The patient (the plaintiff) is a woman, born on August 20, 1934, a farmer. on May 24, 1999, the plaintiff went to X City, X Province Maternal and Child Health Hospital (the defendant) to remove the birth control ring. After the operation, the plaintiff appeared abdominal pain and other symptoms, after symptomatic treatment to alleviate, on the 28th of the same month, ultrasound found a small amount of fluid in the abdominal cavity. And to the city's second people's hospital, the caesarean section, the operation found that intestinal perforation and uterine "small mouth closure".
The plaintiff believes that the perforation of its intestines is the city women's and children's health hospital for the removal of intrauterine devices, sued to the court to order the defendant to compensate for the implementation of the ring surgery, resulting in perforation of the uterus and intestinal perforation of the cost of medical expenses (16,645.9 yuan) and moral damage (50,000 yuan), the defendant did not agree to pay compensation for the reason that they are not responsible for. The court of first instance that the perforation of the intestines is caused by the removal of the ring is difficult to establish, and therefore rejected the plaintiff's claim.
After the plaintiff appealed, and submitted a written application, requesting the city of women's and children's health hospital to do the removal of the birth control ring surgery and its intestinal perforation of causal relationship to be identified. The court of second instance, agreed to the plaintiff's request, and convened the parties *** with the identification of identification units and identification of the scope of the material, commissioned by the Beijing court of science and technology appraisal institute of the plaintiff's request for appraisal. Beijing court of science and technology appraisal institute through the appraisal, that the defendant in the removal of the birth control ring for the plaintiff in the uterus rupture caused by the uterus rupture caused by intra-abdominal infection, and intestinal rupture caused directly by the removal of the ring is unlikely to. 2001 February 1, the court of second instance according to law to make a final judgment.
Abstract of medical records
I. Material from the relevant medical records of the Municipal Maternal and Child Health Hospital
1. Record of the operation to remove the intrauterine device on May 24, 1999: gynecological examination: the vulva was in a transient form, and the mucous membranes were pale. Vagina is free and the amount of secretion is small. The cervix was enlarged. The uterus is anteriorly positioned and slightly enlarged. Adnexa (-). Record of IUD removal: uterine body anterior, cervical hypertrophy, uterine cavity 9cm, hard, remove a medium-sized metal ring, small amount of bleeding, no other abnormalities.
2. May 24, 1999 fluoroscopy application report card: abdominal pain at 4 o'clock, refused to press ...... abdominal plain film did not find obvious abnormalities.
3. Diagnostic X-ray report card of May 24, 1999: no intestinal dilatation or air-liquid planes were found. IMPRESSION: Plain films of the abdomen did not reveal significant x-ray images of intestinal obstruction.
4. May 28, 1999 B-line array real-time visualization report card: a small amount of ascites echoes were detected in the right and left quaternary rib regions, and the sign of intestinal tube floating was seen. The echogenicity of the right colon was mildly abnormal, with increased peristalsis and fluid echogenicity in the intestines. The uterus and both adnexa were not obvious. There was a small amount of fluid in the abdominal cavity (cause of ascites to be investigated).
Summary of the hospitalization record of the Second Municipal Hospital
Date of admission and discharge: May 28, 1999 and November 1, 1999.
Complaint: abdominal distension, poor appetite, nausea and vomiting for 4 days.
Current history: abdominal distension, poor appetite, abdominal pain with nausea and vomiting, not accompanied by acid reflux, belching, diarrhea, fever, etc., started after removal of the IUD 4 days ago. The patient to the maternal and child health hospital, given antispasmodic, analgesic, anti-inflammatory and symptomatic treatment, abdominal pain symptoms have improved, but abdominal distension, nausea, nausea and vomiting the same as before, vomiting for eating soon after that, vomit for the food, this time again the city of women and children's health care hospitals for the ultrasound examination of the abdomen found that the left and right quadriceps area to detect a small amount of ascites, in order to further clarify the cause of ascites to the hospital for treatment. Outpatient clinic to "ascites cause to be investigated" admitted to the hospital ......
