18th convocation ceremony of NBE at New Delhi on 12th May 2014. ThisMedal is awarded to one candidate all over India for every academic session & this is second goldmedal won by the student of Poona Hospital.

• Dr. Neha Kalsekar & Dr. Rakhi Agrawal for successfully passing DNB Anaesthesia• Dr. Sudhanshu Kothadia for successfully passing DNB Orthopedics

We would also like to congratulate all the faculty members of above specialties for their efforts.• Dr. M. Desarda, Senior Surgeon has been honored for his research on the basic concepts of inguinal

canal physiology and invention of an entirely new technique of inguinal hernia repair, now called as“Desarda Repair”. Internationally esteemed medical textbook “Baily & Love’s Textbook of Surgery”has accepted Dr. Desarda’s research and published it in its 26th edition 2013. This has become now apart of curriculum to all medical students worldwide.

INTERNATIONAL NURSES DAY CELEBRATION –Nurses day was celebrated at 12th may 2014. The theme for nurses day was “A force for change – avital resource for health.” Shri. Rajkumar H. Chordia Jt. Mg. Trustee, Poona Hospital & ResearchCentre and Dr. J. Ravindranath, Director, Poona Hospital & Research Centre gave away prizes tovarious SNA and TNAI sports activities. The Nurses Day was celebrated in a grand manner, all thesisters incharge, staff nurses, teaching faculty and student participated and made it a memorable day

l CAMPS -• Smile Train Camp : A camp was held on 28th April 2014 for patients with Cleft Lip and / or Palate.

Total 120 patients were registered & 68 patients were operated upon during the camp. Consultation,investigation, surgery and stay for these patients were entirely free.

• Blood Donation Camp : A total of 7 Blood Donation Camps were arranged during the months March& May 2014. People gave very encouraging response to these Camps. A total of 392 people donatedblood during these camps.

• A Free Eye Checkup Camp : A camp was arranged from 10th May to 25th May 2014. Eye Checkup,Power of Glasses, Diagnosis & Guidance for Cataract, Glaucoma, Squint, Diabetic Retinopathy wasavailable free of cost and Cataract Surgery was available at nominal rates during this camp. Morethan 350 people participated & took benefit of this camp.

CME’S, SEMINAR’S & TRAINING PROGRAMMES –• General Practitioners Association, organized a ‘Practice Management Conference – 2014’ on 16th

March 2014.• Indian Society of Anaesthesiologists, arranged a Scientific Program on ‘ENT and Anaesthesia’ on

27th March 2014.• Kothrud Doctors Association organized a CME – ‘Medicine Update’ on 30th March 2014.• Indian Society of Anaesthesiologists, organized a CME on ‘Role Of Anaesthesiologist Outside

O.T.’ on 25th April 2014.• Department of Medicine, Poona Hospital & Research Centre organized the following CME’s on

� ‘Community Acquired Pneumonia’ & ‘Malaria’ on 16th April 2014.� ‘Stress Test & Stress Echocardiography’, ‘Nuclear Imaging’ & ‘CT Angiography & MRI Heart’

on 13th May 2014.

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(10.00a.m.to12.30p.m.)

DEPARTMENT MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

MORNING 10 A.M. TO 12.30 P.M.

MEDICINE DR. N. M. BEKE Dr. V. GUNDECHA DR. A. BAHULIKAR DR. V. G. SHAH DR. M. TULPULE DR. K. P. RUNWAL DR. A. TAMBOLKAR

SURGERY DR. R. S. DUMBRE DR. D. JAIN DR. A. PORWAL DR. A. FERNANDES DR. B. DIKSHIT DR. S. SHAH DR. A. FERNANDES

GYNAE & OBSTETRICS DR. (MS) S ANPAT DR. (MS) S. KAKATKAR DR. A. SHAH DR (MS) N. DESAI DR. (MS) G. BARVE DR. (MS) N. DESAI ----

PAEDIATRICS DR. P. V. ALATE ---- DR. L. RAWAL DR. P. V. ALATE ---- DR. L. RAWAL ----

ORTHOPAEDICS DR. R. KOTHARI DR. A. DESAI DR. R. ARORA DR. R. KOTHARI DR. A. DESAI DR. N. NAHAR ----

E.N.T. (10.30a.m.-1.30p.m.) DR. A. M. ATHANIKAR DR. (MS) V. SHIRVEKAR DR. (MS) V. JOSHI DR. A. M. ATHANIKAR DR. S. PABALKAR DR. (MS) V. JOSHI ----

OPTHALMOLOGY DR. (MS) V. RAWAL DR. P. GORANE Dr. (MS) S. PURANIK DR. R. BHANGE DR. (MS) V. RAWAL Dr. (MS) S. PURANIK ----

PSYCHIATRY DR. V. G. WATVE DR. D. M. DHAWALE DR. S. CHAUGULE DR. V. G. WATVE DR. D. M. DHAWALE DR. S. CHAUGULE DR. M. DIXIT / DR. H. KULKARNI

DERMATOLOGY DR. H. S. CHOPADE DR. S. TOLAT DR. H. S. CHOPADE ---- DR. H. S. CHOPADE ---- ----

CHEST DISEASES DR. N. ABHYANKAR ---- DR. N. ABHYANKAR DR. AJIT KULKARNI DR. N. ABHYANKAR DR. (MS) V. KHADKE DR. J. JAIN

ONCOLOGY DR. S. M. KARANDIKAR DR. S. M. KARANDIKAR ---- ---- DR. S. M. KARANDIKAR ---- ----

ONCOSURGERY ---- ---- DR. S. MOHITE DR. S. MOHITE ---- DR. S. MOHITE ----

11.30 A.M. TO 12.30 P.M.

CARDIOLOGY DR. M. ASAWA DR. S. SATHE DR. S. HARDAS DR. H. GUJAR / DR. I. ZANWAR DR. P. SHAH DR. C. CHAVAN ----

CARDIAC SURGERY DR. V. NATARAJAN DR. M. BAFANA DR. SHIV GUPTA * DR. R. JAGTAP * DR. V. NATARAJAN DR. R. JAGTAP * * By Appointment Only

DR. V. NATARAJAN DR. V. NATARAJAN

NEUROLOGY DR. N. BHANDARI DR. S. KOTHARI DR. (MS) A. BINIWALE DR. P. K. SHARMA DR. S. KOTHARI DR. P. K. SHARMA ----

NEURO-SURGERY DR. P. BAFNA DR. S. PATKAR DR. N. LONDHE DR. S. PATKAR DR. P. BAFNA DR. S. PATKAR ----

NEPHROLOGY DR. N. C. AMBEKAR DR. S. V. UKIDVE (10-12 p.m.) DR. N. C. AMBEKAR DR. S. V. UKIDVE (10 - 12 p.m.) DR. N. C. AMBEKAR DR. S. V. UKIDVE (10-12 p.m.)

