Elective surgeries could be deferred / postponed if the circumstances, on the day of elective surgery, are not ideal; and any circumstance that could hamper healthcare delivery must be accounted for.
Irrefutable Facts
The patient, a child with squinted eyes and chest deformity, consulted the hospital. Squint correction surgery was advised. The child was referred for a neuro-ophthalmic review.
Neurological problems were ruled out, preoperative investigations revealed faint functional systolic ‘murmur’ and chest wall abnormality.
The child was referred to the cardiologist, who declared him ‘fit for surgery under general anaesthesia.’ Accordingly, the surgeon planned the surgery, and the child was kept nil by mouth. He was taken to the OT in the evening.
Anaesthesia was administered, but the anaesthetist encountered difficulty in intubation. Muscle relaxant was administered. The child suffered cardiac arrest and died despite cardiopulmonary resuscitative measures (CPR).
The child’s parents sued the hospital, cardiologist, surgeon and anaesthetist. It was alleged that on the day of surgery, the child was kept fasting for 9 hours and 20 minutes, due to which he became hypoglycaemic, which led o cardiac arrest.
It was alleged that there was a huge gap between atropinisation and actual surgery. Ideally, it should be administered 45 minutes pre-operatively, but it was administered at the surgeon’s convenience.
Doctor’s Plea
The hospital and doctors stated in defence that the child was referred to the neurologist and cardiologist; both certified him fit for surgery under general anaesthesia.
It was further stated that preoperative ECG, ECHO and X-ray were not necessary for children and persons below 40 years except when medically warranted. It was pointed out that post-administration of anaesthesia, the child developed sinus bradycardia, followed by cardiac arrest, and despite CPR, he died.
Court’s Observations
The court perused medical records and found that the patient suffered from bilateral squint and chest deformity, which were congenital anomalies. The court observed that cardiac anomalies could not be ruled out in such a case, and if the physician had noticed a murmur, then a higher degree of skill and care was expected from the cardiologist. The court concluded that the cardiologist casually declared the patient fit for general anaesthesia.
The court further observed from medical records that the surgery was planned for morning but performed in the evening. Also, the patient was not cooperative; intubation was difficult. Moreover, it was surgeon’s 17th surgery of the day. Hence, the court questioned why the squint surgery was not ‘deferred to another date’ even though it was an elective surgery and not an emergency.
Hence, the court held the hospital, cardiologist, surgeon and anaesthetist negligent.
Prevention Is Better Than Cure
- Fitness of a surgeon is as important as fitness of the patient. Courts in India do take this into account in cases of medical negligence. An elective surgery should be postponed if the surgeon is not fit for any reason. It is advisable, not mandatory, to inform patients / attendants of the reasons for postponing and to document the same.
- Exercise care and caution in certifying a patient fit for surgery, especially when signs and symptoms point out otherwise. Suspicions, if any, of the referring surgeon must be specifically ruled out. Appropriate investigations must be advised. Factors such as patient complaints and medical history must be taken into account. The steps taken and the reasons for certifying fitness must be specifically documented. Furthermore, the responsibility to take requisite care in certifying fitness is more on super-specialists than specialists.
Source : Dr. Reba Modak & Anr. v/s Sankara Nethralaya & Ors.
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