Past history: usually healthy, no hepatitis, tuberculosis, typhoid fever and other infectious diseases and their history of contact, no history of surgery and trauma, no history of drug allergies.
Menstrual history: ...... has been amenorrhea for 15 years, no history of dysmenorrhea.
Physical examination: T36.8 ℃, R19 times / min, P78 times / min, Bp16/9.33Kpa. development is normal, nutrition is moderate, mental clarity, autoposition, examination of the cooperation ...... abdomen is slightly raised, abdominal softness, the right epigastric mild pressure pain, the liver and spleen are not palpated under the ribs, no palpation of abdominal masses, abdominal The percussion is drumming, bowel sounds are normal, ascites sign (+), no deformity of the spine, no edema in both lower limbs ......
The patient felt heavier abdominal pain in the left side at 1:30 on May 29, 1999, the examination: abdominal bulge, left abdominal compression pain is obvious, rebound pain is obvious, the urgent shooting of abdominal standing plain film shows intestinal perforation, the examination of the blood routine WBC11.6×109 / L, N 0.97......
On May 29, 1999, 4:30 to 6:20 pm operation was seen: into the abdominal cavity, there is an overflow of fluid in the abdominal cavity, pumped out, exploring the abdominal cavity, pelvic intestinal interstitial adhesions are heavier, confined parcels, a number of intestinal fluid, separated from the visible Intestinal contents and the smell of bad odor and unpleasant, the outer envelope was pink skin-like, given to remove, ileojejunal junction of about 30cm congestion and edema and limited intestinal dark pus moss serious, and see this section of the intestinal tube has a 2.5cm or so small mouth to the outside of the outward discharge of yellow intestinal fluids, the local tissue is fragile, given to the suture repair and found that the bottom of the uterus in the anterior arm of the hole is closed, the local congestion and edema, rinsing ......
Discharge diagnosis: intestinal perforation, intestinal fistula.
Forensic Medical Opinion
1. On the removal of the ring: the identification of the long-term placement of intrauterine devices (metal rings), there will be a common complication of the birth control ring embedded. Her age (65 years old at the time of the removal of the ring), has been menopausal for 13 years, the cervix and uterus has atrophied, the uterine wall has become weak, this time the removal of the ring has a certain degree of difficulty and the risk of damage to the uterus. In the present case, there was a possibility of uterine damage (rupture) caused by pulling on the incarcerated IUD. In addition, the record of the IUD removal operation shows that the uterine cavity is 9cm, which is larger than normal (a normal adult woman should be about 6cm), and if the IUD is too long into the uterine cavity, there is a possibility that it may directly cause uterine damage (perforation).
2. Regarding the perforation of the uterus: the surgical record of the Second Municipal People's Hospital contained "a small hole in the anterior wall of the uterine fundus was closed, with localized congestion and edema", which was the general pathology of a fresh injury, and the surgeon also believed that "it should not be regarded as a stale injury". Therefore, we believe that the uterine injury is a fresh injury, consistent with the characteristics of the injury 4 days ago, but there is no direct evidence of uterine penetration.
3. On the intestinal perforation: the city's second people's hospital surgical records recorded "into the abdominal cavity, there is an overflow of abdominal fluid, pumping out the abdominal cavity, exploring the abdominal cavity, the pelvic intestinal interstitial adhesion is heavy, confined parcels, a number of intestinal fluid, separated from the visible intestinal contents and the smell of the stench unpleasant .......". ". It is evident that the adhesions in the abdominal cavity were severe and the intestinal contents were seen only after separating the adherent organs, thus having the possibility of intestinal rupture caused by separating the adhesions.