URO-SURGERY DR. S. BHAVE ---- DR. J. DATE DR. S. BHAVE DR. J. DATE ---- ----

PLASTIC SURGERY DR. R. GANDHI DR. S. PANDIT DR. R. GANDHI DR. S. PANDIT DR. S. PANDIT DR. R. GANDHI ----

GASTROENTEROLOGY (MED.) DR. V. THORAT DR. N. DUBALE DR. V. THORAT ---- DR. S. JAIN DR. N. DUBALE ----

GASTROENTEROLOGY (SURG) ---- DR. R. TANDULWADKAR ---- DR. R. TANDULWADKAR DR. M. THOMBARE ---- ----

ENDOCRINOLOGY DR. M. MAGDUM ---- ---- ---- DR. M. MAGDUM ---- ----

HAND SURGERY DR. A. WAHEGAONKAR DR. A. GHOSH ---- DR. A. WAHEGAONKAR DR. A. GHOSH ---- ----

AFTERNOON 1 P.M. TO 3.30 P.M.

MEDICINE DR. C. G. SHETTY DR. (MS) A. SHAHADE DR. (MS) G. DAMLE DR. S.V. NAGARKAR DR. A. CHOPDAWALA DR. A. CHOPDAWALA ----

SURGERY DR. P. PRADHAN DR. B. DIKSHIT ---- DR. A. FERNANDES ---- ---- ----

GYNAE & OBSTETRICS ---- DR. (MS) M. CHIPLONKAR ---- ---- ---- DR. (MS) M. CHIPLONKAR ----

VASCULAR SURGERY ---- ---- DR. D. R. KAMERKAR ---- ---- ---- ----

OPHTHALMOLOGY Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK DR. (MS) V. RAWAL ----

CARDIOLOGY---- ---- ---- ---- ---- ---- ----

NEUROLOGY DR. D. SASTE (2 to 4 p.m.) ---- DR. N. BHANDARI ---- ---- ---- ----

SURGERY3.00 p.m. to 5 p.m. DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR ----

ORTHOPAEDICS 3.00 - 5.00 p.m. DR. S. SONAWANE DR. H. PATKAR DR. S. SONAWANE DR. H. PATKAR DR. S. SONAWANE DR. H. PATKAR ----

ONCOLOGY 2.00 p.m. - 3.00 p.m. ---- ---- DR. A. RANADE / DR. A. BHATT ---- DR. A. RANADE / DR. A. BHATT ---- ----

SPECIALITY CLINICS

HERNIA CLINIC 12.30 p.m. - 1.30 p.m. ---- ---- ---- DR. M. P. DESARDA ---- ---- ----

DIABETOLOGY 8.30 a.m - 9.30 a.m. DR. (MS.) G. DAMLE DR. B. B. HARSHE ---- ---- DR. B. B. HARSHE ----

HEMATOLOGY 9.00 a.m.-11.00 a.m. ---- ---- ---- DR. V. RAMANAN ---- ---- ----

PROCTOLOGY12.00 p.m. to 2.00 p.m. ---- ---- ---- ---- ---- DR. ASHWIN PORWAL ----

DR. V. KARMARKAR

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(10.00a.m.to12.30p.m.)

DEPARTMENT MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

MORNING 10 A.M. TO 12.30 P.M.

MEDICINE DR. N. M. BEKE Dr. V. GUNDECHA DR. A. BAHULIKAR DR. V. G. SHAH DR. M. TULPULE DR. K. P. RUNWAL DR. A. TAMBOLKAR

SURGERY DR. R. S. DUMBRE DR. D. JAIN DR. A. PORWAL DR. A. FERNANDES DR. B. DIKSHIT DR. S. SHAH DR. A. FERNANDES

GYNAE & OBSTETRICS DR. (MS) S ANPAT DR. (MS) S. KAKATKAR DR. A. SHAH DR (MS) N. DESAI DR. (MS) G. BARVE DR. (MS) N. DESAI ----

PAEDIATRICS DR. P. V. ALATE ---- DR. L. RAWAL DR. P. V. ALATE ---- DR. L. RAWAL ----

ORTHOPAEDICS DR. R. KOTHARI DR. A. DESAI DR. R. ARORA DR. R. KOTHARI DR. A. DESAI DR. N. NAHAR ----

E.N.T. (10.30a.m.-1.30p.m.) DR. A. M. ATHANIKAR DR. (MS) V. SHIRVEKAR DR. (MS) V. JOSHI DR. A. M. ATHANIKAR DR. S. PABALKAR DR. (MS) V. JOSHI ----

OPTHALMOLOGY DR. (MS) V. RAWAL DR. P. GORANE Dr. (MS) S. PURANIK DR. R. BHANGE DR. (MS) V. RAWAL Dr. (MS) S. PURANIK ----

PSYCHIATRY DR. V. G. WATVE DR. D. M. DHAWALE DR. S. CHAUGULE DR. V. G. WATVE DR. D. M. DHAWALE DR. S. CHAUGULE DR. M. DIXIT / DR. H. KULKARNI

