July 4  2015, Saturday
eMedinewS
editorial
Folic Acid Update
Dr KK Aggarwal
  • Folic acid (vitamin B9) is a water–soluble B vitamin.
  • It is lost in traditional Indian cooking.
  • Folic acid is essential for DNA repair, cell division and normal cellular growth.
  • Profound deficiency of folic acid during pregnancy is associated with neural tube defects, such as spina bifida in neonates.
  • Deficiency in adults has been associated with megaloblastic anemia and peripheral neuropathy.
  • In both men and women, low serum folate levels can increase homocysteine levels, which are correlated with elevated cardiovascular risk.
  • Low folic acid levels during pregnancy in women with epilepsy have been associated with fetal malformation, and older enzyme–inducing anti-epileptic drugs are known to reduce serum folate levels.
  • The risk of having a pregnancy complicated by a major congenital malformation (e.g., neural tube defect) is doubled in epileptic women taking anti epileptic drugs compared with those women with a history of epilepsy not taking these agents.
  • Risk is tripled with anti–epileptic drugs polypharmacy, especially when valproic acid is included.
  • Consensus statements recommend 0.4–0.8 mg of folic acid per day in all women planning a pregnancy. Ideally, this should be started at least 1 month prior to pregnancy if possible.
  • The guidelines recommend higher daily folic acid doses (4 mg/day) in women with a history of neural tube defects.
  • In addition, enzyme–inducing anticonvulsants, such as phenytoin, carbamazepine, primidone and phenobarbital, are known to decrease folate levels, and valproic acid may interfere with folate metabolism.
  • Other AEDs, such as oxcarbazepine, lamotrigine and zonisamide, do not appear to alter folate levels.
  • Because many pregnancies are unplanned, it is recommended that folic acid supplementation be given routinely to all women of childbearing potential at 0.4 mg/day.
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IMA COURTALLAM -Doctors Day Celebration
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TRENDO 2015
The 3rd Annual meeting of the Endocrine Society of Tamil Nadu and Puducherry will be held in Kodaikanal on 11th and 12th of July 2015. TRENDO 2015 is proposed to address latest updates, emerging concepts, clinical applications and controversies in diabetes, thyroid disorders, gonadal problems, pituitary disorders, metabolic bone disease and adrenal diseases.
News
  • The US Food and Drug Administration (FDA) has approved the first drug for cystic fibrosis (CF) directed at cause of the disease in individuals with two copies of the F508del mutation. The drug combines ivacaftor with lumacaftor and is indicated for patients with CF aged 12 years and older.
  • Current chronic obstructive pulmonary disease (COPD) management programs and guidelines overdiagnose elderly patients and underdiagnose young ones, reported an analysis published online July 1 in the BMJ. The authors call for the adoption of lower limits of normal (LLN) criteria for airflow obstruction that are specific for different populations.
  • Patients with psoriasis who experience bone or joint trauma have a significantly increased risk for psoriatic arthritis than patients not exposed to such trauma, suggested a population-based cohort study presented at the European League Against Rheumatism Congress 2015.
  • Women with a history of anorexia have lower tibial volumetric bone mineral content and lower maximal muscle force even decades later, reports new research published in the Journal of Clinical Endocrinology and Metabolism.
  • Adding a novel immunotherapy to gemcitabine extends survival in patients with pancreatic cancer, especially those with metastatic disease, and maintains and might improve quality of life, suggests new research presented at the 17th World Congress on Gastrointestinal Cancer.
Cardiology eMedinewS
  • The Clinical and Economical Interest of Endovascular Cooling in the Management of Cardiac Arrest (ICEREA) randomized controlled trial suggested that there were no significant differences between those who underwent cooling with an endovascular femoral device and those who underwent basic external cooling on rates of survival without major neurological damages 28 days after the event (the primary end point) or on improvement of favorable outcome at day 90. The findings were published online in Circulation.
  • A new algorithm created by engineering experts at the University of Lincoln, UK, provides more effective Electrocardiogram (ECG) diagnosis for people with heart conditions. The research improves ECG signal classification and improved abnormality detection and diagnosis.
Pediatrics eMedinewS
  • Children with Attention Deficit Hyperactivity Disorder (ADHD) may be successfully supported in classrooms through strategies that do not involve drugs, suggests new research published in the journal Health Technology Assessment.
     
  • A new study indicates that an extra year of secondary schooling could significantly reduce the risk of HIV contraction and could also be a cost-effective strategy for preventing HIV infection. The study is published in The Lancet Global Health.
Dr KK Spiritual Blog
Music as a medicine

Our body is the largest pharmaceutical group in the world and has the capacity to heal each and every disease. The very fact that there is a receptor for every drug in the body means that the body has the capacity to produce that drug. Music is one such modality, which can heal by initiating various chains of chemical reactions in the body.
  • Chanting vowels produces interleukin 2 in the body, which works like a painkiller.
     
  • Chanting nasal consonants produces tranquilizers in the body.
     
  • Sounds like LUM are associated with fear, VUM with attachments, RUM with doubt, YUM with love, HUM with truthfulness and AUM with non–judgmental.
     
  • Various chemicals can be produced in the body by chanting of various vowels and consonants.
     
