This case study is, unfortunately, not uncommon in our set-up and is a fallout of the societal attitude that accepts that those working in government organisations are going to work elsewhere to make extra money. This tolerance accords legitimacy to this illegal practice where the person involved can even afford to be defiant rather than defensive or guilty and may justify his actions.

A poor patient gets injured and is taken to a hospital where he is entitled to get free treatment including the implant but gets restless because he is not being told when and what operation is going to be done. This raises several questions:

1. Is it not the duty of surgeons to inform patients about their injuries, the proposed method of treatment, alternate methods of treatment, the expected period of recovery and the prognosis? The fact that once the patient became restless, he was suggested another place for treatment, certainly raises the suspicion whether this sort of practice was a routine to coerce patients to take treatment in private hospitals.
2. Did the Employees State Insurance (ESI) hospital have an orthopaedic surgeon but ‘no facilities to operate such injuries’? In that case what is the protocol for such patients? There would be some referral centre where such patients would be referred. Was a suggestion made to the patient that he could take treatment at another government hospital? I doubt it, given the fact that the doctor himself judged that ‘in another hospital he will have to wait months for surgery’.
3. Was the doctor, out of ignorance or intentionally, unaware of the conservative method of treatment using traction since the facilities for operative treatment were not available in the government hospital? Did he suggest this alternative to the patient?

Given the serious nature of orthopaedic infections, especially with implants in situ, it is imperative that orthopaedic surgeries be done in the best and the cleanest operation theatre (OT) of the hospital. It was probably the only theatre in the nursing home, forcing one to presume that all other infected cases were also being operated upon in the same theatre. Infection is not surprising in these circumstances; but the infection was apparantly not treated by irrigation and debridements. Was the nursing home was not accredited? I suggest that it should be obligatory for all hospitals to be certified as fit for undertaking orthopaedic operations by a competent regulatory body. Even if the patient had too little money (Rs 70,000/- is not too little for the treatment of these injuries), aggressive treatment could have been done at the ESI hospital where the patient was entitled for treatment. Perhaps his infection was neglected because he had run out of money and his doctor had lost interest in him now. The surgeon admitted to implanting inferior implants in a small nursing home and justified it as ‘you cannot get five-star treatment at two-star rates’. He was pushed into accepting the option which, to him, was probably the only choice available.

The treating surgeon has also overlooked a few principles of good medicine: (i) that the treatment should not harm the patient and should not be more harmful than the disease, even if at the worst it can do no good to him; (ii) that once you operate on a patient, he becomes your lifelong responsibility and you have to look after his interest whether or not he has any money left.

There is, however, another aspect of the case. It is not uncommon for contractors to promise the best treatment to labourers injured in industrial accidents, either out of empathy or to avoid medicolegal repercussions. Injured persons are often unable to resist the temptation of treatment in private hospitals where they presume they will get better facilities and more comforts. However, the minute they refuse a medicolegal case or the expenditure exceeds the estimate, or a few days pass they face the harsh realities of life and have to fend for themselves.

While it is easy to put the entire blame on the doctor in the ESI hospital or on the nursing home, one must realise that it the system which breeds these types of ills. Inability to provide the facilities for quality care in public hospitals, lack of accountability and discipline among physicians working in these organisations and, at times, the patronage of the high and mighty to the dishonest care providers-all make such incidents possible while the guilty remain arrogantly apathetic.