DERMATOLOGY DR. H. S. CHOPADE DR. S. TOLAT DR. H. S. CHOPADE ---- DR. H. S. CHOPADE ---- ----

CHEST DISEASES DR. N. ABHYANKAR ---- DR. N. ABHYANKAR DR. AJIT KULKARNI DR. N. ABHYANKAR DR. (MS) V. KHADKE DR. J. JAIN

ONCOLOGY DR. S. M. KARANDIKAR DR. S. M. KARANDIKAR ---- ---- DR. S. M. KARANDIKAR ---- ----

ONCOSURGERY ---- ---- DR. S. MOHITE DR. S. MOHITE ---- DR. S. MOHITE ----

11.30 A.M. TO 12.30 P.M.

CARDIOLOGY DR. M. ASAWA DR. S. SATHE DR. S. HARDAS DR. H. GUJAR / DR. I. ZANWAR DR. P. SHAH DR. C. CHAVAN ----

CARDIAC SURGERY DR. V. NATARAJAN DR. M. BAFANA DR. SHIV GUPTA * DR. R. JAGTAP * DR. V. NATARAJAN DR. R. JAGTAP * * By Appointment Only

DR. V. NATARAJAN DR. V. NATARAJAN

NEUROLOGY DR. N. BHANDARI DR. S. KOTHARI DR. (MS) A. BINIWALE DR. P. K. SHARMA DR. S. KOTHARI DR. P. K. SHARMA ----

NEURO-SURGERY DR. P. BAFNA DR. S. PATKAR DR. N. LONDHE DR. S. PATKAR DR. P. BAFNA DR. S. PATKAR ----

NEPHROLOGY DR. N. C. AMBEKAR DR. S. V. UKIDVE (10-12 p.m.) DR. N. C. AMBEKAR DR. S. V. UKIDVE (10 - 12 p.m.) DR. N. C. AMBEKAR DR. S. V. UKIDVE (10-12 p.m.)

URO-SURGERY DR. S. BHAVE ---- DR. J. DATE DR. S. BHAVE DR. J. DATE ---- ----

PLASTIC SURGERY DR. R. GANDHI DR. S. PANDIT DR. R. GANDHI DR. S. PANDIT DR. S. PANDIT DR. R. GANDHI ----

GASTROENTEROLOGY (MED.) DR. V. THORAT DR. N. DUBALE DR. V. THORAT ---- DR. S. JAIN DR. N. DUBALE ----

GASTROENTEROLOGY (SURG) ---- DR. R. TANDULWADKAR ---- DR. R. TANDULWADKAR DR. M. THOMBARE ---- ----

ENDOCRINOLOGY DR. M. MAGDUM ---- ---- ---- DR. M. MAGDUM ---- ----

HAND SURGERY DR. A. WAHEGAONKAR DR. A. GHOSH ---- DR. A. WAHEGAONKAR DR. A. GHOSH ---- ----

AFTERNOON 1 P.M. TO 3.30 P.M.

MEDICINE DR. C. G. SHETTY DR. (MS) A. SHAHADE DR. (MS) G. DAMLE DR. S.V. NAGARKAR DR. A. CHOPDAWALA DR. A. CHOPDAWALA ----

SURGERY DR. P. PRADHAN DR. B. DIKSHIT ---- DR. A. FERNANDES ---- ---- ----

GYNAE & OBSTETRICS ---- DR. (MS) M. CHIPLONKAR ---- ---- ---- DR. (MS) M. CHIPLONKAR ----

VASCULAR SURGERY ---- ---- DR. D. R. KAMERKAR ---- ---- ---- ----

OPHTHALMOLOGY Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK DR. (MS) V. RAWAL ----

CARDIOLOGY---- ---- ---- ---- ---- ---- ----

NEUROLOGY DR. D. SASTE (2 to 4 p.m.) ---- DR. N. BHANDARI ---- ---- ---- ----

SURGERY3.00 p.m. to 5 p.m. DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR ----

ORTHOPAEDICS 3.00 - 5.00 p.m. DR. S. SONAWANE DR. H. PATKAR DR. S. SONAWANE DR. H. PATKAR DR. S. SONAWANE DR. H. PATKAR ----

ONCOLOGY 2.00 p.m. - 3.00 p.m. ---- ---- DR. A. RANADE / DR. A. BHATT ---- DR. A. RANADE / DR. A. BHATT ---- ----

SPECIALITY CLINICS

HERNIA CLINIC 12.30 p.m. - 1.30 p.m. ---- ---- ---- DR. M. P. DESARDA ---- ---- ----

DIABETOLOGY 8.30 a.m - 9.30 a.m. DR. (MS.) G. DAMLE DR. B. B. HARSHE ---- ---- DR. B. B. HARSHE ----

HEMATOLOGY 9.00 a.m.-11.00 a.m. ---- ---- ---- DR. V. RAMANAN ---- ---- ----

PROCTOLOGY12.00 p.m. to 2.00 p.m. ---- ---- ---- ---- ---- DR. ASHWIN PORWAL ----

DR. V. KARMARKAR

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Rajasthani & Gujarati Charitable Foundation’s

POONA HOSPITAL & RESEARCH CENTRE

27, Sadashiv Peth, Pune 411 030.Tel. : 24331706, 66096000, Fax : 24338477

DEPARTMENT OF DENTAL SURGERYTimings Monday Tuesday Wednesday Thursday Friday Saturday

09.30 to Dr. Paresh Dr. Anjali Dr. Shashikant Dr. Charudatta --- Dr. Surendra11.30 a.m. Gandhi Gandhi Bamb Naik Rathi

12.30 to Dr. Mukund Dr. Paresh Dr. Mukund Dr. Paresh Dr. Mukund Dr. Charudatta02.30 p.m. Kothawade Gandhi Kothawale Gandhi Kothawade Naik

03.30 to Dr. Shashikant Dr. Surendra --- Dr. Shashikant Dr. Surendra Dr. Anjali5.30 p.m. Bamb Rathi Bamb Rathi Gandhi

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CASHLESS FACILITIES

TPAs : The following TPAs (Third Party Administrators) have a tie up with Poona Hospitalfor their members to avail of the treatment facilities provided by the hospital.* Medi Assist India Pvt. Ltd. * Genins India Ltd.* Medicare TPA Services (I) Ltd. * Park Mediclaim.* MD India Health Care Services Pvt. Ltd. * Raksha TPA Services.* Paramount Healthcare Services Ltd. * Dedicated Health Care Services.* Health India (Bhaichand Amoluk Ins.)