  • Nasal consonants are vibrant sounds and produce vibrations of the autonomic plexus causing balance between sympathetic and parasympathetic states. More the nasal consonants in music, the more will be its relaxing healing power.
     
  • Listening to overtone chanting in music can also heal people in the vicinity of the music.
     
  • Recitation of music can also increase or decrease the respiratory rate of the singer. Lyrics that reduce respiratory rate will lead to parasympathetic healing activity. The respiratory rate of a listener too can increase and decrease if he is absorbed in the song.
     
  • Listening to a song word by word and by understanding its meaning can also change the biochemistry of the listener. A song can create an excitement or a feeling of depression.
     
  • A song can also work like intent by speaking in the form of prayers. Group prayers can have powerful affects and convert intent into reality through the concept of spontaneous fulfillment of desire.
     
  • Music is often linked with dance, both classical and western, which provides additional healing.
     
  • Gestures, mudras, bhavs and emotions associated with songs produce parasympathetic state in both the singer and the listener.
Inspirational Story
A life that makes a difference

An elderly nurse believed there was hope, however, and she made it her mission to show love to the child. Every day she visited Little Annie. For the most part, the child did not acknowledge the nurse’s presence, but she still continued to visit. The kindly woman left cookies for her and spoke words of love and encouragement. She believed Little Annie could recover, if only she were shown love. Eventually, doctors noticed a change in the girl. Where they once witnessed anger and hostility, they now noted an emerging gentleness and love. They moved her upstairs where she continued to improve. Then the day finally came when this seemingly "hopeless" child was released.

Anne Sullivan grew into a young woman with a desire to help others as she, herself, was helped by the loving nurse. It was she who saw the great potential in Helen Keller. She loved her, disciplined her, played with her, pushed her, and worked with her until the flickering candle that was her life became a beacon of light to the world. Anne Sullivan worked wonders in Helen’s life, but it was a loving nurse who first believed in Little Annie and lovingly transformed an uncommunicative child into a compassionate teacher. "If it had not been for Anne Sullivan, the name of Helen Keller would have remained unknown." But if it had not been for a kind and dedicated nurse, the name of Anne Sullivan would have remained unknown. And so it goes. Just how far back does the chain of redemption extend? And how for forward will it lead?

Those you have sought to reach, whether they be in your family or elsewhere, are part of a chain of love that can extend through the generations. Your influence on their lives, whether or not you see results, is immeasurable. Your legacy of dedicated kindness and caring can transform lost and hopeless lives for years to come.

You can never overestimate the power of your love. It is a fire that, once lit, may burn forever.
Media
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Wellness Blog
Reduce liquids to reduce weight

When it comes to losing weight, cut down on liquid calories rather than food.

"Weight loss from liquid calories is greater than loss of calorie intake from solid food, as per Dr. Liwei Chen, an assistant professor of epidemiology at the School of Public Health at the LSU Health Science Center in New Orleans, in the American Journal of Clinical Nutrition.

Body is able to self–regulate its intake of solid food. If you eat too much solid food at lunch, you’ll tend to eat less at dinner. But the same self–regulation is not in place for what you drink. The body does not adjust to liquid calories, so over time, you gain more weight.

Cutting back on calories from sugary drinks–by only one serving per day–can account for nearly two–and–a–half pounds of lost weight over 18 months.

Beverages are categorized into eight categories
  1. Sugar–sweetened beverages (including soft drinks, fruit drinks, fruit punch, or high–calorie beverages sweetened with sugar)
  2. Diet drinks such as diet soda and other diet drinks that were artificially sweetened
  3. Milk (including whole milk,2 percent milk, and 1 percent skim)
  4. 100 percent fruit and vegetable juice
  5. Coffee and tea with sugar
  6. Coffee and tea without sugar
  7. Alcoholic beverages
  8. Water with no calories
The best drinks are water, plain soda and tea/coffee with no sugar.
Events
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Make Sure
Situation: A known epileptic child died of a seizure while swimming.

Reaction: Oh my God! Why was he allowed to swim?

Lesson: Make sure that patients with uncontrolled epilepsy are not allowed to swim.
Dr Good Dr Bad
Situation: A patient with diarrhea was found to have increased pulse rate.

Dr. Bad: Nothing to worry.

Dr. Good: You have fluid deficiency.

Lesson: Increased heart rate is the first sign of hemodynamic decompensation.

(Copyright IJCP)
eMedi Quiz
Raised serum level of lipoprotein (a) is a predictor of:

1. Cirrhosis of liver.

2. Rheumatic arthritis.

3. Atherosclerosis.

4. Cervical cancer.

Yesterday’s Mind Teaser: Commonest cause of sporadic encephalitis is:

1. Japanese B virus

2. Herpes simplex virus.

3. Human immunodeficiency virus.

4. Rubeola virus.

Answer for yesterday’s Mind Teaser: 2. Herpes simplex virus.

Correct Answers received from: Prabha Sanghi, Dr Sushma Chawla, Dr Jainendra Upadhyay, Dr Bitaan Sen & Dr Jayashree Sen, Dr K Raju, Daivadheenam Jella, Dr Nikhil Mohanty, Dr Avtar Krishan.

Answer for 2nd July Mind Teaser: 3. No surgery for gallbladder stones.

