Testing Times For Apollo Hospital

Indraprastha Apollo Hospital is in the eye of a storm because of allegedly trying to cover up Rahul Mahajan's drug overdose. Did Apollo conduct the correct battery of tests? Nayantara Som gives an interesting insight into the mystery surrounding the case

Credited with ushering in the highest clinical standards in the country, boasting of the latest technology and advanced surgery, reversing brain drain within the medical community, holding the honour of the first listed healthcare group, bagging the first JCI accreditation in healthcare and giving private healthcare industry a major boost, the Apollo Hospitals Group has a coveted list of honours.

Suddenly it seems to have lost its sheen in the wake of allegations of covering up the drug overdose of late BJP leader Pramod Mahajan's son Rahul. While Rahul has been granted bail and new dimensions of the alleged intrigue are emerging every day, a posse of Indraprastha Apollo Hospital doctors and management staff are facing the heat, being regularly questioned by the Delhi Police.

Sequence Of Events

Indraprastha Apollo Hospitals was still basking in the glory of JCI accreditation, when it was suddenly thrust in the limelight once again. Only, this time it fell into chaos and ignominy. On June 2, 2006 (a Friday) around three in the morning, Rahul Mahajan and Vivek Maitra, aide to the senior Mahajan, were admitted to Indraprastha Apollo Hospital. Before any confirmation from the hospital, speculation was rife about drug overdose. A pouch of white powder was reportedly recovered from 7 Safdarjung Road, the senior Mahajan's official home. Maitra's death also pointed towards drug overdose.

Mahajan's brother-in-law and BJP leader Gopinath Munde dismissed the speculation, saying that it was a case of "suspected poisoning". Now, all hopes were pinned on Indraprastha Apollo Hospital's report to solve the mystery. In its first press statement, Apollo Hospital spokesperson Karan Thakur said that all Rahul's vital body functioning was stable but under observation. He said it could be a case of food poisoning.

Then, came the revelatory Dr Lal's Path Lab report,which clearly stated that there were traces of drugs in Rahul's blood. The quantitative test done by Lal found 3.9 milligrams of cocaine per litre of urine. Alcohol was found in the blood, but in permissible limits. Traces of drugs like cholinesterase, opiates, barbiturates, benzodiazepine, cannobinoids were also found.

A report by the Central Forensic Sciences Laboratory endorsed traces of cocaine and heroin found in the stomach wash and vomit of Mahajan and Maitra. Sources said that while the test report of Mahajan showed traces of two psychotropic substances, the gastric lavage of Maitra showed traces of ethanol besides metabolites of cocaine and heroin.

All hell broke loose as the noose tightened around Apollo and it soon retracted its statement. When Dr Anupam Sibal, Director, Medical Services, Indraprastha Apollo Hospital, was asked about the presence of drugs, he initially said: "Perhaps yes, perhaps no." When pressed, he added, "It could be said that cocaine is present though in a very minute quantity. It is quite normal."

Needle Of Suspicion

There are several loopholes in the various declarations made by the hospital which do not make sense, claim the Delhi police. The Delhi police registered an FIR against Apollo under Section 182 of the IPC at the Sarita Vihar police station in South Delhi for attempting to obfuscate the case by giving false information. A high-level team led by ACP BB Chaudhry has been interrogating Apollo doctors and other employees to get a clear idea about the sequence of events. Police claim that 'tampering' was done at the highest levels in the hospital to cover up this sensational case.

The police have questioned Apollo for declaring Rahul's condition as stable when actually he was wheeled in an unconscious state with his blood pressure, respiratory rate and oxygen level at extremely low levels. His blood pressure was around 95/65 and his pulse rate was around 83.

Moreover, the police reason that there was no rationale for Apollo to put Rahul on a ventilator. Police suspect that Apollo had admitted Rahul in the Intensive Care Unit (ICU) only to shield him from interrogation. There was also overwriting in the entry records of Rahul and Maitra in the admission register, which further increases suspicion, allege police.