INSURANCE COMPANIES : Poona Hospital also provides cashless facilities topolicy holders of the following Insurance Companies* ICICI Prudential, * MAX BUPA Health Insurance* Bajaj Allianz Gen. Insurance Co. Ltd. * Cholamandalam MS Gen. Ins.* Future Generali Total Insurance Solutions * Religare Insurance Co. Ltd.* Star Health & Allied Insurance Co. Ltd. * Apollo Munich* IFFco Tokio General Insurance * Reliance General Insurance* ICICI Lombard General Insurance (I Health Care),

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Continued from Page 10....

● Vehicular or occupational accidents ● Sexual offences ● Requirement of age estimation ● Suspected or evident criminal abortion ● Brought dead with improper history ● Unconscious patients where cause is not clear ● Hanging, strangulation, drowning, suffocation ● Cases sent by police or court for medical

examination ● Unnatural death of a lady within 7yrs of

marriage ● All cases where relatives or patient alleges foul

play.● Any other case with legal implications.

Consent :Normally under medical ethics, examination of the patient is possible only after taking consent. A conscious patient has the right to refuse examination. Consent is not needed in following situations:● Medical emergencies● Notifiable diseases ● Medical emergencies● Immigrants ● On request of medical examination of a person

by the police or by court order● Consent is not required from relative for

conducting medicolegal post-mortems.If an unconscious unknown patient is brought by police, life-saving surgery can be done after consent of 2-3 doctors.Documentation :Compiling a medico-legal report includes● Date and time of admission of the patient.● Complete name, age, sex, profession, complete

postal address of the patient. ● Complete name, address and contact number of

the person who brings the patient. (Informant)● Detailed history of the event with time, precise

location, details of primary treatment at any other hospital.

● Detailed examination of vitals & each system.● Detailed description of each injury like type,

part of body, size and number. If possible mention what object they were caused due to and if they are simple or grievous.

● 2 identification marks on the patient’s body. ● Whether patient is under alcohol influence

based on motor in-coordination, pupillary size, ataxia, smell of alcohol at breath, slurred speech. (difficult to distinguish in presence of intracranial injury).

The important points to remember while noting above details are :

Fill each column correctly, write legibly, do not overwrite, initial all corrections, avoid short forms. If the patient is dying, inform magistrate to record 'dying declaration'.

Dying declaration: A statement oral or written made by the patient in a fit mental condition, on the verge of death, regards events leading to his death, is admissible in evidence. Intimate the magistrate to record the declaration. If limited time, the attending doctor should record the same in presence of the police.

Certification :The doctor on duty looking after the patient has to certify if the patient is coherent enough to give statement and countersign the statement.

Confidentiality :A medicolegal report is of confidential nature and neither the accused nor the respondent is entitled to get a copy of the same unless the police issue a no-objection certificate.

Samples to be collected :

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● Blood in EDTA, gastric lavage, saliva, hair, vaginal swabs etc. are to be collected, sealed with patient details and handed over to the police.

● Any foreign body like bullet recovered from the patient after surgery should be sealed and handed over to the police. The clothes and other articleson the body of the patient which have injury marks like stab related tear, bullet entry points etc. should also be sealed and handed over to the police. These may beentered as evidences.

How long should MLC records be kept ?As per law, there is no specified time limit after which the records can be destroyed. Hence they have to be preserved as long as possible. Most hospitals have a policy of maintaining MLC records for variable periods.

To summarise, do not avoid MLC recording where needed, ensure methodical examination and proper documentation, inform the police timely and medically manage the MLC case just as a non-MLC case.

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• One of the first patients to arrive at the doctor’s chamber was an elderly lady.

Seeing that the doctor was going to be late, the nurse decided to give the lady some company.

‘Hello,’ she said, approaching the lady, ‘I am the doctor’s nurse.’

Squinting her eyes to look up at the nurse, the lady queried, ‘Oh, is the doctor sick?’

• A man was having a particularly bad day. It had started to rain as he left his house and he was drenched even before he reached the bus stop. This was followed by a suffocating journey in an overcrowded bus. When he finally got off at his stop, he discovered that his wallet has been stolen. After office as he was returning home he was mugged, stripped of his watch, jacket and shirt, and beaten badly.

Somehow he managed to make his way to the hospital. The doctor on duty at the emergency ward looked shocked at his condition and asked in a con-cerned voice, ‘Sir, has anyone taken your pulse?’

To which the man replied wearily, ‘No, Doctor, I think I still have that.’

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The Dictionary Meaning of consent -Permission for something to happen or agreement to do something. Synonyms; agreement, assent, concurrence, accord.

Consent is a propositional attitude, so intransitive, complete, wholly specific consent is an illusion.

The concept of consent comes from the ethical issue of respect for autonomy, individual integrity and self determination. The term consent means voluntary agreement, compliance, or permission. Section 13 of the Indian contract act lays down that two or more persons are said to consent when they agree upon the same thing in the same sense (meeting of minds). In law, the tort of battery is defined as ‘Application of force to the person of another without lawful justification’ and therein lies the essence of requirement of consent for any medical treatment. “Every human being of adult years and sound mind has a right to determine what should be done with his body and the surgeon who performs operation without his patient’s consent commits assault for which he is liable in damages.”

“The health of my patient will be my first consideration.” These words of Declaration of Geneva of the world Medical Association bind the physicians towards their duty to promote and safeguard the health of the people.

The consent may either be implied or express.

1. An implied consent - is a consent which is not written, that is, its existence is not expressly asserted, but nonetheless, it is legally effective. It is by far the most common variety of consent

*General Surgeon, E-mail : sanjeevanee@yahoo.com , Cell : 9823480050

Informed Consent and Its Medicolegal ImplicationsDr. Sanjeevanee Kelkar *

in both general and hospital practice, provided by the demeanour of the patient. It implies consent to medical examination in a general sense but not to procedures more complex than inspection, palpation, percussion & auscultation.

2. An express consent - is one in terms of which are stated in distinct & explicit language. It may be oral or written. For the majority of relatively minor examinations or therapeutic procedures, oral consent is employed, but this should preferably be obtained in the presence of a disinterested party.

3. Substitute Consent – In case of mentally unsound person or unconscious patients or in case of minor any of the parents can give substitute consent.

Oral consent, where properly witnessed, is as valid as written consent, but the latter has the advantage of easy proof & permanent form.