4. On the appraisee's course of disease: ① no physical abnormality before the removal of the ring, the city's maternal and child health hospital obstetrician and gynecologist said, "there is no contraindication to surgery before the operation". The current material also did not see the appraised person has a history of other diseases; ② ring removal operator said "in the process of removing the ring, the plaintiff said a little uncomfortable, due to pulling the ring, the plaintiff's expression of discomfort ......"; ③ ring removal, on the way home or after arriving at home, feel the pain in the abdomen; ④ municipal maternal and child health care hospital obstetrician and gynecologist said "no contraindications to surgery before surgery". (iii) After the IUD removal operation, on the way home or after arriving home, she felt pain in her abdomen; (iv) On the day of the IUD removal operation at the Municipal Women's and Children's Healthcare Hospital (1999.5.24), it was recorded on the fluoroscopy and ultrasound application form that she had abdominal pain at 4:00 p.m. ......, which indicated that abdominal pain did occur after the IUD removal operation; (v) The Municipal Women's and Children's Healthcare Hospital conducted an ultrasound on 1999.5.28 and found ascites And found ascites, suggesting that the yellow abdominal pain and other symptoms are persistent.
To summarize, consider that the condition of the appraised person may be: uterine rupture caused by IUD removal surgery, the formation of infected foci at the rupture opening, the intra-abdominal omentum and small intestines to the infected foci of the aggregation. As the intra-abdominal infection was not serious at the beginning, the initial clinical manifestations were not obvious and the symptoms were atypical, so it was not easy to be detected and treated in time. With the gradual aggravation of intra-abdominal infection, resulting in congestion and edema or even necrosis at the infected places of small intestinal organs, serious adhesion of pelvic organs and small intestines, etc., it is very easy to cause rupture of intestinal tubes that have already become necrotic during dissection and exploration to separate the organs. It is therefore considered more likely that the rupture of the uterus, which caused intra-abdominal infection in the assessee, was caused during the removal of the ring, while the rupture of the intestinal tubes was unlikely to have been directly caused by the removal of the ring.
The court of first instance decision
The court of first instance, based on valid evidence, found that the facts were: on May 24, 1999, the plaintiff went to the defendant to request that she be operated on for the removal of the birth control ring. The defendant sent a medical personnel in accordance with the relevant operating procedures for the implementation of the operation, the operation went smoothly. May 28, 1999, the plaintiff complained of abdominal distension, nausea, nausea, vomiting as the reason for the second people's hospital in the city, the city hospital in the temporary diagnosis at the time of admission for ascites to be investigated. May 29, the city hospital of the plaintiff for emergency exploration, diagnosed as intestinal perforation. The plaintiff was then admitted to the city hospital for treatment of this disease.
The court of first instance at the same time also held that the device used to remove the birth control ring surgery, not easy to cause uterine perforation. Even if the uterine perforation is caused, it is unlikely to close and form a trace within four days, especially in the case of intestinal perforation, intestinal adhesions, and a large amount of fluid in the abdominal cavity. In addition, the length of the IUD could not reach the location of Plaintiff's perforation (the ileojejunal junction), and the anterior wall of the uterine fundus and the ileojejunal junction were not in the same straight line due to the constant peristaltic movement of the intestines, so it was difficult to claim that the perforation was caused by the IUD removal device. In view of the foregoing, the plaintiff's sole reliance on the surgical records of another hospital as a basis for compensation is insufficient evidence, and is therefore not supported by this court. Therefore, according to the Chinese people's *** and the general principles of civil law, article 134, the judgment is as follows: dismiss the plaintiff's claim, the litigation fee of 2510 yuan borne by the plaintiff.