Another point to be pondered is, why did the Apollo Hospital authorities hold their first press conference regarding this case on 3rd June (Saturday) giving Rahul a clean chit, when it already had in hand Dr Lal's report, declaring traces of drugs in Rahul and Vivek's samples? Even if Apollo's report was negative, should not they have informed the media about Lal's report?

Though Apollo claims that they received Lal's report on Sunday, when Express Healthcare Management contacted Dr Arvind Lal, Managing Director, Dr Lal Path Laboratory, he said, "We gave our report to Apollo on Friday, that is on 2nd June."

Dr Pratap Reddy

There are other crucial questions left unanswered: Why was Rahul admitted to Apollo rather than a nearby hospital like the All India Institute Of Medical Sciences (AIIMS) considering the gravity of his illness? While people's preference for private healthcare over public ones for superior care and treatment could be the prime reason for this, experts are not ready to rule out political linkages and affiliations. When Apollo's image was being tarnished, why was Apollo chief Dr Pratap Reddy absent from press briefings? Perhaps some logical explanation from them would have cleared the cloud of doubt surrounding the case.

It is also alleged that Apollo pumped in a lot of fluids that diluted the concentration of substances in the body. Police also claim that that they have ample evidence to prove that Apollo chief, Dr Pratap Reddy, his aide, Rajji Chandru and late BJP leader Pramod Mahajan's aide Harish Sharma were in constant touch with each other between June 1 and 2, between the time when Rahul Mahajan was admitted and when the police were informed about Vivek Maitra's death and the junior Mahajan's admission. They believe that between 2:55 am and 5 am Reddy, Chandru and Sharma managed to wipe out all the evidence possible, to save Rahul.

Did Apollo Follow Standards?

While the police will probe the alleged cover-up, the million-dollar question is: Did Apollo adhere to the standard routine tests? Initially, Apollo had conducted a urine toxicology test for 14 drugs. The hospital authorities claimed that the tests for all the 14 drugs were negative.

Dr Sushil Shah, Chairman, Metropolis Health Services opines that he cannot pass "an opinion on half facts", but hastens to add, "Apollo conducted the routine tests of blood and urine as required in a situation of drug overdose. The standard protocol was followed. They are not wrong just because the tests were negative."

A drug like cocaine takes 48 hours to metabolise and show in the urine

Though Apollo conducted both urine and blood tests for Rahul, experts question the rationale behind Apollo first conducting a urine test. "As a drug like cocaine takes 48 hours to metabolise and show in the urine, it is better to conduct first blood test and then urine tests," an expert informs.

There are other interesting aspects of the case. Experts point out that since it was a case of drug overdose, the second test conducted by Dr Lal Laboratories should have not just shown traces of cocaine, but should have shown high levels of the drugs. "A test for suspected overdose initially might show a negative result, but if conducted after a couple of hours should have shown a positive result," points out Dr Shah, adding, "I would have repeated the test exactly after three hours in a new urine test, which metabolises later."

According to Dr Shah, finding traces of cocaine and heroin in Rahul's urine does not mean that the test is positive. Even Lal's report claimed to find traces of drugs and did not claim that the tests were positive. He elaborated by drawing an analogy. Human chorionic gonadotropin, commonly known as HCG, is secreted in the blood of pregnant women. Sometimes, traces of HCG might even be detected in women who are not pregnant.

Dr A Velumani, Managing Director, Thyrocare Laboratories, feels that the goof-up has happened because Apollo was caught unawares. "It looks as if they were struggling to declare something. Apollo has semi-adequate methods. So, that could have been also been a reason." Dr Sudha Sheth, President, Bombay Nursing Home Association, gives Apollo the benefit of doubt. "It could have been a genuine mistake. It is difficult to know. Everything depends on when the tests were conducted."

