DEATH OF LADY DOC. AT BEAUTY SALON Strident call for stringent control of medical clinics Clinic grossly lacking in drugs to tackle an emergency, no anaesthetist present

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 nonmedical beauty parlours are not regulated but western beauty products are wellregulated. “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

“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, airconditioning 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 officebased 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.

Citing the example of lipo- suction, he said that patients need to be evaluated for such a procedure. For every person who is obese, this may not be the answer.

Dr. Perera, meanwhile, lashing out at socalled clinics said now beauty parlours with no facilities and no medically qualified personnel were also engaging in minor surgical proce- dures, administering injections, with some seemingly getting into major procedures as well.

He alleged that Dr. Gamage’s clinic sported ‘certificates of participation’ at cosmetic surgery workshops which certainly were no indication that he had been trained in the field.

“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.”