To be legally valid, the consent that is given must be informed & intelligent, that is, the consent must be given after understanding what it is given for & of the risks involved. It is therefore imperative for the doctor to give reasonable information to his patient about the following —1. Diagnosis.2. Nature of treatment or procedure.3. Risks involved.4. Prospects of success.5. Prognosis if the procedure is not performed.

6. Alternative methods of treatment.

Thus, what the law requires is that-

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A. The patient be fully informed of every risk and factual material for the making of a proper Consent.

B. The consent itself based upon such material disclosure.

All informed consent rules recognise the so-called therapeutic exceptions- e.g. the apprehensive or neurotic patients who may be harmed by such full disclosure (Either by discarding a needed procedure with minimal risk or else in suffering psychological harm from such disclosure and thus becoming an increased surgical risk). In such instances it is advisable for the doctor to obtain informed consent from a responsible relation, or in his absence, to obtain medical consultation & chart the intentional omission & the therapeutic exception-basis in regard thereto.

TABLE NO. 1

CONSENT IS LEGALLY VALID ONLY WHEN

i. The patient is above 18 years of age, conscious, and in a sound state of mind, and is given by the person himself.

ii. Consent is given before performing the procedure, and is given freely, voluntarily and directly, without fear, force or fraud.

iii. The patient has to be informed about the procedure and the treatment completely.

iv. Making sure that the patient understands all the information. The doctor should also bear in mind the patient’s intellectual capacity while explaining the details.

v. The doctor should explain the nature of the condition, the reason of the procedure and also make it a point to be specific about side effects.

In this regard what is safe to tell the patient-these guidelines....

“If the risk of untoward result is statistically high, the patient should be informed regardless of the effect on his/her morale. If the risk is statistically

low, but the consequences of a rare untoward occurrence may be severe, the patient should likewise be informed.On the other hand, if the statistical risk is low or the severity of the risk is not great, the physician may safely tailor his warning so as not to excite the patient’s fears”Most of the hospitals are nowadays following the norms with considerable importance for the concept of written, witnessed, or express consent for 2 reasons1. It is not possible to cover by implied method

of consent, the increased number of diagnostic & therapeutic procedures, which are being routinely, carried out. e.g. Sophisticated radiological investigations, interventional radiology procedures, Cardiac catheterisation, are all sufficiently risky to require express consent.

2. The consent is valid only for a specific procedure, when the general nature of that procedure has been explained to the patient who can assess the risks & decline the procedure if he so wishes (Informed Refusal).

In view of the above legal position, the usual blanket consent forms utilised by most hospitals & surgeons to do whatever he/she thinks best for the patient under the circumstances (sometimes even including post-mortem), may later turn to be of no value in the court particularly as it does not refer to any specific procedure or operation that was originally contemplated and consented to, or the patient was not given sufficient information to make an informed consent.

TABLE NO. 2

FEW EXAMPLES WHERE THE CONSENT NEED NOT BE TAKEN

i. When a patient is infected with any disease professional secrecy should be maintained. But if there are chances of spreading infection to public at large, it is the duty of

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the doctor to inform (Notifiable Diseases) ii. For vaccination, no consent is required as

law authorises it. iii. Suicide attempted cases. iv. Court can order psychiatric examination

and treatment. v. Cases of alcohol consumption, medical

examination or even collection of blood sample to estimate alcohol level, without consent at the request of police officer.

A medical practitioner must remember the following PRINCIPLES IN RESPECT TO CONSENT in relation to examination or treatment.1. Normally an O.P.D. patient for examination,

the consent of the patient is implied. But when the patient is unconscious & any delay in obtaining the consent would be dangerous, the doctor may examine & treat without consent such a gravely ill patient who needs immediate treatment or surgery. Save this exception, a doctor should not examine or treat any patient without his consent. Even in such cases, care should be taken that the surgical procedures do not go beyond the minimum required to save life, and whenever possible, amputation of limbs, etc, is postponed till such time that proper informed consent can be obtained.

2. Operative & other procedures such as blood transfusion require a special consent.

Written consent for special situations - a, examining Private parts of a patient, b. To determine age, potency, or virginity and c. Examination of cases of alleged sexual

offence, etc.3. Examination of a patient without his consent

legally amounts to trespass or an assault-even an indecent assault in appropriate circumstances. This is true in the examination of Medico-legal cases, as the person ( not the patient) has not come voluntarily to the

doctor, but brought by the police & thus implied consent cannot be taken for granted. (Exception laid down in section 53(1) CrPC.

4. Except for during clinical trials, there is no legal requirement for providing informed consent regarding the administration of vaccines.

5. Written consent & counselling is required for testing blood for HIV.

6. A clinical researcher has to get an informed consent from a research participant before enrolling that person into clinical trial. This needs to be collected according to guidelines from the fields of Medical Ethics & Research Ethics.

7. If Genetic testing is considered, the patient & the family member should be informed about the potential implications of positive result, including psychological distress & the possibility of discrimination. The patient or caretaker should be informed about the meaning of negative result, technical limitations & the possibility of false negative & inconclusive results. For these reasons genetic testing should only be performed after obtaining informed consent. Genetic testing should usually be limited to situations in which the results may have an impact on the MEDICAL MANAGEMENT.

The patient must fully understand the risks, benefits, & limitations undergoing the analysis.

Informed consent should include a written document, drafted clearly & concisely in a language & format that is comprehensible to the patient, who should be made aware of the disposition of the test results. It should also include ta discussion of the mechanics of testing. Most molecular testing for hereditary disease involves DNA-based analysis of peripheral blood. In the majority of circumstances, test results should be given only to the individual in person & preferably with a support person in the room.

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practitioner. Under section 54 CrPC, an arrested person may be examined by a doctor at his request to detect evidence in his favour.

TABLE NO. 3

SITUATIONS WHERE THE CONSENT IS NOT REQUIRED

i. In emergency, i.e. patient is not in a condition to give consent and there is no one accompanying the patient to give consent, but condition warrants immediate treatment / surgery, to save life can be done without consent. A witness / colleague must be consulted and documented with signature by the medical officer.

ii. Patient cannot give consent; no one accompanying the patient in emergency, life saving procedures are carried out without consent.

iii. In emergency- surgical operations do not go beyond the minimum required to save life.

