My father K.K. Sabharwal was admitted in emergency on 22nd Mar’2012 around 8:30pm as he was
vomiting, sweating and shivering. I thought he must have got a Gastric attack due to which he was
continuously vomiting. I took his previous history with me where he was treated for Brain (in Indian
Spinal Injuries) and Heart (Fortis). Since his doctor don’t go much to ISH, we got his in Fortis. While handing over my dad at emergency, I handed over his history file to the doctor on duty.
Doctor asked my dad where are you feeling pain. My dad told him that I’m feeling pain in my
stomach and I’m feeling cold. They kept him for 2 hours in emergency and shifted him to ward for
further check‐up since it was night no check‐up could be done. I told them Ok you can admit him for
a day and confirm what’s the issue? They told me that we have to check his stomach and lower
abdomen as he is complaining pain there. They transferred him to ward under Mass and Surgery
department. We told the doctor please consult with his previous doctors before starting any medication as his doctors come in Fortis regularly. The doctor on duty confirmed us that we have contacted them and the treatment is on. Between 1‐2 am, ICU team in charge came to me and told me that your dad is critical and needs to be shifted to ICU immediately. I questioned them why. He is fine so why he is been shifted to ICU.ICU doctor in charge told me that he is critical and he has to be kept under intensive care. I said OK. Please go ahead. In ICU, When he was been transferred from one bed to other bed, he fell down on the bed itself because his body right side got weak. I shouted at the incharge please see that he has fallen. Then they rescued him and transferred him to other bed.
Day 2‐ 23rd mar’12:
I went into ICU and spoke to my dad. How is he feeling now? He said that he is fine and want to go
home. He introduced me to the nurses on duty. I requested ICU Sister to get the TPA form
filled from the doctor. She told me that he will be transferred under Neurology team so the
appointed doctor will fill the same. I have asked her for the doctor name and she told me that he is
Dr. Amit Srivastava. I went to him in OPD and requested him to fill the same. He told me that I will
first examine your father and then fill the TPA. Between 11‐12pm he examined my father and filled
the TPA form. Around 1pm, I again met him and asked him that what’s the issue? He told me that we
have done his CT scan but was not fruitful. He is critical and we have to get his MRI done ASAP. I said
Ok. I asked him when that will happen. He told me that since we don’t have a MRI in our premises,
we will have to send him to Mahajan Imagine point, hauz khas. Then he called Mahajan’s and asked
them to do his MRI ASAP. They told him that till 6pm they are booked and can’t do MRI before that.
He booked the same then I told the doctor since he is critical, can we do it little early. He again called
Mahajan and luckily they said Ok and asked the doctor to send the patient at 3pm. Since Fortis
ambulance was not available, I asked the doctor that can I take him in my car. He said no, we will
arrange for the ambulance for him. He is not in position to be taken in the car. I said Ok and told him
that do I need to be there with him. He said its ok we will handle the same. Around 4:30pm I called
Mahajan’s and checked with them, my dad is referred for MRI in your office, is MRI done. The lady at
the reception told me that you dad is getting restless and there is no attendant with him and MRI is
still to happen. I reached Mahajan’s at 5 pm and saw my dad waiting for MRI to happen. He was
getting restless and taking out his cough. I told my dad to relax and asked him are you Ok. He said
I’m Ok and I want to go home post this MRI. I said OK. After MRI, I will speak to doctor. I screamed at
Mahajan’s that why are you not doing the MRI . He is so restless. They told me that your dad came
here at 4:30pm (this happened because fortis arranged the ambulance which came late and thus he
reached late to Mahajan) and the appointment was given for 3pm. Now our other patient is in MRI
which will finish in next 5‐10 minutes and then we will send your dad inside. Finally at 5:30pm, my
dad was taken in for MRI and I was with him. He was weak and we picked him and placed him in MRI
equipment for diagnosis. I told my dad, if you feel uncomfortable, he shake your leg or hand, I will
take you out. After 10 min, Doctor immediately came inside the MRI room and took him out and
started pumping. I said what happened, they told me that we didn’t find any movement and he may
have got a cardiac arrest. Mahajan didn’t have any equipment to revive my dad, there was only
manual pumping happening for 15 minutes at Mahajan. My dad pulses were going and coming. He
was taken to ambulance immediately at 6:15 pm so that he could be transferred to Fortis. Fortis is
15 Km away from Mahajan and take approx... 20 Minutes to reach there. Since it was Peak hours, it
took ambulance to reach in 35 minutes. In the ambulance, the oxygen got finished (My sister is
witness for the same) because it was only half cylinder available in the ambulance. My dad was
suffering. Due to inadequate supply of oxygen, he got silent. We reach fortis at 6:50 pm where he
was made wait for 5‐7 minutes more since no stretcher or oxygen was sent outside to rescue him.