The court of second instance decision
In the second trial, the appellant (the plaintiff's side) that the appraisal opinion is scientific and fair, the municipal health care hospital that the appraisal conclusion is uncertain, is only an analysis of the possibility of the appraisal is not appropriate to use. In this regard, the court of second instance held that: the appraisal of the causal relationship by the Beijing Court Science and Technology Appraisal Institute divided the cause of the plaintiff's intestinal perforation into two stages of evolution, namely, uterine rupture leading to intra-abdominal infection and rupture of the intestinal tube caused by caesarean section performed by the Municipal No. 2 Hospital, which was in line with the development of the plaintiff's condition; and that the rupture of the yellow intestinal tube and the Therefore, even though the appraisal opinion used the uncertain judgment of "greater possibility" and "unlikely", the Court still considers that the appraisal conclusion is a scientific and fair opinion based on the appraisal material under the existing scientific and technological level, and the reason why the term is not certain is that the appraisal authority adopts a scientific and prudent attitude towards the two parties. The reason for the lack of certainty in the terminology is that the appraisal authority is scientific and prudent attitude to take a responsible approach to both parties. In conclusion, the court of second instance that the possibility of the appraisal opinion is a scientific, reasonable and correct judgment, can be considered that the plaintiff's intestinal rupture was caused by the health center for the plaintiff to remove the ring rupture of the uterus caused by abdominal infection and in the city of the second people's hospital surgery to explore the separation of the organs, that is, health care center for the plaintiff to remove the ring is the cause of the rupture of the intestinal tube directly.
The court of second instance that, after the identification of the health care center for the plaintiff has been identified as a ring removal surgery and Huang's intestinal rupture there is a causal relationship, so it should be inferred that the health care center in the operation of the surgery there is fault, the fault infringement of the plaintiff's right to physical health, the plaintiff caused mental suffering, the health care center should be caused by the consequences of the damage caused by the plaintiff to bear civil liability. The judgment is as follows: (1) revoke the judgment of the first instance; (2) the health care hospital compensation for the plaintiff's medical expenses 16645.90 yuan, 8000 yuan of mental comfort ......
Brief comment on the case
In recent years, the medical dispute cases are gradually rising, in the legal profession, the health sector has launched an unprecedented discussion, people's understanding of the The understanding of such cases continue to deepen and improve, especially the intervention of forensic identification, so that some of the complex medical issues more clear, this case through the forensic identification, reasonable and objective description of the plaintiff in a series of clinical manifestations of the removal of the ring, so that the case can be a more reasonable judgment. From the two trial process and judgment, the author believes that there are a number of issues need to be explored.
I, the correct trial of medical disputes is the guarantee of fair and comprehensive identification
Because of medical disputes involved in the case of medicine in the ever-changing injuries and / or disease, its clinical manifestations, disease regression will be due to the intervention of various factors and different results, so that the trial of medical knowledge of little understanding of the facts accurately grasped by trial staff, is reluctant to difficult. Through the normal procedure, in the case of both parties recognized, entrusted the relevant appraisal organs, such as all levels of medical malpractice appraisal committee, forensic medicine appraisal institutions, etc. on the case of the relevant matters for identification, evaluation, is the correct trial of medical disputes in China's feasible channels. The case of the first trial, did not identify the focus of the "plaintiff intestinal perforation and whether there is a causal relationship between the removal of rings", will inevitably lead to bias in the judgment.