What constitutes informed consent.For Surgeons—the word “Informed” is important---Because of the extremity of the clinical need, patients might agree to surgery on the basis of no information at all. Agreement of this kind however does not constitute a form of consent that is morally or legally acceptable. Worse still, if the patients are given no information, their subsequent choices may be based on misunderstanding, and lead to plans & further decisions, that they would not have otherwise made.

Appropriate & accurate information before surgery. It should include -1. The condition & reason why he warrants

surgery,2. The proposed surgery type & how it will

correct the condition.3 . Anticipated prognosis, & expected side-effects

of the proposed surgery.4. Unexpected hazards of proposed surgery.

8. The consent must not be obtained by fraud, undue pressure or duress. It must be free, voluntary, and given after a full explanation of the reasons for which it is required. (Informed Consent).

9. In any case where there could possibly be any doubt, written consent should be obtained.

10. The consent should be broad enough to cover everything contemplated as likely to be required but the so-called blanket consent forms should be avoided. It is also usual to point out that the procedure need not be carried out by any particular doctor as this aspect has given rise to court proceedings in some cases.

11. Consent should be obtained from the parent or guardian where a person is incapable, through age or through lack of understanding, of giving a valid consent. In India, a person of above 18 years of age can give consent to medical examination & treatment.

12. When consent has been obtained, the examination should whenever possible, be made in presence of a third person, preferably a female nurse, especially while a male doctor is examining a female patient & Vice versa.

13. In any procedure affecting the right’s of a spouse, e.g. Sterilisation, hysterectomy, artificial insemination, etc informed consent from such spouse should also be obtained.

14. Under section 53(1) of Criminal Procedure Code, an accused can be examined by a medical practitioner at the request of the police, even without his consent, and by use of force, if there is reasonable ground to believe that such examination will afford evidence, as to the commission of an offence.

This examination may include taking of fluids in cases of intoxication, etc. Section 53(2) lays down that whenever a female patient is to be examined, the examination shall be made only by, or under the supervision of, a female registered medical

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5. Any alternative and potentially successful treatments other than proposed surgery.

6. Consequences of no treatment or no surgery at all.

Where possible how to explain ---A. Quiet place for discussion.B. Written material in patient’s preferred language

to supplement verbal communication,C. Patient should be given time to think-before

making decisions.D. The person obtaining the consent should

ideally be the surgeon who will carry out the treatment. It should not be –as sometimes the case—a junior member of the team/ staff who has never conducted such a procedure & thus may not have enough understanding to counsel the patient properly.

GOOD COMMUNICATION SKILLS go hand in hand with properly obtaining informed consent for surgery. Asking patients if they have any doubts or further questions.Maintaining the confidentiality of the patient need not be overemphasised.

There is no obligation to provide or to continue life sustaining treatment. If doing so is futile - it will not achieve goal

of extending life If patients are imminently and irreversibly

close to death If patients are so permanently and seriously

brain damaged that, lacking awareness of themselves and others, they will never be able to engage any form of self directed activity.

All these circumstances should be recorded in patient’s medical record along with a note of another senior clinician’s agreement.

TABLE NO.4.

WHEN DO CONSENTS BECOMEINVALID ?

i. For criminal abortion or criminal operation - since it is a crime - consent is invalid.

ii. Consent by minor or mentally ill. iii. For sterilization – consent of both partners

should be taken. iv. For MTP - Patient should be more than

18 years to give consent by her self – otherwise invalid.

v. For artificial insemination – consent of both partners of recipient and donor has to be taken. Donor’s Anonymity is maintained.

vi. Request of police officer for examination. No officer can force medical examination. It legally amounts to assault or battery. Subject to exception under section 53 (1) CrPC.

vii. Employer cannot force an unwilling employee to submit for medical examination.

viii. For organ transplantation - Consent should have been obtained when patient was alive for actual removal of organs from dead body. Consent of the kin is necessary.

ix. In criminal cases the victim cannot be examined without consent. In any medico legal case an individual cannot be forced for medical examination.

x. Consent obtained by fraud or intoxicated person – is invalid.

Referecnces :1. Bailey & Love’s Short Practice of Surgery,

25th Ed. 2008.2. Harrison’s principles of Internal Medicine,

18th Ed. 2012.3. Parikh’s Textbook of Medical Jurisprudence,

Forensic Medicine & Toxicology. 6th Ed. 2000.

4. Legal First Aid (Oxford Healthcare Communication).

5. Internet.

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Amnbr _wbo gwa{jV AmhoV H$m ?gm¡. d¡embr \$UgiH$a *

AmO àË`oH AmB© d{S>bm§À`m _ZmV hmM àíZ Amho, H$m ~a§? doJdoJù`m ñVamVrb nmbH$m§Zm AmO hm àíZ J§^ra dmQ>Vmo`, Ë`mMr àË`oH$ {R>H$mUr MMm© Mmby Amho.

nwÊ`m_Yrb XmoZ Zm_d§V emim§_Ü`o ñHy$b~g_Ü`o EH$m ZD$ dfm©À`m, Am{U EH$m Ad¿`m Mma dfm©À`m _wbrda AË`mMma Pmbo. ~mV_r dmMyZ gJù`m§À`mM Vrd« à{V{H«$`m C_Q>ë`m. Ë`mM emioVrb _wbtMo nmbH$ YmñVmdbo. AmO ømM OmJr Amnbr _wbJr AgVr Va? `m H$ënZoZo, ^rVrZo gJio nmbH$, {ejH$hr hmXabo. amJmdyZ g§VmnyZ Ë`m§Zr emioda _moMm© Zobm. AnamYr S´>m`ìha ŠbrZabm ~oX_ _ma {Xbm d nmo{bgm§À`m ñdmYrZ Ho$bo. Xþgè`m {Xder _wbtZm emioV nmR>dVmZm gJù`m _wbm§À`m nmbH$m§_Ü`o hrM {^Vr {Xgbr H$s AmVm _wbtZm emioV H$g§ nmR>dm`M§? AmB© ZmoH$ar H$aV Agob AWdm Kar Agob Var amoO _wbm§Zm ñdV: emioV gmoS>Uo, AmUUo eŠ` Amho H$m? ̀ m {Z{_ÎmmZo _Zm_Ü`o àíZm§Mo H$mhÿa CR>bo! hm àíZ Ho$di emionwaVm, OmÊ`m`oÊ`mMr ~g/ìh°Z AWdm nmiUmKa BVH$mM _`m©{XV Amho H$m? hm àíZ Ho$di _wbtnwaVm _`m©{XV Amho H$m? _wbo gwa{jV AmhoV H$m? Z¸$sM Zmhr. `m KQ>ZoÀ`m {Z{_ÎmmZo AZoH$ boI Ambo, AZoH$ à{V{H«$`m ì`ŠV$ Pmë`m nU {df` BWo g§nVmo H$m? gË` n[apñWVr Aer Amho H$s _wbtBVH$sM bhmZ _wbohr Agwa{jV AmhoV. b¢{JH$ AË`mMmamMo ~ir _wbr§ BVHo$M

*Medical Social Worker.