Instead olf doctor who was with my calling asking emergency staff to be ready with stretcher and
oxygen but no one was out ready with the two things. I went inside the emergency and shouted to
get the stretcher and oxygen to my father then the ward boy came with the stretcher and took him
inside. After 25 minutes for regular equipment pumping, ventilator support, my dad heartbeat got
revived but through life supporters. Doctor told me that he is ok now but those crucial minutes sent
him in complete silent. We were hoping he will open his eyes in next 15 to 20 minutes, which he
didn’t. We kept on praying god keep our dad OK. He was transferred to ICU immediately with
ventilator support. Surprisingly a patient from the ICU was sent to an external premise for diagnosis
without critical care equipment and team of doctors.
Day 3‐24th Mar’2012
In the morning, DR Atul Prasad Head Neurology examined him. Post he examined him, he came to
me and told me that your Dad’s brain is dead and can’t be revived. Tell us what to do. Shall we keep
him on life support medicine and ventilator or remove them. I told him how this is possible. He was
very much conscious last evening before MRI and today you are telling his brain is dead. I told them
you continue with your medicine and life support equipment for my father. After 7 days, he passed
away.
My Concerns:
1. Why emergency doctor on duty could not realise that he has got a brain stem stroke on Day
1 especially when the file was given to them with his previous history? As a lay man, when I
surfed the net, it told me the symptoms of brain stem stroke which very much matched
when I got my father to Fortis.
2. Why he was transferred to Mass and Surgery department?
Doctors should be aware about such things when they are aware about the history
on day1
3. When we told Dr Gupta in Mass & Surgery who was overlooking the case in room no 208
that he is feeling disoriented and is seeing double, He smirked and said that is because of
weakness and not because of brain.
4. Why we were told that they have contacted previous doctor who had treated him earlier?
5. Why he was taken for MRI 15 Kms away from the hospital since he was critical and as
highlighted by the doctor. Why nearby Radiologist was not contacted. Indian Spinal Injuries
hospital has MRI. Is Fortis going to take critical care patients 15Kms away and in peak hours?
6. Why experience Doctors were not sent to handle crisis if something goes wrong?
7. Why Ambulance didn’t reach Mahajan at 3pm if the appointment was fixed at 3pm?
8. Why Ambulance was not well equipment with sufficient oxygen? Oxygen got finished on
way back to hospital. Why was critical care equipment not present? There was no
defibrillator.
9. Why Emergency staff was not ready with the stretcher and equipment when the
ambulance doctor asked them to come out.. They came out after 10 minutes when I went
inside the emergency and shouted.
10. Why doctors were negative from Day 1 that he can’t be revived? Why they have asked us to refer other doctors when the case was out from their hand?
11. Every day morning it was a torture for us to be asked to take a decision of taking the life support out when we had communicated that we will not? Legally it is our choice and we
are not to be asked more than once for the same.
12. Last but not the least, If the doctors in emergency would have initiated the procedure for
curing the brain stem stroke on March 22nd night itself we would not have lost ~15 hours and more for initiating the medicines for the stroke and thus a cardiac arrest could have been averted. Loss of precious time caused us the loss of a loving father, grandfather and most importantly a husband.
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