Correct Answers received: Dr Jainendra Upadhyay, Dr Pravin H Patel, Dr Pandit Hantodkar, Dr Avtar Krishan.
eMedinewS Humor
Sales Practice

The out–of–work newlywed took a temporary job as a vacuum cleaner salesman to make ends meet. After 3 days of intensive training, the sales manager told him to go home and practice his pitch on his wife.

The next morning, the manager asked the novice how he made out.

"Well," the man began, "I did what you said, and after I finished, I asked her if she would buy the vacuum cleaner from me. She said ‘Yes.’ Then I asked her ‘Why?’ She replied, ‘Because I love you.’"
Quote of the Day
Hard work beats talent when talent fails to work hard. Kevin Durant
Reader Response
Dear Editor, I strongly disagree with the view that antihypertensive medicines should be given at night. Dr Sohan Singh Hayreh, an Ophthalmologist who has worked lifelong on Ocular circulation, has shown in multiple, extensive studies, that such regimen only worsens the natural nocturnal hypotension. When blood pressure plummets to dangerously low levels at night it hampers blood perfusion and precipitates anterior ischemic optic neuropathy and consequent visual loss. Trying to achieve reduction of cardiac mortality, you would only increase the ocular morbidity and worsen quality of life, since vision is equated with life! Aggressive blood pressure management has led to an increase in "Low Tension Glaucoma", Vascular Optic atrophy and other conditions which were rarer in past generations. Please use logical caution before embarking on such a dangerous regimen. Regards: Dr Hemang
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Rabies News (Dr A K Gupta)
Can the wound be deepened for cleaning purpose?

We should never try to deepen the bite wound. Deepening of wound for cleaning depends on area of injury, extent of injury and the aim should be to preserve as much tissue as possible and to excise only the dead tissue.
IJCP Book of Medical Records
IJCP’s ejournals
CPR 10
Total CPR since 1st November 2012 – 101090 trained
Video of the Day
Sameer Malik Heart Care Foundation Fund
The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number or by filling the online form.

Madan Singh, SM Heart Care Foundation Fund, Post CAG

Kishan, SM Heart Care Foundation Fund, Post CHD Repair

Deepak, SM Heart Care Foundation Fund, CHD TOF
Press Release
Obesity is a disease

Any weight gain after the age of 18 years in females and 20 years in males is obesity unless proved otherwise.

Also any weight gain after the age of 35 years and after the age of 50 years is considered obesity.

"Obesity is a disease and should be tackled under the supervision of doctors", said Padma Shri, Dr B C Roy & DST National Science Communication Awardee, Dr K K Aggarwal, President Heart Care Foundation of India and Hony Secretary General Indian Medical Association.

Obesity can be managed either by eating low refined carbohydrates, low fat and or low calories diet. Exercise alone without dietary modification usually fails. The need for surgery in obesity arises only if the lifestyle and medical management fails.

Anti-obesity drugs are often need to be added to facilitate weight reduction in individuals with comorbid conditions.

A 10% weight reduction can reduce the need of anti–BP medicines by 50% and anti diabetes drugs by upto 40%.

It is possible to get rid of such diseases in some cases merely by weight reduction. Weight reduction can also reduce the severity of snoring. Obese people have more blood pressure, snoring, osteoarthritis and cancer.
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eIMA News
WMA Urges Australian Government to reconsider attempt to silence physicians
The World Medical Association has called on the Australian Government to allow doctors to speak out about the health of asylum seekers held in Australian detention centres.

In a letter to Australia's Prime Minister Tony Abbott, the WMA's President Dr. Xavier Deau and Chair Dr. Ardis Hoven say that the recent Australian Border Force Act effectively silences physicians who address the health conditions of asylum seekers. The legislation imposes a penalty of two years' imprisonment on any person, doctor or otherwise, who discloses information obtained by that person while working as an employee of a service provider to the relevant Government Department, namely Immigration and Border Protection.

In their letter, the WMA leaders say: ‘This we must assume extends to doctors working in refugee centres who report on their observations arising from their work.

‘This is in striking conflict with basic principles of medical ethics. Physicians have to raise their voice, if necessary publicly, when health conditions of their patients, be those free or in detention, are unacceptable. From the incoming reports we must assume that this is the case in the detention centres under the responsibility of the Australian Government. We applaud and support those colleagues who advocate for their patients and speak out.

‘We support the motion by the Australian Medical Association National Conference calling on the Australian Government to amend the legislation to provide an exemption for public interest disclosure. Nothing less would be appropriate for a democratic state.'

Commenting on the letter, Dr. Deau said: ‘This is effectively an attempt by the Australian government to gag physicians by making their advocacy for the health care of asylum seekers in Australian detention camps a criminal offence. Such a procedure is not acceptable‘.
IN THE SUPREME COURT OF INDIA CIVIL APPELLATE JURISDICTION
CIVIL APPEAL No. 8065 OF 2009

V. KRISHNAKUMAR .. APPELLANT

VERSUS
STATE OF TAMIL NADU & ORS. ..RESPONDENTS
With CIVIL APPEAL No. 5402 OF 2010
JUDGMENT
S. A. BOBDE, J.

