PSYCHIATRY

13-60.1 Psychiatry-Drug reaction-Development of agranulocytosis, vomiting, loose motion and high fever-Patient seeing dreams and uttering words during sleep and becoming short tempered, diagnosed as a case of psychiatry-Alleged to be reaction prescription of over-dose of tablet Sizopin without W .B.C. count test-Opposite party not prescribing dose in excess as prescribed in the literature of manufacturers of the drug-W .B.C. count and differential count taken before prescribing the medicine- Vomiting, fever, etc. only after discontinuation of the medicine not said to be due to said drug-No evidence to show that treatment not as per medical ethics-No negligence or deficiency in service-From a bare look of the literature published by the manufacturer company of Sizopin medicine and the prescription of the opposite party it is found that the opposite party has prescribed Sizopin tablet of 25 mg. to be taken one in morning, one in afternoon and two at night, i.e., 4 tablets per day this means 100 mg. per day, this dose could have been increased from 100 mg. per day up to the level of 450 mg. per day but the opposite party doctor restricted the dose only up to 100 mg. per day for a week which is well within the prescribed doses, therefore, the allegations of the overdose levelled by the complainant is baseless.

The opposite party has submitted that the patient was under his treatment from 15.10.1998 and on 9.3.1999 he prescribed Sizopin, on 12.3.1999 the blood report of Chirayu Hospital reveals that the W .B.C. count was 13,600 per cu. mm. as against 4500 to 11000 per cu. mm. being the normal value. The Neutrophils were 82% as against 40 to 75% of the normal values. This means that even after four days of taking of Sizopin the blood level was more than the normal. Again W .B.C. counts were 4,600 per cu. mm. on 20.4.1999 this was also above 4,500 which minimum normal value. On the basis of this report-dated 12.3.1999 the opposite party repeated the medicine Sizopin on 26.3.1999. Again on 19.4.1999 because the complainant did not bring the blood and stool test report which was advised by him, therefore, special letter to purchase Sizopin was not given. It is, therefore, clear that the precautions ofW .B.C. count and differential count before prescribing medicine were taken by the opposite party and he cannot be blamed for any negligence.

The opposite party has also produced' , Minutes of the Round Table Symposia Sizopin. The Indian Experience' , in which experiments of different doctors treating the psychiatric patient were given. In their expert opinion they have mentioned that Sizopin is effective in treating the patient and when the side effect of agranulocytosis is observed, the use of medicine is stopped and within 5- 7 days the patient recovers to the normal level. In the present case, the use of Sizopin was not recommended after 19.4.1999. This means that the doctor has taken proper care as per medical norms that unless W.B.C. count test is done Sizopin will not be recommended, therefore, the special letter for purchase of Sizopin was not issued on 19.4.1999.

Sizopin purchased on 9.3.1999 for 15 days continued up to 25.3.1999 thereafter, these medicines were purchased on 12.4.1999, this also makes clear that the patient was not using the Sizopin from 26.3.1999 to 12.4.1999 and on 19.4.1999 when there was complaint about fever, medicines were discontinued. Therefore, it cannot be said that the vomiting, fever, loose motion etc. was due to Sizopin. Therefore, the cause of vomiting, loose motion and high fever cannot be attributed to Sizopin. Moreover, the complainant has not produced the opinion of any expert doctor to show that the treatment given was not as per medical ethics and principles. [Vaqar Mohammad Khan & Anr. v. Dr. S.K. Tandon, 2002 (2) CPJ 169 (MP SCDRC)]

Foreign Cases 13-60.2 Psychiatry-Negligence-Bolam case-Electro-convulsive therapy- Relaxant drugs not administered, and patient not restrained by manual control- Patient sustained fractures- Two recognised schools of thought on method of treatment-Doctor following one school not negligent-Duty to warn of risks- Consent-Plaintiff must show if he had been warned he would not have consented-In 1954, J.H. Bolam, the plaintiff, who was suffering from mental illness, was advised by a consultant attached to the defendant's hospital to undergo electrononvulsive therapy (ECT). He signed a form of consent to the treatment but was not warned of the risk of fracture involved. There was evidence that the risk of fracture was very small, i.e., of the order of one in ten thousand. On the second occasion, when the ECT was given to the plaintiff in the defendants' hospital he sustained fractures. No relaxant drugs or manual control (save for support of the lower jaw) were used, but a male nurse stood on each side of the patient throughout the treatment. The use of relaxant drugs would admittedly have excluded the risk of fracture. Among those skilled in the profession and experienced in this form of treatment, however, there were two schools of opinion, one of which (since 1953) favoured the use of relaxant drugs or manual control as a general practice, and the other of which, thinking that the use of these drugs was attended by risk of death, confined the use of relaxant drugs to cases where there were particular reasons for their use. The instant case was not such a case. Similarly, there were two bodies of competent opinion on the question whether, if relaxant drugs were not used, manual control should be used. Different views were also held among competent professional men on the question whether a patient should be expressly warned about risk of fracture before being treated, or should be left to inquire what the risk was; and there was evidence that in cases of mental illness explanation of risk might well not affect the patient's decision whether to undergo the treatment. The plaintiff having sued the defendants for negligence in not using relaxant drugs or some form of manual control and in failing to warn him of the risk involved before the ECT was given, the Jury gave the verdict that the defendants were not negligent. In the summing-up, the Jury were directed by McNair, J: .that a doctor is not negligent if he is acting in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art, merely because there is a body of such opinion that takes a contrary view; [principle stated in Hunter v. Hanleyl, applied that when a doctor was dealing with a mentally sick man and had a strong belief that his only hope of cure was submission to electro-convulsive therapy, the doctor could not be criticised if, believing the dangers involved in the treatment to be minimal, he did not stress them to the patient;

In order to recover damages for failure to give warning the plaintiff must show not only that such failure was negligent but also that if he had been warned he would not have consented to the treatment. [Bolam v, Friem Hospital Management Committee, [1957] 2 All ER 118: 1 BMLR 1 (QBD).]

13-60.3 Psychiatrist-Patient committed suicide as nurse not looking after properly-Hospital liable-A woman was admitted to a mental hospital suffering from acute depression, She made two suicide attempts while there and her physician told the head floor nurse after her wrist was sutured for the second time that she was not to leave the ward, The nurse did not note this order on the patient's chart and the patient walked out with no objection from the nurses on the next shift, She left the hospital grounds . and ran in front of a car and was run over, She had permanently disabling orthopedic injuries and severe organic brain damage, The jury's award of $275,000 in damages against the hospital was upheld on appeal. [Adams v, State, 429 P 2d 109, Wash 1967.]

13-60.4 Psychiatrist-Electro-shock treatment-Discharge of patient thereafter-Heavy sedatives given-Patient burned himself-Failure to warn about drug and discharge amounted to negligence-A psychiatrist gave a telephone order for discharge from the hospital of a patient shortly after the patient had an electroshock treatment, He did not seethe patient. He also ordered a prescription for a heavy sedative to be taken home by the patient, He did not warn either the patient or the patient's wife about the strength of the drug, The patient was so confused and sedated when he got home that he set himself on fire with a cigarette, did not wake up, and was critically burned, The court applied the national standard, not local practice, as to the method of evaluating the patient for discharge from the hospital and in failing to warn of the properties of the drug. Conceding that either or both might not have constituted negligence if a general practitioner had done them, the court nonetheless held that a specialist was presumed to be aware of national standards and hence required to meet them. [Christy v, Salitennan, 179 NW 2d 288, Minn 1970,]