INSIGHTS

When a patient arrives in theatre, it is the anaesthetist’s responsibility to examine the patient and administer an anaesthetic tailored to that individual patient. 

Anaesthetists have to cater for a procedure that might have complications resulting in extended surgical time. During the entire process, the anaesthetist has to be alert, ensure proper monitoring and effectively administer any anaesthetics required by a specific patient undergoing a specific procedure. 

Because anaesthetists are human beings, being in theatre constantly for a procedure lasting a number of hours, might not always be possible.  This article focuses on the situation when an anaesthetist leaves theatre while a patient is under anaesthetic.  

MEDICAL NEGLIGENCE

Medical negligence occurs when practitioners fail to exercise the standard of skill and care expected of reasonably competent practitioners in their branch of the profession.

The essential elements of medical negligence in South Africa

1. The harm suffered must be the direct the result of the action or lack thereof by the medical professional.

2. The injury suffered must be the direct result of the medical practitioner’s actions or omission of action. If the practitioner followed the correct procedure, there is no wrongfulness and the injury suffered is thus not the result of negligence.

3. The patient must be able to prove the treatment received was not in accordance with the expected and reasonable standard of care by a professional with the same level of qualification and training. To prove this, medical experts will peruse all the available documents and provide an objective opinion.

4. There will be no negligence if the patient did not suffer any harm.

5. There must be a doctor and patient relationship, in other words, the doctor owes the patient a duty of care.

Essentially if an anaesthetist is negligent in managing a patient, that patient can sue the anaesthetist. The onus is on the patient to prove that the above elements are present.

The following is a practical example from a case a few years ago. 

An 11-year-old female weighing 33kg with a known history of allergy to Morphine was a pedestrian victim of a motor vehicle accident.  She sustained bilateral femur fractures which were treated with external fixation.  She was discharged with external fixators in situ.  She was re-admitted for the removal of the external fixators four months later.  The patient was known to the anaesthetist who had anaesthetised her previously.  The patient entered theatre at 11h26 and anaesthesia commenced. The surgery commenced at 11h40.  At some time between 11h45 and 11h50, the anaesthetist left the patient under the observation of a nursing sister to get a drink of water in the theatre tearoom.  The anaesthetist was summoned back between 11h55 and 12h00 as the patient was developing a significant bradycardia and there was no oxygen saturation reading.  The anaesthetist commenced resuscitation immediately. 

The patient’s parents issued summons against the anaesthetist. An expert on the case determined that the patient sustained a severe cerebral ischaemic hypoxic injury following a cardiac arrest during her surgery on 2 June 2017. It appeared likely that the cardiac arrest was caused by a massive pulmonary embolus occurring during surgery, possibly related to lower limb manipulation for contractures. The cardiac arrest was unexpected. There was a delay, due to the anaesthetist’s absence, in the response to changes in some monitored parameters – namely ST segment analysis, ETCO2 and an increasing tachycardia. An expert on behalf of the anaesthetist determined that it was doubtful whether these meaningfully delayed the onset of CPR (as it was instituted on development of the bradycardia prior to cardiac electrical arrest) or the outcome thereof. If the anaesthetist had been in theatre at the time of the early monitoring changes at 11h50 – 11h55, it is likely that he would have started to work through the possible causes, but he would in all likelihood only have commenced CPR when BP readings and saturation tracing failed and a bradycardia occurred – i.e. at 11h55 – 12h00. Because of the nature of the pulmonary embolism, the CPR would still have taken 10 – 20 minutes to generate a cardiac output, even if commenced 5 minutes earlier. The conduct of the pre and post-arrest phases of the resuscitation was according to standard of care and could not be criticised. The matter is still proceeding and the parents are obtaining instructions to withdraw the action against the anaesthetist.

THE SOUTH AFRICAN SOCIETY OF ANAESTHESIOLOGISTS (SASA) GUIDELINES 2022

SASA is the national professional body representing the interests of all anaesthesia practitioners and their patients. Their anaesthesia practice guidelines aim to set the same standard for the practice of safe anaesthesia at all levels in the South African context.

