Strident call for stringent control of medical clinics
Tough action against medical clinics going beyond their mandate and doctors posing off as specialists, was the strident call from health circles as Colombo was in shock over the death of a woman doctor on Tuesday in a clinic dispensing cosmetic surgery.While an urgent clamour went out for the establishment of a Specialist Register with details of where they practise which would be accessible to the public and strict regulation of all medical clinics, the question being asked by the public is: Where are the watchdogs of the health
sector? Unregulated beauty salons were another major cause of concern.
As a multi-pronged investigation got underway into the death of the woman doctor, with a police probe and a magisterial inquiry, the post-mortem findings, a report from the Government Analyst and a report on the drugs and devices found within the clinic are awaited. (See box for what they found in the clinic)
The Private Health Sector Regulatory Council (PHSRC) is to request the Provincial Director of Health for the Western Province to carry out his own probe, the Sunday Times learns. This came amidst assurances from Health Minister Maithripala Sirisena that the PHSRC Act would be amended to give it more teeth.
A family of three, father and two children, are in mourning down Senanayake Mawatha in Nawala while the clinic in three units on the sixth floor of ‘Visakha Residence’ along Visakha Road in Bambalapitiya has been sealed with two policemen guarding them.
The victim, in her late forties, was none other than Medical Officer, P.A. Priyangi, who was ironically working in the Plastic Surgery Unit of the Lady Ridgeway Hospital for Children.
“Dr. Gamage’s clinic is registered as a ‘Medical Clinic and Dispensary’ with the PHSRC under the name of Dr. V.G.N. Vagith in 2012, 2013 and 2014 under the category full-time General Practice,” confirmed PHSRC Director, Dr. Kanthi Ariyaratne, explaining that usually the registration process starts with an application being forwarded by the Provincial Director of Health Service of the relevant province.
‘General practice’ would generally mean the treatment of minor ailments such as coughs and colds. Such medical clinics are bound by guidelines — the person running it should be a qualified doctor, it should be ethical medical practice, there should be essential equipment, the floor area should be adequate, there should be proper washing facilities and clinical waste management, drugs should not be expired and they should also be stored properly, the Sunday Times learns.
If it is a medical clinic, an emergency tray with such drugs as adrenaline and hydrocortisone is vital to deal with severe allergies, stressed Dr. Ariyaratne.
“The drugs seized from Dr. Gamage’s clinic will be checked at the National Drug Quality Assurance Laboratory. The report should be ready in two weeks,” said Health Ministry’s Additional Secretary and Cosmetics, Devices and Drugs Authority Director Dr. Amal Harsha de Silva.
When asked, Dr. de Silva said that non-medical beauty parlours are not regulated but western beauty products are well-regulated. “No cosmetic, drug or device comes through the Customs without our approval,” he said adding, however, that people could smuggle such products in their baggage but that too had reduced drastically with the Customs being vigilant.
For what exact cosmetic procedure Dr. Priyangi went to the clinic with the board, ‘Dr. Nimal Gamage, MBBS, MD’ in Colombo 4, was not clear but according to a statement issued by Dr. Gamage to the police, she had become ill after being administered an injection
with the antibiotic ‘Cefotaxime’. Sources told the Sunday Times that she had apparently gone to get “something done to her face”.
According to the source a sample of the drug-injection site has been sent for analysis and there is suspicion that she may have been given a cocktail of four-five drugs (analgesics) to keep the pain down.
With Dr. Priyangi’s death, the tip of an ice-berg of issues and severe flaws in the health regulatory system have surfaced, numerous doctors told the Sunday Times, while others said that in defence of the health authorities, they could not work to maximum capacity due to a dearth of staff.
According to documents in the possession of the Sunday Times, a written complaint had gone from the Association of Plastic Surgeons of Sri Lanka as far back as March 10, 2011 to the Health Ministry about the ‘Illegal practice of medicine in Sri Lanka – Dr. Nimal Gamage’ when the latter allegedly launched an advertising blitz about the wonderful procedures he was capable of.