To save itself from controversy, experts say that at press conferences, Dr Sibal or the team of Apollo doctors should have explained in clear terms the difference between a qualitative and a quantitative test.

Standard Protocol For Treatment

A standard protocol is followed by all hospitals for a suspected case of drug overdose. There are two phases to the treatment of drug overdose-the clinical and the laboratory aspect. In the preliminary stages, the case is handled by the hospital to stabilise the patient before sending his blood and urine samples to the laboratory. "A urine test is preferable because it is common and simpler," says Dr Sheth.

Treatment of drug overdose is a complicated issue as a myriad of facts like medical history of the patient, the drug taken by the patient, amount of the drug taken, accounts of family members and witnesses, have to be taken into consideration.

In the initial stages of treatment, doctors have no clue about the drugs taken by the patient. Signs and symptoms are the only key to come to a definite conclusion. Dr FD Dastur, Director, Medical Education and Consultant Physician, PD Hinduja National Hospital and Medical Research Centre, maintains that one has to be a little disciplined in such cases. "We cannot accept anything at face value. The case can be complicated at times. The patient can have a medical problem. For instance, after the ingestion of the drug the patient may have sustained a fall and a head injury and the latter may in fact be the cause of unconsciousness. Whatever the cause, emergency treatment must be given to ensure the patient can breathe in oxygen and that the blood can effectively carry the oxygen to the various tissues. Once the patient is stabilised, the search for the drug can be instituted." The circulation of oxygen to the various tissues in the body is checked because this in turn detects the nature of the drug. The gastric condition of the patient is checked. According to the gravity of the situation, the patient is either sent to the general ward or the ICU.

In the laboratory, pathologists usually consult the clinicians dealing with the case as to the type of drug to be detected. Dr Tester F Ashavaid, Head, Department of Lab Medicine, Hinduja Hospital explains, "Usually we verify if it's an organophosphorous poison. In case of an overdose, we ask the clinician what drug is suspected."

Benzodiazepine is the commonest drug tested for. In a case of drug abuse, the usual drugs tested for are Amphetamine, Methamphetamine, Cocaine, Barbiturates, Cannabinoids, Opiates, Benzodiazepine, Methadone and Phenylcyclidine Phosphate. Spot urine of the person is usually taken and tested by the Immunoassay Method.

Doctors have an option to conduct two kinds of tests—qualitative or quantitative. Both are fast and results are available within a few hours. Spot test, chemiluminescence immunoassay test, high-pressure liquid chromatography test are an array of tests conducted for accurate and quick results. In some cases, the creatinine test is conducted to monitor the functioning of the kidneys. A person into illicit drugs might dilute the urine, to prevent its detection by a qualitative or a quantitative test. A creatinine test detects even the faintest trace of drugs taken. The normal level in such a test varies anywhere between 0.22 and 1mg. If diluted, the levels will be very low.

Qualitative Vs Quantitative Tests

Despite being technologically advanced, both qualitative and quantitative tests have their shortcomings. In the case of a qualitative test, the levels of drug intake cannot be detected. The test will merely reveal a positive or a negative result. On the other hand, a quantitative test is an extremely sensitive test as it indicates the varying levels of drugs. "The main disadvantage of this test is that it cannot be used on a routine basis. It is expensive technology; skilled technicians are required even if the hospital can afford to conduct such technologies. Hospitals hence prefer to outsource such tests to referral laboratories," says Dr Shah.

The Reality

"There is no regular market for drug testing. Out of 100 cases, only two to three cases come in" - Dr A Velumani Managing Director Thyrocare Laboratories

The stark reality is that even with thousands of drug addicts, most hospitals are not equipped to conduct these tests. It comes as a surprise that even JCI-accredited hospitals like Apollo outsource such tests. "Drug abuse is not adequately addressed in India. Even if a case comes up in a hospital, at the most a person is detoxified. There is no regular market for drug testing. Out of 100 cases, only two to three cases come in," says Dr Velumani.

