Criticare - A special feature on Anaesthesiology

Eventuality on the table: Is anaesthesiologist liable?

Dr Suganthi Iyer

Many a times when an eventuality occurs on the operating table, there is a confusion whether the anasthesiologist is liable or not. The following judgment could clear the ambiguity related to the question.

Mrs P was admitted in Jeevan Vikas Kendra hospital under Dr F for excessive bleeding and white discharge during periods. She was investigated, D & C was done and later posted for hysterectomy. Pre-operative investigations and fitness were obtained by Dr A. She was transferred to a private nursing home of Dr F where she was operated on, but she died on the operation table. The complaint was lodged in Maharashtra State Commission.

The complainant statement was as follows :

1. Shifting of the patient from a well-equipped Jeevan Kendra Hospital to an ill-equipped nursing home – Sukhada Maternity Nursing Home was aimed at making profit.

2. The non-availability of blood wherein the patient was having a rare blood group, weighing 124kg and medically a “morbid obesity patient”.

3. The doctor’s negligence was further compounded by prolonged duration of operation for seven hours .

4. Excessive blood loss during operation and therefore IV fluid and heamacel was used. The blood has inherent property of carrying oxygen. In case of blood loss, the blood pressure may be maintained by infusion IV fluids at faster rate. However, if the blood is not replaced, it can cost definite hypoxia, which is difficult to estimate on the operation table.

The nursing home had no arrangement for machine-operated artificial respirator and adequately long needle was not available to inject the medicine intra cardiac at the crucial stage to revive the patient.

The State Commission observed :

It was obviously a hasty and unwise act to treat a risk factor patient under inadequate arrangement when the authorities were fully aware of the diagnosis.

The Hemacel is used as a plasma substitution and not itself a substitute for blood and is used when blood is not available in an emergency. The Commission concluded that the use of hemacel during operation itself demonstrated that blood in required quantity was not kept ready and was not available with the surgeon.

The Commission substantiated that the prolonged duration of the operation extending to seven hours itself showed want of professional skills and average medical surgical knowledge on part of the surgeon and this exposed the patient to the risk factor of prolonged anaesthesia which may have accelerated the death of the patient.

The post mortem report was “shock due to anaesthesia (unnatural)”. However, the State Commission concluded that the surgeon appeared to blame on the anaesthesiologist with regard to the fact that there was no privity of contact between the patient and the anaesthesiologist and that the latter cannot be liable, even if provided negligent in her duty as her services were hired by the surgeon. The State Commission declared the surgeon guilty of medical negligence due to lack of ordinary care, which a medical practitioner should have exhibited.

An appeal was filed in the National Commission by the Surgeon who stated that in the field of medical science, duration of surgical pressure varies from patient to patient and surgeon to surgeon and no hard and fast rule can be placed down and that the patient was fully investigated pre-operatively and was maintained throughout the operation and the patient’s death was a mere accident

The anaesthesiologist stated that the operation extended beyond estimated time. She monitored and maintained the patient’s vital parameters. Unavailability of blood was also informed to the surgeon to enable him to take necessary steps. Though the surgery started at 8.45 am, blood was available only at 2.15pm. Till then, the blood pressure was maintained by IV fluids like glucose saline, ringer lactate, glucose five per cent, hemace, etc.

The complainant in his appeal stated that the surgery was neither rare one nor was it required to be performed at an emergency basis. Hence, the pre-operative requirement of prior availability of blood before commencement of surgery should have been done.

The National Commission passed an order of negligence against the surgeon for the following reasons :

1. When preparation for planned abdominal surgery arises unanticipated, bleeding may occur during any laparotomy and hence several units of cross matched blood should be available in the theatre before the surgery.

2. For not providing for machine-operated artificial respirator. In nursing homes, where a surgery is performed over long period and which does not have machine-operated respirators or in the event of power failure, it is the duty of the nursing home to have a standby arrangement for such contingencies.

3. The intra cardiac injection was unsuccessful since the needle failed to penetrate the heart due to obesity. Hence, a long needle should have kept.

4. For the surgeon not anticipating that complication that might arise in a major surgery on an obese patient with a rare blood group.

Is the anaesthesiologist who participated in the process of delivery of medical services to the beneficiary as much liable as a common surgeon herself, if her negligence is established? It is held that even if the services of the anaesthesiologist were hired by the surgeon, then also, the deceased happened to be beneficiary of the medical services of the anaesthesiologist and hence a “consumer”. The services of the anaesthesiologist are invariably paid by the patient themselves and their charges generally have been shown separately in the bill. The words “In pursuance of the contract or otherwise” in the section makes it amply clear that privity of contract is not necessary for a claim to be made under CPA as long as there is hiring or availing of services for a consideration. Section 2 (1)(d) of CPA defines consumer as “one who hires or avail of services for a consideration”. This does not refer to privity of contract.

Section 2 (1)(g) of CPA defines deficiency of services as “Fault, imperfection, short coming or inadequacy in the quality nature and manner of performance which is required to be maintained under any law being in force and undertaken to be performed by a person in pursuance to contact or otherwise in relation to any services”.

The words “In pursuance of a contract or otherwise” in the section makes it clear that a privity of contract is not needed for a claim to be made under CPA as long as there is consideration for services. Hence the anaesthetist who participated in the delivery of medical services to the beneficiary is as much liable as the main surgeon, if her negligence is established.

Common instances of negligence in anaesthesia

• Simultaneously administration of hypnotic, narcotic, sedatives, muscle relaxant etc without due care.
• Lack of care while passing intra tracheals tube or lack of expertise in the same.
• Lack of due care in administration of hypotensives.
• Lack of due care for maintenance of patency of airway.
• Use of equipment.
• Equipment with which anaesthesia is administered may be faulty.
• Hypoxia leading to anaesthesia death.
• Prolonged of anaesthesia beyond reasonably standard time.

The writer is assistant medical director at PD Hinduja Hospital. Email:drsiyerin@yahoo.co.in