These two Civil Appeals are preferred against the judgment of National Consumer Disputes Redressal Commission (hereinafter referred to as the `NCDRC') rendering a finding of medical negligence against the State of Tamil Nadu, its Government Hospital and two Government Doctors and awarding a sum of Rs.5,00,000/- to V. Krishnakumar. Civil Appeal No. 8065 of 2009 is preferred by V. Krishnakumar for enhancement of the amount of compensation. Civil Appeal No. 5402 of 2010 is preferred by the State of Tamil Nadu and another against the judgment of the NCDRC. As facts of both the appeals are same, we are disposing the appeals by this common judgment.

2. On 30.8.1996, the appellant V. Krishankumar's wife Laxmi was admitted in Government Hospital for Women and Children, Egmore, Chennai (hereinafter referred to as the "Hospital"). Against the normal gestation period of 38 to 40 weeks, she delivered a premature female baby in the 29th week of pregnancy. The baby weighed only 1250 grams at birth. The infant was placed in an incubator in intensive care unit for about 25 days. The mother and the baby were discharged on 23.9.1996. A fact which is relevant to the issue is, that the baby was administered 90-100% oxygen at the time of birth and underwent blood exchange transfusion a week after birth. The baby had apneic spells during the first 10 days of her life. She was under the care of Respondent No.3 - Dr. S. Gopaul, Neo-paediatrician and Chief of Neonatology Unit of the Hospital and Respondent No.4 - Dr. Duraiswamy of the Neonatology Unit of the Hospital. The Respondent No.2 is the Director of the Hospital, which is established and run by the Respondent No.1 - State of Tamil Nadu under the Department of Health.

3. The baby and the mother visited the hospital on 30.10.1996 at the chronological age of 9 weeks. Follow up treatment was administered at the home of the appellant by Respondent No.4, the Government Doctor, Dr. Duraiswamy during home visits. The baby was under his care from 4 weeks to 13 weeks of chronological age. Apparently, the only advice given by Respondent No.4 was to keep the baby isolated and confined to the four walls of the sterile room so that she could be protected from infection. What was completely overlooked was a well known medical phenomenon that a premature baby who has been administered supplemental oxygen and has been given blood transfusion is prone to a higher risk of a disease known as the Retinopathy of Prematurity (hereinafter referred to as ‘ROP’), which, in the usual course of advancement makes a child blind. The Respondent No.3, who was also a Government Doctor, checked up the baby at his private clinic at Purassaiwakkam, Chennai when the baby was 14-15 weeks of chronological age also did not suggest a check up for ROP.

4. One thing is clear about the disease, and this was not contested by the learned counsel for the respondents, that the disease occurs in infants who are prematurely born and who have been administered oxygen and blood transfusion upon birth and further, that if detected early enough, it can be prevented. It is said that prematurity is one of the most common causes of blindness and is caused by an initial constriction and then rapid growth of blood vessels in the retina. When the blood vessels leak, they cause scarring. These scars can later shrink and pull on the retina, sometimes detaching it. The disease advances in severity through five stages - 1, 2, 3, 4 and 5 (5 being terminal stage). Medical literature suggests that stage 3 can be treated by Laser or Cryotherapy treatment in order to eliminate the abnormal vessels. Even in stage 4, in some cases, the central retina or macula remains intact thereby keeping intact the central vision. When the disease is allowed to progress to stage 5, there is a total detachment and the retina becomes funnel shaped leading to blindness. There is ample medical literature on the subject. It is, however, not necessary to refer all of it. Some material relevant to the need for check up for ROP for an infant is:
“All infants with a birth weight less than 1500 gms or gestational age less than 32 weeks are required to be screened for ROP.”1

1AIIMS Report dated 21.8.2007

Applying either parameter, whether weight or gestational age, the child ought to have been screened. As stated earlier, the child was 1250 gms at birth and born after 29 weeks of pregnancy, thus making her a high risk candidate for ROP.

5. It is undisputed that the relationship of birth weight and gestational age to ROP as reproduced in NCDRC's order is as follows:

“Most ROP is seen in very low-birth weight infants, and the incidence is inversely related to birth weight and gestational age. About 70-80% of infants with birth weight less than 1000 gms show acute changes, whereas above 1500 gms birth weight the frequency falls to less than 10%.”

6. Again, it seems that the child in question was clearly not in the category where the frequency was less than 10% since the baby was below 1500 gms. In fact, it is observed by the NCDRC in its order that the discipline of medicine reveals that all infants who had undergone less than 29 weeks of gestation or weigh less than 1300 gms should be examined regardless of whether they have been administered oxygen or not. It is further observed that ROP is a visually devastative disease that often can be treated successfully if it is diagnosed in time.

7. The need for a medical check up for the infant in question was not seriously disputed by the respondents.

8. The main defence of the respondents to the complaint of negligence against the appellant's claim for compensation was that at the time of delivery and management, no deformities were manifested and the complainant was given proper advice, which was not followed. It was argued on behalf of the respondent that they had taken sufficient precautions, even against ROP by mentioning in the discharge summary as follows:
“Mother confident; Informed about alarm signs; 1) to continue breast feeding 2) To attend post natal O.P. on Tuesday.”