_wbohr AmhoV. dV©_mZnÌm_Ü`o Amnë`mbm XaamoO EH$Var ~mV_r dmMm`bm {_iVo Á`mV _wbm§darb AË`mMmamMr ~mV_r AgVo.

AmO emioÀ`m ~g_Ü`o KS>boë`m `m XmoZ KQ>Zm! `mMm AW© _wbo Amnë`m KamV gwa{jV AmhoV H$m? Z¸$sM Zmhr. Joë`mM AmR>dS>çmV EH$ ~mV_r dmMbr, {nË`mH$Sy>Z _wbrda ~bmËH$ma! AmB©À`m {ZYZmZ§Va Jobr VrZ df} hm ZamY_ Amnë`mM _wbrda AË`mMma H$aV hmoVm. Ë`mZo {Z_m©U Ho$boë`m XheVr_wio {VZo H$moUmg_moa dmÀ`Vmhr Ho$br Zmhr.

AmO AZoH$ KQ>Zm AmnU dmMVmo, M°Zobdarb ~mVå`m§ _Ü`o Ë`mMr H$hmUr a§JdyZ a§JdyZ XmIdVmV. Aaoao {~Mmar _wbJr? H$m` Xþï> _mUyg Amho hm? Aem Vrd« à{V{H«$`m EoH$m`bm {_iVmV. Ë`mZ§Va nwT>o H$m`? ho gJi§ Ag§M MmbV amhUma H$m? AmO `m KQ>Zm§da, AË`mMmam§~Ôb CKS>nUo, OmhranUo MMm© AmnU H$aVmo`. `mMm AW© nydu Ago AË`mMma hmoV ZìhVo H$m? XþX]dmZo `mMo CÎma Amho "hmo hmoV hmoVo'. A{Ve` dmB©Q> Jmoï> åhUOo ho AË`mMma AmoiIrVë`m, ZmË`mVë`m ì`ŠVtH$Sy>ZM hmoV hmoVo! AOyZhr hmoV AmhoV. gmYmaUnUo bhmZnUmnmgyZ, åhUOo H$im`bm bmJë`mnmgyZM AmnU _wbm§Zm {eH$dV AgVmo H$s AZmoiIr bmoH$m§er ~moby Z`o/H$moUr Mm°H$boQ>/ImD$ {Xbm Var KoD$ Z`o. bhmZ _wbo hr CnOVM AZmoiIr _wbm§Zm Km~ê$Z amhVmV Am{U Ë`m_wio Ë`m§À`mOdi OmV ZmhrV. nU AmoiIrÀ`m

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bmoH$m§Mo H$m`? Ë`m§À`mH$S>o Va _wbo bJoM OmVmV Am{U AZoH$Xm AË`mMmambm ~ir nS>VmV. Aem {d{dY KQ>Zm EoH$ë`m H$s Ë`mÀ`m _wimer OmD$Z à{V~§YmË_H$ Cnm` H$m` H$aVm `oVrb. `mMm {dMma H$amdmgm dmQ>bm. `m_Ü`o nmbH$, {ejH$, eoOmarb ì`ŠVr gJù`m§MmM g_mdoe Agob.

nwÊ`mVrb XmoZ emim§_YyZ KS>boë`m KQ>Zm§Z§Va {d{dY Vkm§Zr Amnbr _Vo ì`ŠV Ho$br AmhoV. `mV {d{dY nmVitda H$m_ H$am`Mr Amnë`mbm JaO Amho. gdm©V àW_ O~m~Xmar Amho Vr nmbH$m§Mr.

l Amnë`m _wbmda ~maH$mB©Zo bj R>odm. Ë`mÀ`m dV©ZmV, ImÊ`m {nÊ`mV H$mhr ~Xb hmoV AmhoV H$m `mda bj Agy Úm.

l Eadr emioV AmZ§XmZo CËgmhmZo emioV OmUmar _wb§ emioV Om`bm Q>miV AmhoV H$m? `mMo H$maU emoYm`bm Amnë`m _wbm§er g§dmX AgUo Iyn _hËdmMo AmhoV.

l A{Ve` _hÎdmMr Jmoï> åhUOo _wbm§Zm "Mm§Jbm' d "dmB©Q>' ñne© AmoiIm`bm {eH$dm. EImXr ì`ŠVr AmoiIrMr qH$dm AZmoiIr ZH$moem nÜXVrZo ñne© H$aV Agob Va Ë`mMm à{VH$ma H$gm H$amb ho$_wbm§Zm {eH$dbo nm{hOo, _hÎdmM§ åhUOo Aem H$moUË`mhr KQ>Zo~Ôb Amnë`m AmB©d{S>bm§Zm Ë`m§Zr gm§{JVbo nm{hOo ho hr Ë`m§Zm {eH$dm.

X¡Z§{XZ OrdZmV Amnë`m _wbm§er gwg§dmX AgUo `mgmR>r A{Ve` Oê$arMo Amho. {Xdg^amÀ`m ì`ñV {XZH«$_m_wio AmOH$mb nmbH$m§Zm _wbm§~amo~a A{Ve` H$_r doi AgVmo. Á`m_wio Amnbm g§dmX ahmV Zmhr. bhmZ _wbm§Mr AI§S> ~S>~S> Mmby AgVo nU Vr dm`\$i Z g_OVm Ë`mÀ`m àË`oH$

gm§JÊ`mbm AmnU Oa _hÎd {Xbo, ZrQ> EoHy$Z KoVbo Va _wbm§Zmhr dmQ>Vo H$s AmB© - d{S>bm§H$Sy>Z H$mhrVar XIb KoVbr OmV Amho.