Paragraph 2.1 sets out the general duties of an anaesthetist.   The duties of an anaesthesia provider include, but are not limited to, the following:

1. Maintaining personal knowledge and skills;
2. Anaesthetists may be directly responsible for only 1 anaesthesia at any specific time unless acting in a supervisory capacity, delegating responsibility for patient's supervision to a suitably trained substitute when a local anaesthetic technique is used for pain relief without commitment surgery, or labour epidural;
3. Supervising the recovery room activities and providing services related to the management of acute pain;
4. Providing services related to resuscitation and advanced airway management in adults and children;
5. Taking responsibility for supervising the maintenance of anaesthesia, for the safe use of anaesthetic drugs, for the proper completion of documentation and records, for the recordal of proper informed consent;

This list is not exhaustive and there are many additional duties that are required from an anaesthetist. 

It is of the utmost importance that continuous education and evaluation of anaesthesia knowledge and skills are developed and maintained to support safe anaesthesia.  For this reason, SASA recommends that competent assistance by an anaesthetic nurse and/or theatre technician should always be available on site where an anaesthesiologist is expected to provide anaesthesia.  Therefore, the guidelines also set out the training of the anaesthesia support personnel which include the nursing staff. 

SPECIFIC GUIDELINES ON AN ANAESTHETIST LEAVING THEATRE

Chapter 5 of the guidelines discuss the appropriate management of a patient during the anaesthetic period.

1. The anaesthetist’s primary responsibility is to the patient under their care. It is emphasised that the anaesthetist should remain with the patient throughout the conduct of all general anaesthesia, major regional anaesthesia, and procedural sedation and analgesia until the patient is transferred to the care of personnel in the appropriate care unit.

2. If the attending anaesthetist leaves the operating room temporarily, care of the patient must be delegated to another anaesthetist. 

3. The anaesthetist should notify the surgeon that he or she is going to leave theatre for a few minutes and provide the reason for doing so. 

4. Anaesthetists may briefly delegate routine care of a stable patient to a competent person who is not a trained anaesthesia provider (untrained physician, nurse, technician, etc) only under the most exceptional circumstances, for example to provide lifesaving emergency care to another patient.  That person’s only responsibility will be to monitor the patient during the anaesthetist’s absence and to keep the anaesthetist informed until he or she returns to theatre.  In this situation, the anaesthetist remains responsible for the patient's care and must inform the operating room team that he is leaving theatre.

5. Before delegating the patient's care to an anaesthesia assistant, the anaesthetist must ensure that the patient's condition is stable, and that the anaesthesia assistant is competent, experienced and familiar with the operative procedure and the operating room environment and equipment. 

6. The attending anaesthetist must remain immediately available when care is delegated to an anaesthesia assistant.

7. An intra-operative handover of care between two anaesthetists should be documented in the anaesthesia record and follow a structured protocol. 

8. It is unacceptable for an anaesthetist to simultaneously administer general anaesthesia, major regional anaesthesia or moderate to de-procedural sedation on more than one patient. 

LEGAL RESPONSIBILITIES

The writer is currently dealing with a civil matter relating to an anaesthetist leaving theatre (the above-mentioned example). From research, the following should be noted:

1. Following such an incident, there will probably be an investigation by the Hospital management. This might be compulsory but I suggest that you obtain legal advice from your indemnity insurer.

2. An anaesthetist must ensure that there is contemporaneous detailed record keeping in all circumstances, as this is vital in the event of a civil action against them.

3. Anaesthetists must be familiar with the various legislation that regulates their practice. The following are of most importance:

1. 1. The Health Professions Act 56 of 1974, which establishes the statutory regulatory body, the Health Professions Council of South Africa. The aims and objectives of the council are among others, to protect the public in matters involving the rendering of health services. The Council will investigate complaints from patients.
2. 2. The Inquests Act 58 of 1959, which requires any person who has reason to believe that a death is due to unnatural causes, to report such a death to the police. The prosecutor allocated to the matter will then submit all relevant information to the inquest magistrate, who then decides whether an inquest should be held.

CONCLUSION

Anaesthetists should be familiar with the SASA guidelines. They should ensure that they do not leave theatre while a patient is under anaesthesia. In the event they do leave the operating theatre, they should ensure that they follow the SASA guidelines and make detailed clinical notes detailing their compliance with these guidelines.

If a serious incident occurs unexpectedly, make immediate contact with your professional indemnity liaison officer. If you are a member of the MPS, you can contact MPS directly at CaseManagement@medicalprotection.org.za.

This article was published in the April Edition of the SAMA Insider Magazine. Read the article on page 24 here.