9. It must, however, be noted that the discharge summary shows that the above writing was in the nature of a scrawl in the corner of the discharge summary and we are in agreement with the finding of the NCDRC that the said remarks are only a hastily written general warning and nothing more. After a stay of 25 days in the hospital, it was for the hospital to give a clear indication as to what was to be done regarding all possible dangers which a baby in these circumstances faces. It is obvious that it did not occur to the respondents to advise the appellant that the baby is required to be seen by a paediatric ophthalmologist since there was a possibility of occurrence of ROP to avert permanent blindness. This discharge summary neither discloses a warning to the infant's parents that the infant might develop ROP against which certain precautions must be taken, nor any signs that the Doctors were themselves cautious of the dangers of development of ROP. We are not prepared to infer from ‘Informed about alarms signs’ that the parents were cautioned about ROP in this case. We find it unfortunate that the respondents at one stage took a stand that the appellant did not follow up properly by not attending on a Tuesday but claiming that the mother attended on a Wednesday and even contesting the fact that she attended on a Wednesday. It appears like a desperate attempt to cover up the gross negligence in not examining the child for the onset of ROP, which is a standard precaution for a well known condition in such a case. In fact, it is not disputed that the Respondent No.3 attended to and examined the baby at his private clinic when the baby was 14-15 weeks and even then did not take any step to investigate into the onset of ROP. The Respondent No.4 also visited the appellant to check up the baby at the home of the appellant and there are prescriptions issued by the said Respondent No.4, which suggests that the baby was indeed under his care from 4 weeks to 13 weeks.

10. The NCDRC has relied on the report dated 21.8.2007 of the All India Institute of Medical Sciences, New Delhi (hereinafter referred to as ‘AIIMS’). In pursuance of the order of the NCDRC, a medical board was constituted by AIIMS consisting of five members, of which, four are ophthalmological specialists. The board has given the following opinion:-

“A premature infant is not born with Retinopathy of Prematurity (ROP), the retina though immature is normal for this age. The ROP usually starts developing 2-4 weeks after birth when it is mandatory to do the first screening of the child. The current guidelines are to examine and screen the babies with birth weight<1500g and <32 weeks gestational age, starting at 31 weeks post-conceptional age (PAC) or 4 weeks after birth whichever is later. Around a decade ago, the guidelines in general were the same and the premature babies were first examined at 31-33 weeks post-conceptional age or 2-6 weeks after birth.

There is a general agreement on these above guidelines on a national and international level. The attached annexure explains some authoritative resources and guidelines published in national and international literature especially over the last decade.