_wbm§gmR>r nwaogm doi d Ë`mMm XOm© Mm§Jbm AgUo Iyn _hÎdmMo Amho ~è`mMXm _wbm§À`m dV©ZmV \$aH$ {XgVmo. H$mhr doim _wb§ A{Ve` AmH«$_H$ hmoVmV, gmÜ`m gmÜ`m Jmoï>tZr {MS>VmV, amJdVmV. emioV Om`bm Ìmg XoU, A§Wê$U Amob H$aU§, PmonoVyZ XMHy$Z CR>Z§, em§V Pmon Z bmJU§. H$mhr doiog _wb§ \$maM em§V hmoVmV. {_Ì _¡{ÌUr qH$dm H$moUË`mhr ZmVodmB©H$m§Zm Z ^oQ>Uo, EH$Q>o amhUo Agohr ~Xb {XgyZ `oVmV. EH$ OmJê$H$ nmbH$ åhUyZ AmB© dS>rbm§Zr `mda Vkm§Mm g„m KoVbm nm{hOo. _mZgmonMma Vk, _Zmo{dH$ma Vk qH$dm bhmZ _wbm§da hmoUmè`m AË`mMmam§g§~§Yr H$m`© H$aUmè`m g§ñWm§Mr _XV KoVbr nm{hOo. Amnë`m _wbmda H$moUmH$Sy>Z AË`mMma Pmbm Amho `mMr ImÌr nQ>VmM JaO Agë`mg nmobrgm§Mr qH$dm H$m`XoVkm§Mr _XV KoVbr nm{hOo.

nmbH$m§Zr OmJê$H$ Va ahm`bmM hd§ nU `mMm A{VaoH$ hmoUma Zmhr `mMr H$miOrhr ¿`m`bm nm{hOo, ZmhrVa A{VH$miOr, {^VrnmoQ>r _ZmV gVV g§e`mMo ^yV amhrb d ñdV:Mo _Z:ñdmñÏ` hadyZ ~gmb.

emim d {ejH$m§Mr O~m~Xmar :

_wbtda ZwH$Ë`mM KS>boë`m AË`mMmamÀ`m KQ>ZoZ§Va bjmV Amb§ H$s emim§Zr gwa{jVVoMo AZoH$ {Z`_ nmibo ZìhVo. H$m`Xoera ~m~tMr nyV©Vm Ho$br ZìhVr. nmbH$m§à_mUoM {ejH$m§Zrhr gwg§dmX H$aUo _hËdmMo Amho.

{ejH$m§Mr ^y{_H$m :

ñHy$b ~g_Ü`o Pmboë`m AË`mMmamÀ`m KQ>ZoZ§Va gdmªZr

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EH$_wImZo _{hbm _XVZrg AgÊ`mMr _mJUr Ho$br Amho. Or Jmoï> H$m`ÚmZo ~§YZH$maH$ Amho {VMr nyV©Vm H$aÊ`mg AmO Omoa bmdÊ`mMr JaO nS>V Amho. X¡Z§{XZ Aä`mg, Aä`mgmì`{V[aŠV BVa Jmoï>tgmR>r {ejH$m§Zm doi XoUo ~§YZH$maH$ Amho. nmbH$m§BVHo$M {ejH$hr _wbm§À`m OdiMo AgVmV. _wbm§Mm {dœmg g§nmXZ H$ê$Z Ë`m§Zr _wbm§er g§dmX gmYë`mg _wbohr _moH$ionUmZo ~mobm`bm {eH$Vrb d H$moUË`mhr ÑîQ>çm Ë`m§Zm Agwa{jV dmQ>ë`mg {ejH$m§er ~mobVrb.

g§ñWmMmbH$m§Zrhr _wbm§À`m gwa{jVVo g§~§YrÀ`m {Z`_m§Mo H$mQ>oH$moanUo nmbZ Ho$ë`mg Aem àH$maÀ`m KQ>Zm Z¸$sM Q>miVm `oVrb. ñHy$b ~gÀ`m MmbH$mMr, _XVZrgmMr g§nyU© Mm¡H$er H$ê$ZM Zo_UyH$ H$amdr.

H$m`ÚmMr ^y{_H$m :

H$moUË`mhr JwÝømda {Z`§ÌU R>odUo H$Yr eŠ` Amho ? Oa Ë`m JwÝømgmR>r H$R>moa {ejm Agob Va Am{U _hËdmMo åhUOo H$m`ÚmMr A§_b~OmdUr hmoV Amho Zm! ~aoMgo JwÝhoJma AmO amOamognUo {\$aVmZm {XgVmV. Ë`m_wio AË`mMma H$ê$Z COi _mÏ`mZo dmdaUmè`m§Zm XheV ~gob Aer {ejm Pmbr nm{hOo. VaM Aem VèhoZo dV©Z H$aÊ`mnydu Vr ì`ŠVr Z¸$sM {dMma H$aob.

ZwH$VmM ""bhmZ _wbm§darb b¢{JH$ emofU{damoYr H$m`Xm 2012'' hm ApñVËdmV Ambm Amho. `m H$m`ÚmÀ`m à^mdr A§_b~OmdUrZo ho JwÝho Z¸$sM {Z`§ÌUmV R>odVm `oVrb.

Agm gdmªJrU {dMma H$ê$Z _wbm§darb AË`mMmambm à{V~§Y H$aUo Z¸$sM eŠ` hmoB©b.

q q q

• Rajan went to Shanghai. He fell ill so he called up the hotel manager and asked if he knew the best doctor of the city. The manager said, ‘If you want my advice it’s Doctor Xu who is the best.’

When Rajan asked him why, he explained, ‘You see, once I got wet in the rain. I started sneezing so I rushed to Doctor Su. After his treatment I got the cough. Then I was rushed to Doctor Cu, whose pills did not work either and the cough turned into a severe fever. Then I was sent to Doctor Fu and it became acute hyperthermia. After that I was sent to Doctor Hu; his treatment made it pneumonia. At last my family took me to Doctor Xu. They said he was out of town and my life was saved.’

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