Lack of awareness about the tests has left the medical community unsure about the drugs to be tested for. Experts unanimously emphasise the fact that cases of overdose are rare considering the vast array of other cases that comes in every day. Dr Shilpa Shah, Pathologist, Breach Candy Hospital mentions, "We hardly get such cases. Requisition of drugs of abuse is very rare. People mainly from the high classes or those from the low classes are into drugs. The high society people do not come in to the hospitals for various reasons while the lower class cannot afford such treatment." Thus, installing a technology just for such a test is not economically viable.

Has Credibility Of Corporate Hospitals Taken A Beating?

The Rahul Mahajan saga has raised questions about the credibility of corporate hospitals. They are blamed for focusing on profits rather than patient care. However, Dr Charulata Pamnani, Chief Pathologist, Asian Heart Institute differs, "Just with one incident it would not be fair to blame all corporate hospitals. I come from a corporate hospital and I know the pain and the management put together to provide the services."

We Are Harassed: Apollo

Much to the chagrin of Apollo, the police have so far already grilled around 60 doctors and employees. Lalit Bhasin, Counsel for Apollo Hospital told Express Healthcare Management, "This is harassment of the management of Apollo, of the staff and the doctors. Everyday, new doctors are added to the list."

The management is miffed that even women employees were called in for questioning to the station, until Apollo protested. Now, the police have agreed to question them in the hospital itself.

According to inside sources, "doctors are on the verge of tears" after being grilled for hours. Doctors have to often sit in the police station for hours, skipping their OPD visits.

On the flip-flop, Apollo sources say, "It is a case of information gap." On the police allegation of keeping Rahul in the ICU longer, Bhasin says, "It is for the medical team and not the police to decide how long a patient should be kept in the ICU."

The Ripple Effect

The number of patients flocking to the premier hospital has also substantially reduced. Apollo has to even face its bitter fate in the stock market; its stock price has nose-dived.

On June 7, 2006, on the BSE, shares of Apollo Hospitals fell by about two percent or Rs 8 to Rs 4. The shares are down by 6.75 percent from Rs 431.10 on May 30, 2006.

When it comes to corporate hospitals, Apollo Hospitals dominates the stock market's interest. Of all the corporate hospital projects that raised money through primary issues, Apollo is the only one to retain investors' fancy.

In 1999-2000, Apollo expanded dramatically following its merger with Deccan Hospitals, Indian Hospital Corporation and Om Sindoori Hotels. In 1999-2000, Apollo's operating income was Rs 256 crore, while other income was Rs 23 crore. The aggregate income was Rs 279 crore. The company also posted a net profit of Rs12.4 crore for the quarter ended March 31, 2006. However, as evident from the graph, one incident was enough to trigger scepticism, consequently pulling down market prices.

Are We Being Too Harsh On Apollo?

Is it fair to target Apollo just because of a single incident? After all, one incident is not a yardstick to pass a sweeping judgment about the credentials of a hospital. Apollo is an internationally acclaimed hospital and its services and credentials are trusted by patients.

According to Apollo sources, "The hospital is not accused of killing anybody. At the end of the day, Apollo did what all doctors in such a situation would definitely do—save the patient from death. Rahul was hanging between life and death and amidst all the chaos, Apollo managed to pull him back to life. This aspect unfortunately has not been appreciated."

According Dr Alok Roy, VP, Operations, Fortis Hospital, Noida, "It was political situation which led Apollo to do what they did. I agree what Apollo did was not right, but at the same time the amount of police involvement is unnecessary."

While Apollo is credited with introducing international standards, lack of decentralisation of power and empowering some people with unbridled power have left a few of its senior employees disgruntled.

This incident has put all hospitals on alert, which Apollo or for that matter the entire medical community will not forget for years to come. And if there is a positive outcome of the controversy, it is the renewed emphasis on ethics, transparency and accountability for hospitals.

ehm@expresshealthcaremgmt.com