This had followed an article in a newspaper headlined, ‘Nimal Gamage medical center…….a modern miracle capable of rolling back years to make you look great!!!’ which appeared in connection with the National Healthcare Exhibition 2011 organised by the Department of Health, Western Province.
The complaint had also been copied to the Sri Lanka Medical Council (SLMC) and several other institutions including private hospitals, the newspaper concerned and several electronic media groups.
It had been of no avail. Although the Association of Plastic Surgeons pointed out that Dr. Gamage was not a surgeon, that he was a private practitioner in internal medicine and cardiology and did not have a post-graduate degree in surgery either from the United States of America (USA) or Sri Lanka, that he has had no training in plastic surgery from any recognised institution and has never been a board certified specialist and there was blatant advertising violating medical ethics, no action seemed to have been forthcoming.
Dr. Gamage continued to advertise on his website ‘Lanka Cosmetic’ that he had 25 years of experience in the USA and was trained in the latest techniques of cosmetic laser and cosmetic surgery.
His website also stated: “Liposculpting with local anaesthesia provides patients with safe liposuction with less pain. No risk to life, faster recovery and better results compared to traditional liposuction performed under general anaesthesia.
“My technique of tumescent liposuction is unique. Having trained as a cardiologist in USA provides me with skills required to evaluate patients preoperatively. I do not use any sedatives or other analgesics……..”
Having secured his MBBS from the Colombo Medical Faculty in 1982, what Dr. Kevin Nimal Gamage, as he was registered in the USA, he conveniently failed to reveal was that he had board certification in the USA for internal medicine but no qualifications as a specialist in plastic and cosmetic surgery.
Another crucial factor was that Dr. Gamage’s licence had been revoked in June 1995 by the Medical Board of California for many malpractices including sexual misconduct and fraudulently creating medical records and insurance claims. In 2005 he had been placed on a seven-year probationary period. In 2009, his appeal to terminate his probation had been turned down. It was then that he returned to Sri Lanka.
The strictures on him as laid out on March 3, 2004 by the Medical Board of California included “no solo practice, no physician assistant supervision, 3rd party chaperone present while consulting, examining, treating female patients”.
However, back in Sri Lanka, he had become a so-called popular cosmetic surgeon, firstly working from a medical clinic in Colombo 7 and later moving to Visakha Road, having his clinic in one apartment building and his residence in another apartment building down the same road.
Not only didn’t the Health Ministry heed the warnings of the Association of Plastic Surgeons, but a senior health administrator and an oft-quoted nurse in a premier Government hospital in Colombo took upon themselves the task of extolling the virtues of this “unqualified specialist” on national TV at prime time, doctors alleged.
A young woman who “nearly went” to Dr. Gamage for treatment last year after seeing the hype on TV told the Sunday Times, “Just check the Youtube”. The Sunday Times found that throughout 2012, 2013 and even as recently as May, this year, the television publicity was immense.
When this young woman and her mother rang the bell of the apartment in June, last year, what met their eyes had confused them. “Several young women in clothes which did not seem to suit a medical clinic were moving about,” she said, while after a cursory chat and not a single test, Dr. Gamage allegedly told her that her hands were blocked with fat. He had assured her that not only her hands can be cured but he can also make her more beautiful. The booking fee for the procedure was Rs. 10,000 and the arms liposuction Rs. 80,000.
This young woman never went back, but many including politicians, both men and women, and VIPs have been frequent clients of Dr. Gamage, sources said.
Several who had various issues after Dr. Gamage’s procedures have been treated at the National Hospital and other hospitals, the Sunday Times understands.
With the clinic being sealed this week, many doctors pointed out that the vital basis on which medicine is practised, ‘Do no harm’, had not been adhered to, while the health authorities had turned a blind eye.
|A month to determine cause of death
The post-mortem examination on the woman doctor was conducted by Colombo’s Chief Judicial Medical Officer, Dr. Ajith Tennakoon, on Wednesday.