However, in spite of ongoing interest world over in screening and management of ROP and advancing knowledge, it may not be possible to exactly predict which premature baby will develop ROP and to what extent and why.”
Review of literature of ROP screening guidelines
Year
Source
First screening
Who to screen
2006
American Academy of Pediatrics et al
31 wks PCA or 4 weeks after birth whichever later
<1500gms birth weight or <32 wks GA or higher
2003
Jalali S et al. Indian J Ophthalmology
31 wks PCA or 3-4 wks after birth whichever earlier
<1500 g birth weight or <32 weeks GA or higher
2003
Azad et al. JIMA
32 wks PCA or 4-5 wks after birth whichever earlier
<1500 g birth weight or < 32 wks GA or higher
2002
Aggarwal R et al. Indian J Pediatrics
32 wks PCA or 4-6 wks after birth whichever earlier
< 1500 gm birth weight or < 32 wks GA
1997
American Academy of Pediatrics et al
31-33 wks PCA or 4-6 wks after birth
<1500 gm birth weight or <28, wks GA or higher
1996
Maheshwari R et al National Medical J India
32 wks PCA or 2 wks after birth whichever is earlier
<1500 gm birth weight or < 35 wks GA or 02> 24 hours
1998
Cryotherapy ROP group
4-6 wks after birth
<1250 gms birth
One thing this report reveals clearly and that is that in the present case the onset of ROP was reasonably foreseeable. We say this because it is well known that if a particular danger could not reasonably have been anticipated it cannot be said that a person has acted negligently, because a reasonable man does not take precautions against unforeseeable circumstances. Though it was fairly suggested to the contrary on behalf of the respondents, there is nothing to indicate that the disease of ROP and its occurrence was not known to the medical profession in the year 1996. This is important because whether the consequences were foreseeable or not must be measured with reference to knowledge at the date of the alleged negligence, not with hindsight. We are thus satisfied that we are not looking at the 1996 accident with 2007 spectacles.2
2See Roe v. Minister of Health (1954) 2 QB 66 and the discussion in ‘Medical Negligence’, Michael Jones, 4th Edition, Sweet & Maxwell, London 2008 at page 270.
11. It is obvious from the report that ROP starts developing 2 to 4 weeks after birth when it is mandatory to do the first screening of the child. The baby in question was admitted for a period of 25 days and there was no reason why the mandatory screening, which is an accepted practice, was not done. The report of the AIIMS (supra) states that ‘it may not be possible to exactly predict which premature baby will develop ROP and to what extent and why’. This in our view underscores the need for a check up in all such cases. In fact, the screening was never done. There is no evidence whatsoever to suggest to the contrary. It appears from the evidence that the ROP was discovered when the appellant went to Mumbai for a personal matter and took his daughter to a paediatrician, Dr. Rajiv Khamdar for giving DPT shots when she was 4½ months. That Doctor, suspected ROP on an examination with naked eye even without knowing the baby's history. But, obviously Respondent Nos.3 and 4 the Doctors entrusted with the care of the child did not detect any such thing at any time. The helpless parents, after detection got the baby's eyes checked by having the baby examined by several doctors at several places. Traumatised and shocked, they rushed to Puttaparthy for the blessings of Shri Satya Sai Baba and the baby was anesthetically examined by Dr. Deepak Khosla, Consultant, Department of ophthalmology at Baba Super Specialty Hospital at Puttaparthy. Dr. Khosla did not take up the case since the ROP had reached stage 5. After coming back from Puttaparthy, the baby was examined by Dr. Tarun Sharma alongwith the retinal team of Shankar Netralaya, who were also of the same opinion. The parents apparently took the baby to Dr. Namperumal Swamy of Arvind Hospital, Madurai, who advised against surgery, stating that the baby's condition was unfavourable for surgery. The appellant then learnt of Dr. Michael Tresse, a renowned expert in Retinopathy treatment for babies in the United States. He obtained a reference from Dr. Badrinath, chief of Shankar Netralaya and took his only child to the United States hoping for some ray of light. The appellant incurred enormous expenses for surgery in the United States but to no avail.
12. Having given our anxious consideration to the matter, we find that no fault can be found with the findings of the NCDRC which has given an unequivocal finding that at no stage, the appellant was warned or told about the possibility of occurrence of ROP by the respondents even though it was their duty to do so. Neither did they explain anywhere in their affidavit that they warned of the possibility of the occurrence of ROP knowing fully well that the chances of such occurrence existed and that this constituted a gross deficiency in service, nor did they refer to a paediatric ophthalmologist. Further it may be noted that Respondent Nos. 3 & 4 have not appealed to this Court against the judgment of the NCDRC and have thus accepted the finding of medical negligence against them.
Deficiency in Service
13. In the circumstances, we agree with the findings of the NCDRC that the respondents were negligent in their duty and were deficient in their services in not screening the child between 2 to 4 weeks after birth when it is mandatory to do so and especially since the child was under their care. Thus, the negligence began under the supervision of the Hospital i.e. Respondent No.2. The Respondent Nos. 3 and 4, who checked the baby at his private clinic and at the appellant's home, respectively, were also negligent in not advising screening for ROP. It is pertinent to note that Respondent Nos. 3 and 4 carried on their own private practice while being in the employment of Respondent No. 2, which was a violation of their terms of service.
Compensation
14. The next question that falls for consideration is the compensation which the respondents are liable to pay for their negligence and deficiency in service. The child called Sharanya has been rendered blind for life. The darkness in her life can never be really compensated for in money terms. Blindness can have terrible consequences. Though, Sharanya may have parents now, there is no doubt that she will not have that protection and care forever. The family belongs to the middle class and it is necessary for the father to attend to his work. Undoubtedly, the mother would not be able to take Sharanya out everywhere and is bound to leave the child alone for reasonable spells of time. During this time, it is obvious that she would require help and maybe later on in life she would have to totally rely on such help. It is therefore difficult to imagine unhindered marriage prospects or even a regular career which she may have otherwise pursued with ease. She may also face great difficulties in getting education. The parents have already incurred heavy expenditure on the treatment of Sharanya to no avail. It is, thus, obvious that there should be adequate compensation for the expenses already incurred, the pain and suffering, lost wages and the future care that would be necessary while accounting for inflationary trends.
15. There is no doubt that in the future Sharanya would require further medical attention and would have to incur costs on medicines and possible surgery. It can be reasonably said that the blindness has put Sharanya at a great disadvantage in her pursuit for making a good living to care for herself.
16. At the outset, it may be noted that in such cases, this court has ruled out the computation of compensation according to the multiplier method. (See Balram Prasad vs. Kunal Saha, (2014) 1 SCC 384 and Nizam's Institute of Medical Sciences vs. Prashant S. Dhananka and Others, (2009) 6 SCC 1.
The court rightly warned against the straightjacket approach of using the multiplier method for calculating damages in medical negligence cases.
Quantification of Compensation
17. The principle of awarding compensation that can be safely relied on is restitutio in integrum. This principle has been recognized and relied on in Malay Kumar Ganguly vs. Sukumar Mukherjee, (2009) 9 SCC 221 and in Balram Prasad's case (supra), in the following passage from the latter:
“170. Indisputably, grant of compensation involving an accident is within the realm of law of torts. It is based on the principle of restitutio in integrum. The said principle provides that a person entitled to damages should, as nearly as possible, get that sum of money which would put him in the same position as he would have been if he had not sustained the wrong. (See Livingstone v. Rawyards Coal Co.).”
An application of this principle is that the aggrieved person should get that sum of money, which would put him in the same position if he had not sustained the wrong. It must necessarily result in compensating the aggrieved person for the financial loss suffered due to the event, the pain and suffering undergone and the liability that he/she would have to incur due to the disability caused by the event.
Past Medical Expenses
18. It is, therefore, necessary to consider the loss which Sharanya and her parents had to suffer and also to make a suitable provision for Sharanya's future.
19. The appellant - V. Krishnakumar, Sharanya's father is the sole earning member of a middle class family. His wife is said to be a qualified accountant, who had to sacrifice her career to attend to the constant needs of Sharanya. Sharanya's treatment and the litigation that ensued for almost two decades has been very burdensome on account of the prolonged physical, mental and financial hardships, which her parents had to undergo. It appears that the total expenditure incurred by the appellant from the date of the final verdict of the NCDRC (27.5.2009) until December, 2013 is Rs.8,13,240/-. The aforesaid amount is taken from the uncontroverted statement of expenditure submitted by the appellant. The appellant has stated that he had incurred the following expenditure for Sharanya's treatment, for which there is no effective counter, till December, 2013:
Year
Year
Year
a) Till December 2003
28,63,771/-
Exhibit P1-P4
b) January 2004 - October 2007
2,57,600/-
Annexure A-8
c) 27.5.2009 to December 2013
8,13,240/-
I.A. No.2 of 2014 in Civil Appeal No. 8065 of 2009
d) January 2014 - March 2015
2,03,310/-
Based on I.A. No.2 of 2014 in Civil Appeal No 8065 of 2009
Total (a)+(b)+(c) +(d)
41,37,921/-
20. Since there is no reason to assume that there has been any change in the expenditure, we have calculated the expenditure from January 2014 to March 2015 at the same rate as the preceding period. In addition, we also deem it fit to award a sum of Rs. 1,50,000/- in lieu of the financial hardship undergone particularly by Sharanya's mother, who became her primary caregiver and was thus prevented from pursuing her own career. In Spring Meadows Hospital and Another v. Harjol Ahluwalia (1998 4 SCC 39) this court acknowledged the importance of granting compensation to the parents of a victim of medical negligence in lieu of their acute mental agony and the lifelong care and attention they would have to give to the child. This being so, the financial hardship faced by the parents, in terms of lost wages and time must also be recognized. Thus, the above expenditure must be allowed.
21. We accordingly direct that the above amount i.e. Rs.42,87,921/- shall be paid by the Respondent Nos.1 to 4. In addition, interest at the rate of 6% p.a. shall be paid to the appellant from the date of filing of the petition before the NCDRC till the date of payment.