Second, the key to correctly hearing medical disputes is to accurately understand and use of forensic identification
The authors believe that, due to the current situation of forensic identification agencies can only be evaluated objectively from the medical point of view of medical behavior, can not be done from the legal point of view of the elaboration of the forensic identification of medical disputes, which is the focus of the work of the future. Therefore, to fully understand the basis of the use of forensic identification opinions, accurate understanding of forensic identification opinions, pay attention to the following aspects:
1. Fully understand the forensic identification opinions: the forensic identification of this case is from the medical point of view, around the identification of the purpose of the analysis of the plaintiff's ring removal and postoperative uterine rupture and intestinal perforation found between the cause and effect of the plaintiff and the development process of its condition, an objective description. The development process was objectively explained. The main reasons for the use of the phrases "more likely" and "less likely" in the appraisal opinion are: (1) medical dispute appraisal is a kind of inferential appraisal, which is based on the consequences (the regression of the disease) to reverse the presumption of possible causes (including all medical behaviors); (2) medical dispute appraisal is a kind of inferential appraisal. medical behavior); (2) the limitations of the medical discipline. As medicine is a constantly evolving discipline, the existing medical theory will inevitably have a lack of understanding or even error; (3) the limitations of the evidence. Medical units to cure the disease to save lives for the purpose, in the process of diagnosis and treatment of patients, some evidence can not be obtained. In this case, there is no direct evidence of "whether the uterus is perforated", although the operator of the Second Municipal People's Hospital responsibly observed that "the anterior wall of the bottom of the uterus has a small hole that is closed, and the local area is congested and edematous", which can be determined that the uterus has a fresh injury, but whether or not there is a perforation, it is not possible to The uterine tissue was extracted for pathologic section observation. As the court of second instance held, the conclusion of the appraisal was a scientific and impartial opinion based on the appraisal materials available under the existing scientific and technological level. The court of second instance, based on the appraisal opinion, concluded that "the rupture of the plaintiff's intestinal tube was caused by the rupture of the uterus when the health center administered the ring to the plaintiff, which led to an abdominal infection, and was caused by the exploration and separation of the organs during the operation at the Second Municipal People's Hospital, which means that the health center's administration of the ring for the plaintiff was the direct cause of the rupture of the plaintiff's intestinal tube." This conclusion is based on a full analysis of the expert opinion. The authors believe that in order to fully understand the forensic science opinion, do not only look at the final conclusion, but also focus on analyzing the analysis and description part of the appraisal, so as not to cause bias in understanding.
2. From the legal point of view of the use of forensic identification: as mentioned above, forensic identification sometimes only on the fact of causation, as the case of identification, the identification of the fact of causation only clear (medical). How to correctly convert it to legal causation, this is the legal profession in the future to further explore the problem. At present, the doctrine of legal causation mainly has quite causation, statute intention, foresight and sufficient cause. Therefore, legal causation is a complex issue, relying only on any one doctrine is unlikely to solve all the problems, especially the medical process is a very complex process. The regression of the same disease can vary greatly depending on the circumstances of the disease, the patient's own physical condition, the timing of the consultation, the hospital's medical conditions and level, and the doctor's experience, and so on, so it is necessary to analyze the specific circumstances of each case. The key point in this case is whether the removal of the ring caused uterine perforation, but the author believes that more important is the cause of uterine perforation, the forensic identification analyzed the cause of uterine damage: (1) the plaintiff's own condition: uterine atrophy, uterine wall weakness, and the complications of incarceration of the IUD; (2) the removal of the IUD into the uterine cavity for too long. Both factors were possible contributors to the uterine injury, and it is worth exploring which doctrine of legal causation should be applied in this case. The appraisal only on the fact of causation, but neglected to elaborate from the legal point of view, is a defect.
Third, on the exemption problem
The authors believe that, in the trial of medical disputes, not only to safeguard the interests of the majority of patients, but also take into account the interests of the medical unit, in the case of medical behavior with negligence and cause personal injury to the patient, to take into account the characteristics of the hospital itself, the medical profession is a high-risk occupation, the complexity of different patients with different kinds of conditions Diagnosis and treatment, but also in the process of constantly looking for treatment options, sometimes inevitably this or that deviation or negligence, how to correctly evaluate the medical behavior of negligence, what should be considered as having the conditions of exemption from liability, will be the future of the judiciary, the health sector, as well as the forensic community *** with the discussion of the issue.
The authors believe that the determination of exempting conditions should be considered mainly from the complexity of the injury and/or disease, the quality of the patient's own body, the overall condition of the hospital's medical equipment and its level of medical care, and the doctor's own level of experience. In this case, there were two causes of uterine perforation, and after the perforation due to the patient's own condition led to atypical clinical symptoms, health care hospitals due to the limitations of the medical equipment and level of the final formation of intra-abdominal infections, whether this situation can be exempted from liability, how much should be exempted from liability, need to be further explored.