S'pore anaesthetist leaves high-risk surgery to take phone calls, gets 2.5 years suspension

The patient suffered a cardiac arrest during operation and passed away in the ICU the next day.

Ruth Chai | January 12, 2023, 02:18 PM

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An anaesthetist at Gleneagles Hospital was suspended for two-and-a-half years by the Singapore Medical Council (SMC) disciplinary tribunal after he was found guilty of leaving the operating theatre to take phone calls several times during a high-risk surgery.

His patient suffered a cardiac arrest during the open reduction internal fixation bone cement right femur surgery.

He was resuscitated, but suffered further complications to his health, and eventually died the following day in the intensive care unit.

The doctor, Islam Md Towfique, pleaded guilty to a charge of professional misconduct, in failing to provide appropriate care and management to his patient, with his conduct amounting to "serious negligence".

The grounds of the decision of the discipline tribunal inquiry were published on SMC's website on Jan. 11, following the hearings conducted in October and November 2022.

"While patient was under general anaesthesia the patient’s basic bodily functions such as breathing, are largely dependent on the anaesthetist," the tribunal stated, adding that Islam's negligence further lowered the patient's chance of survival due to the delay in recognising the patient's deteriorating vital signs and subsequent initiation of resuscitative treatments.

Islam's conduct also resulted in "significant harm to public confidence in the medical profession," the tribunal added.

"High-risk surgery"

The patient underwent surgery on Sep. 1, 2016.

Islam was the patient’s sole attending anaesthetist for the operation.

The patient was considered a high anaesthetic risk patient as he was 64-years-old, obese, had significant co-morbidity of ischaemic heart diseases, and multiple myeloma.

The surgery was also considered "high-risk", and required the anaesthetist to be constantly present while the patient was under anaesthesia.

However, during the operation, Islam left the operating theatre several times.

During these occasions, he was talking on his mobile phone, for up to 9 minutes at a time.

During one of these occasions, he would monitor the patient's vital signs through a window while outside the operating theatre.

The standard procedure was to be physically present at the patient's side.

While he was gone, he did not brief the nurse who was assisting him on what to do during his absence.

No qualified anaesthetic personnel or medical officers were present to monitor the patient in his absence.

Alarm went off

While the operation was ongoing, an alarm went off as the patient's blood oxygen levels and pulse became unreadable.

Even after the finger probe was switched to an ear probe, no blood oxygen level could be detected.

Islam then ordered emergency blood, and the hospital's CCTV recordings showed that he was in the corridor outside of the operating theatre when the blood products were brought into the operating theatre.

When he returned to the operating theatre, he commenced the blood transfusion without delay.

Islam failed to detect and closely monitor the changes in the patient’s vital signs and failed to initiate early supportive and resuscitative treatments when the patient suffered from intraoperative acute pulmonary embolism, which is a complication that has a higher risk of occurring in cancer patients.

"[Islam] wrongly judged that he could leave the operating theatre during the operation to make phone calls, as he thought that he did not leave the patient too far away and was contactable in seconds. He wrongly assessed that he was able to handle the total management of the patient by anticipating the patient’s needs in advance, based on his experience and knowledge," the tribunal read.

The patient then entered cardiac arrest, but was resuscitated by a team of four doctors, including Islam. He was then transferred to the intensive care unit to recover.

The patient passed away the next day.

In the post-mortem report, it was stated that the patient's cause of death was pulmonary thromboembolism – when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung.

"The chances of the patient surviving a massive pulmonary embolism would be very low. While the chances of the patient’s survival were low, they may have been further lowered by [Islam's] delay in recognising the changes in the patient’s vital signs and consequent delay in initiating supportive and resuscitative treatments," the tribunal read.

Failed to uphold basic and elementary standard

In the sentencing submissions, SMC submitted that Islam's culpability was high for a few reasons, namely failing to uphold a basic and elementary standard of treatment by leaving the patient's side for seemingly no good reason numerous times, which led him to fail to take prompt action by increasing the patient's oxygen levels to 100 per cent and administer medication to raise the patient's blood pressure.

Islam had displayed a wilful disregard for the patient's welfare despite knowing that it was a high-risk operation on a high-risk patient.

SMC also found a lack of remorse from Islam, who likened the process of conducting an operation to driving, intending to illustrate that operations were like second nature to him.

Although Islam told the tribunal that he had informed the assisting nurse that he would be stepping out of the theatre, it was not clear if he had informed the nurse on every occasion when he stepped out.

It is permissible for anaesthetists to leave the operating theatre under certain circumstances, such as being required to help with resuscitation in another operating theatre or to use the washroom, but the nature of Islam's calls were not urgent and he could have taken them when he was not operating.

The tribunal was also concerned that Islam was giving instructions from the induction room when there was a "massive blood transfusion" to be carried out.

SMC sought a 36-month suspension

In response to the sentencing submissions, Islam said only "little to no direct harm" was caused to the patient as the patient was successfully resuscitated.

He maintained that the likelihood of the patient surviving a massive pulmonary embolism was initially very low, hence there was not much he could have done.

He added that his departure from the operating theatre was brief, and he could have been contacted in seconds if complications arose since he was right outside.

Finally, he said that there were no official guidelines or notices regarding the making of phone calls while anaesthetists are taking care of their patients.

However, the tribunal disagreed and reiterated that Islam's level of culpability was high and that the level of harm was within the highest end of the moderate range.

Islam was handed a suspension of two years and six months, and was also censured and warned to refrain from "engaging in the conduct complained of, or any similar conduct, in future".

He was also ordered to pay costs to SMC and for the hearing.

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