Future Medical Expenses
22. Going by the uncontroverted statement of expenditure for the period from the final verdict of the NCDRC to December, 2013, the monthly expenditure is stated to be Rs. 13,554/-, resulting in an annual expenditure of Rs. 1,62,648/-Having perused the various heads of expenditure very carefully, we observe that the medical costs for Sharanya's treatment will not remain static, but are likely to rise substantially in the future years. Sharanya's present age is about 18 ½ years. If her life expectancy is taken to be about 70 years, for the next 51 years, the amount of expenditure, at the same rate will work out to Rs. 82,95,048/-. It is therefore imperative that we account for inflation to ensure that the present value of compensation awarded for future medical costs is not unduly diluted, for no fault of the victim of negligence. The impact of inflation affects us all. The value of today's rupee should be determined in the future. For instance, a sum of Rs. 100 today, in fifteen years, given a modest 3% inflation rate, would be worth only Rs.64.13. In Wells v. Wells3 the House of Lords observed that the purpose of awarding a lump sum for damages for the costs of future care and loss of future earnings was to put the plaintiff in the same financial position as if the injury had not occurred, and consequently the courts had the difficult task of ensuring that the award maintained its value in real terms, despite the effect of inflation.
3(1999) 1 A.C. 345.

Apportioning For Inflation
23. Inflation over time certainly erodes the value of money. The rate of inflation (Wholesale Price Index-Annual Variation) in India presently is 2 percent4 as per the Reserve Bank of India. The average inflationary rate between 1990-91 and 2014-15 is 6.76 percent as per data from the RBI. In the present case we are of the view that this inflationary principle must be adopted at a conservative rate of 1 percent per annum to keep in mind fluctuations over the next 51 years.
4Handbook of Statistics, Reserve Bank of India
The formula to compute the required future amount is calculated using the standard future value formula:-

FV = PV x (1+r)n
PV = Present Value
r = rate of return
n = time period

Accordingly, the amount arrived at with an annual inflation rate of 1 percent over 51 years is Rs.1,37,78,722.90 rounded to Rs.1,38,00,000/-.