Sources at the Judicial Medical Office said that the cause of death will be known only after the examination of tissue samples taken from the body. The investigation will possibly take about a month.
Meanwhile, Government Analyst Sakunthala Tennakoon said that she was awaiting specimens from the postmortem.
Doctor warned verbally after probe
Lamenting the lack of a Specialist Register, sources at the Sri Lanka Medical Council (SLMC) said that after an investigation against Dr. Nimal Gamage, he had been warned verbally by the Professional Conduct Committee in December 2013.
The SLMC warned him to be on good professional conduct, while taking note of the fact that his probation period in the US had expired.
When asked why the SLMC which is the guardian of medical standards did not see it fit to inform the public, the source said that no complaints about Dr. Gamage’s practice here had reached them.Pointed out that the Association of Plastic Surgeons had copied to the SLMC its complaint to the Health Ministry, as far back as 2011, the source said it had not submitted an affidavit as was required.
However, when a private sector physician informed the SLMC that Dr. Gamage was under a cloud in the US, the SLMC had written to the Medical Board of California and got the details. On a complaint made by the then Registrar, as was possible under the regulations, the SLMC initiated an inquiry against Dr. Gamage.
When persistently questioned as to how an MBBS doctor pretending to be a Plastic Surgeon was treating patients, the source said that only a Specialist List was available and many requests made to the Health Ministry to amend the Medical Ordinance to regulate specialist practice, after establishing a Specialist Register. But the ministry was dragging its feet.
Clinic grossly lacking in drugs to tackle an emergency, no anaesthetist present
“It was a death trap. A disaster waiting to happen,” said Consultant Plastic Surgeon Dr. Dulip Perera who was part of the team which visited Dr. Nimal Gamage’s clinic to collect drugs and devices for examination and investigation.
Recreating what had happened on Tuesday as told by the clinic staff, Dr. Perera said when the doctor was administered an injection she had begun struggling and allegedly requested hydrocortisone as she had had some training in the field of anaesthesia. But it was unavailable. Then she had tried to sit up, but dropped back with froth coming from her mouth.
“The clinic had no suckers to clean the airways, no intravenous cannulae. Half a vial of adrenaline seemed to have been given, not intravenously as required but intramuscularly,” he said, adding that a deep-sedation vial, half of which had been used had also been taken into custody.
How can a cosmetic surgery clinic be set up in the “unlikely place” of a residential flat, asked Dr. Perera, explaining that the supposed operating room (OR) was like a small utility room. Not a single essential needed in an OR, such as suckers to clear the airways, intravenous cannulae, face-mask and ambu-bag, oxygen lines, air-conditioning etc., was there.
Lending their voices to Dr. Perera’s calls for stringent regulation, Consultant Plastic Surgeons Dr. Romesh Gunasekera and Dr. Thushan Beneragama also stressed the need for immediate action.
Such unregulated places are mushrooming, said Dr. Gunasekera explaining that the so-called clinic at Visakha Road was a “bastardisation of the concept of office-based surgery in the US which is well regulated”. No surgical procedure should be done without an anaesthetist being present along with the surgeon and facilities for resuscitation.
Dr. Perera, meanwhile, lashing out at so-called clinics said now beauty parlours with no facilities and no medically qualified personnel were also engaging in minor surgical procedures, administering injections, with some seemingly getting into major procedures as well.
“The place was one of disorder. Old and dusty plastic flowers decorated the walls and the unwashed curtains seemed about five years old. The operating room was ‘equipped’ with an old theatre table, may be even a dentist’s chair. Except saline and a generic antibiotic, all other drugs had expired. There were also butterfly cannulae which are inadequate to administer anaesthesia,” said Dr. Perera.
Pointing out that sterility standards were extremely poor, he explained that instruments had been boiled, wrapped in cloth and placed in an old fridge which was not working. “Some instrument trays had not been washed in a long time and I could flick off sediment with my finger.”