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COVER
STORY: KUMARAMANGALAM CASE
The
Final Diagnosis
An inquiry
report indicts Apollo for faulty diagnosis in the Kumaramangalam case
and damages its image
by
Subhadra Menon
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| Kumarmangalam's
fever went unexplained till it was too late |
Few
inquiry reports come out on time. This one was on the dot. Three weeks
after Union power minister P.R. Kumaramangalam died, the inquiry set up
by Union Health Minister Dr C.P. Thakur has been given the final touches.
INDIA TODAY learns that the report has three main points. One, there is
a case of "mis-diagnosis" that can be made out against Delhi's
Indraprastha Apollo Hospital for having failed to detect Kumaramangalam's
blood cancer. Two, Kumaramangalam himself comes in for a bit of a stick
and has been labelled as an "uncooperative" patient for having
failed to follow up with his treatment. And three, there might be some
kind of penal action against Apollo, which the Health Ministry is still
conjuring up.
The inquiry
committee, comprising six eminent doctors and headed by Dr C.P. Singh,
medical superintendent of Delhi's Ram Manohar Lohia Hospital, is categorical
on the mis-diagnosis. Kumaramangalam was admitted to Apollo on April 14
this year, suffering from a fever that hadn't abated in two weeks. He
was kept there for nine days and a series of tests conducted. A chest
X-ray was done which showed a pneumonic patch (pneumonia) that could explain
the fever. A urine sample showed infection, which again could spell fever.
The CT scan and the complete blood test showed nothing substantial, nor
did the bronchoscopy - an examination of the airways of the lungs-done
because Kumaramangalam was a smoker. Where the doctors in Apollo erred,
it is inferred, is that they did not do a bone marrow examination (where
bone marrow from the hip is extracted and studied under a microscope).
Four months after he left Apollo, the minister was admitted to the All
India Institute of Medical Sciences (AIIMS) where the diagnosis of acute
myeloid leukaemia (AML) or blood cancer was made and then reconfirmed.
There his condition deteriorated and nine days after he was admitted,
he died at the ICU while on a respirator.
Was a
bone-marrow test required? The mis-diagnosis lies in the fact that
Apollo failed to do a bone marrow test. "I am shocked that they actually
missed it," says a senior doctor at AIIMS. International protocol
for unexplained fever categorically demands a bone-marrow examination.
AML is a life-threatening disease in which cancer cells start proliferating
in the bone marrow and then spill over into the blood stream. To diagnose
AML, you can either take a complete blood test or do the more definitive
bone-marrow examination. True, Apollo did a complete blood test which
showed nothing. But AML in a very early stage might not show in the blood
test. However, the cancer will always show up in a bone-marrow examination.
Apollo doctors
say Kumaramangalam's fever did not merit a bone-marrow test and also explain
that it is possible that he developed the cancer once he left Apollo.
AML can, in fact, move fast from first presentation to serious illness.
Says Dr Prathap C. Reddy, chairman of the Apollo Hospitals Group: "You
can't do a bone marrow on everybody who walks in, especially someone who
had a low white blood cell (WBC) count." The WBC count generally
rises dramatically when there is an infection or proliferation of cancer
cells in the blood.
Though there
is indictment of a mis-diagnosis, the report also seems to leave a loophole
for Apollo. This is because it specifically mentions that Kumaramangalam
was an uncooperative patient. It is known that once the fever abated,
the minister insisted that he be discharged, despite the hospital's unwillingness
to do so. He was specifically asked to follow up but he didn't even when
the feverish bouts returned and he lost weight and appetite. Kumaramangalam
also seemed to first believe he had malaria since he had just returned
from a trip to the Andamans. He, it is learnt, insisted on being treated
for it, even though there were no symptoms. Adds Prasada Rao, a senior
consultant on internal medicine at Apollo who treated the minister at
the time: "We treated him for malaria on an empirical diagnosis."
This mention of uncooperativeness, experts feel, will definitely help
Apollo in its defence. It can resort to the plea that had he come back
with the same symptoms, a bone marrow test would definitely have been
done.
That brings
us to the action that is being contemplated against Apollo by the Health
Ministry. Dr Thakur has gone on national television harping on the mis-diagnosis
and the indictment of Apollo. His party colleagues, especially Union Information
Technology Minister Pramod Mahajan and newly appointed BJP Vice-President
Madan Lal Khurana, have already called for strict action against Apollo
insinuating all kinds of irregularities. But as things stand, it will
not be easy for the Centre to take action against Apollo. Health is a
state subject and the hospital is registered with the Delhi Government.
Dr Thakur knows that. "If we learn that we can't do much then I will
give the report to the Delhi Government and request it to take action."
The Delhi Government, on the basis of the report, can move to cancel Apollo's
licence. However, that may turn out to be a long legal wrangle, since
Apollo is sure to take them to court.
What will
happen in the end is still unclear. But the report itself has brought
no joy to the Kumaramangalam family. Says Kitty Kurmaramangalam, the minister's
wife: "He has gone and left us with this burning fire." Yet,
the wheels of justice must move rapidly so that the accused, if found
guilty, are punished. Only then will it deter such acts of negligence.
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