Comparative law
24. This Court has referred to case law from a number of other major common law jurisdictions on the question of accounting for inflation in the computation of awards in medical negligence cases. It is unnecessary to discuss it in detail. It is sufficient to note that the principle of apportioning for inflationary fluctuations in the final lump sum award for damages has been upheld and applied in numerous cases pertaining to medical negligence. In the United States of America, most states, as in Ireland and the United Kingdom, require awards for future medical costs to be reduced to their present value so that the damages can be awarded in the form of a one-time lump sum. The leading case in the United States, which acknowledges the impact of inflation while calculating damages for medical negligence was Jones & Laughlin Steel Corporation v. Pfeifer5, wherein that court recognized the propriety of taking into account the factors of present value and inflation in damage awards. Similarly, in O'Shea v Riverway Towing Co.6, Posner J., acknowledged the problem of personal injury victims being severely undercompensated as a result of persistently high inflation.
5(1983) 462 US 523
6(1982) 677 F.2d 1194, at 1199 (7th Cir)
In Taylor v. O' Connor7, Lord Reid accepted the importance of apportioning for inflation:
“It will be observed that I have more than once taken note of present day conditions - in particular rising prices, rising remuneration and high rates of interest. I am well aware that there is a school of thought which holds that the law should refuse to have any regard to inflation but that calculations should be based on stable prices, steady or slowly increasing rates of remuneration and low rates of interest. That must, I think, be based either on an expectation of an early return to a period of stability or on a nostalgic reluctance to recognise change. It appears to me that some people fear that inflation will get worse, some think that it will go on much as at present, some hope that it will be slowed down, but comparatively few believe that a return to the old financial stability is likely in the foreseeable future. To take any account of future inflation will no doubt cause complications and make estimates even more uncertain. No doubt we should not assume the worst but it would, I think, be quite unrealistic to refuse to take it into account at all.”
In the same case Lord Morris of Borth-y-Gest also upheld the principle of taking into account future uncertainties. He observed:
“It is to be remembered that the sum which is awarded will be a once-for-all or final amount which the widow must deploy so that to the extent reasonably possible she gets the equivalent of what she has lost. A learned judge cannot be expected to prophesy as to future monetary trends or rates of interest but he need not be unmindful of matters which are common knowledge, such as the uncertainties as to future rates of interest and future levels of taxation. Taking a reasonable and realistic and common-sense view of all aspects of the matter he must try to fix a figure which is neither unfair to the recipient nor to the one who has to pay. A learned judge might well take the view that a recipient would be ill-advised if he entirely ignored all inflationary trends and if he applied the entire sum awarded to him in the purchase of an annuity which over a period of years would give him a fixed and predetermined sum without any provision which protected him against inflationary trends if they developed.”
More recently the Judicial Committee of the UK Privy Council in Simon v. Helmot8 has unequivocally acknowledged the principle, that the lump sum awarded in medical negligence cases should be adjusted so as to reflect the predicted rate of inflation.
8(2012) UKPC 5
25. Accordingly, we direct that the said amount i.e. Rs.1,38,00,000/- shall be paid, in the form of a Fixed Deposit, in the name of Sharanya. We are informed that the said amount would yield an approximate annual interest of Rs. 12,00,000/-.
26. We find from the impugned order of the NCDRC that the compensation awarded by that Forum is directed to be paid only by Respondent Nos. 1 and 3 i.e. the State of Tamil Nadu and Dr. S. Gopaul, Neo-pediatrician, Government Hospital for Women & Children, Egmore, Chennai. No reason has been assigned by the Forum for relieving Respondent Nos. 2 and 4. Dr. Duraiswami, Neo Natology Unit, Government Hospital for Women & Children, Egmore, Chennai, who also treated Sharanya during the course of his visits to the house of the appellant.
27. It is settled law that the hospital is vicariously liable for the acts of its doctors vide Savita Garg vs. National Heart Institute, (2004) 8 SCC 56, also followed in Balram Prasad's case (supra). Similarly in Achutrao Haribhau Khodwa v. State of Maharashtra, (1996) 2 SCC 634 this court unequivocally held that the state would be vicariously liable for the damages which may become payable on account of negligence of its doctors or other employees. By the same measure, it is not possible to absolve Respondent No. 1, the State of Tamil Nadu, which establishes and administers such hospitals through its Department of Health, from its liability.

Apportionment of Liability
28. In the circumstances, we consider it appropriate to apportion the liability of Rs. 1,38,00,000/- among the respondents, as follows:
  • Rs. 1,30,00,000/- shall be paid by Respondent Nos. 1 and 2 jointly and severally i.e. The State of Tamil Nadu and the Director, Government Hospital for Women & Children, Egmore, Chennai; and
  • Rs. 8,00,000/- shall be paid by Respondent Nos. 3 and 4 equally i.e. Rs. 4,00,000/- by Dr. S. Gopaul, Neo- pediatrician, Government Hospital for Women & Children, Egmore, Chennai and Rs. 4,00,000/- by respondent no. 4 i.e. Dr. Duraisamy, Neo Natology Unit, Government Hospital for Women & Children, Egmore, Chennai.
    The above mentioned amount of Rs. 1,38,00,000/- shall be paid by Respondent Nos. 1 to 4 within three months from the date of this Judgment otherwise the said sum would attract a penal interest at the rate of 18% p.a.
29. Further, we direct that the amount of Rs. 42,87,921/- in lieu of past medical expenses, shall be apportioned in the following manner:
  • Respondent Nos. 1 and 2 are directed to pay Rs. 40,00,000/- jointly, alongwith interest @ 6% p.a. from the date of filing before the NCDRC; and
  • Respondent Nos. 3 and 4 are directed to pay Rs. 2,87,921/- in equal proportion, alongwith interest @ 6% p.a. from the date of filing before the NCDRC.
30. In the event the Respondent Nos. 1 and 3 have made any payment in accordance with the award of the NCDRC, the same may be adjusted.
31. Accordingly, Civil Appeal No. 8065 of 2009 is allowed in the above terms and Civil Appeal No. 5402 of 2010 is dismissed. No costs.

J., (JAGDISH SINGH KHEHAR)
J. (S.A. BOBDE)
NEW DELHI
JULY 1, 2015
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