Anaesthetist suspended after leaving high-risk surgery repeatedly for phone calls

SINGAPORE — For leaving an operating theatre several times to speak on his mobile phone, an anaesthetist has been suspended for two-and-a-half years by a Singapore Medical Council (SMC) disciplinary tribunal.

Dr Islam Md Towfique pleaded guilty to a charge of professional misconduct over a procedure in 2016 in which an elderly man, considered a "high anaesthetic risk patient", underwent surgery. 

The patient suffered a cardiac arrest in the operating theatre and was resuscitated. He died the following day in the intensive care unit.

“While the chances of the patient’s survival were low, they may have been further lowered by the respondent's delay in recognising the changes in the patient’s vital signs and consequent delay in initiating supportive and resuscitative treatments,” said the tribunal.

The grounds of the tribunal's decision were made public on Tuesday (Jan 10) after the hearings in October and November last year.

WHAT HAPPENED 

On Sept 1, 2016, the 64-year-old patient underwent an open reduction internal fixation bone cement right femur surgery at Gleneagles Hospital, where Dr Islam was the patient’s only attending anaesthetist for the operation. 

The patient was considered a high anaesthetic risk as he was elderly, obese, and had significant co-morbidity of ischaemic heart diseases. He had a coronary stent and was taking cardiac and anti-lipid medication. 

 He also had multiple myeloma, a cancer of plasma cells.

The operation, which lasted about two-and-a-half hours, was a “high-risk surgery”, said the tribunal. 

“The appropriate care and management for the patient required the doctor to be constantly present while the patient was under anaesthesia for the operation,” added the disciplinary tribunal. 

Despite this, Dr Islam left the operating theatre several times on various occasions during the operation and talked on his mobile phone.

“A responsible and competent anaesthetist is required to be constantly physically present by the patient’s side to closely monitor a patient at all times during an operation,” stated the tribunal. 

The operating theatre has two sets of intervening doors - one set leads to an induction room, while the other leads to the corridor.

An induction room is where patients are prepared for surgery before being transferred to the operating theatre.

On one occasion, when Dr Islam was in the induction room, he looked at the patient’s vital signs monitor through the window of the door between the induction room and the operating theatre. 

“But the relevant benchmark standard required him to have been constantly physically present by the patient’s side to closely monitor the patient at all times during the operation,” said the disciplinary tribunal. 

The tribunal added that Dr Islam had left the operating theatre several times during the operation without briefing the AU nurse — the nurse from the hospital’s anaesthetic unit assisting the operation — as to what she should do in his absence. 

No qualified anaesthetic personnel or medical officers were present to monitor the patient in Dr Islam’s absence. 

From the pre-anaesthetic assessment, the doctor anticipated that the patient would suffer from blood loss during the operation and was aware that a small embolism (blocked artery) and cardiac ischaemia — when the heart's ability to pump blood is reduced — were problems that could possibly arise during the operation.

During the operation, an alarm went off and both the patient’s blood oxygen levels and pulse reading became unreadable. The electrocardiogram (ECG) monitor continued to show readings, while no blood oxygen level could be obtained even after using an ear probe. 

Dr Islam ordered emergency blood. 

Closed-circuit television recordings showed that the anaesthetist was in the corridor when blood products were brought into the operating theatre. He returned to the operating theatre and there was no delay in the transfusion of blood into the patient. 

“As a result of the respondent's absences from the operating theatre when the operation was being performed on the patient, he failed to detect, recognise and/or 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,” said the tribunal. 

Dr 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, stated the grounds. 

“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 added.

The patient suffered from cardiac arrest in the operating theatre but was resuscitated by a team of doctors, including Dr Islam. The patient was then sent to the intensive care unit to recover before he died the next day. 

A postmortem report found the cause of death to be pulmonary thromboembolism, a blockage of blood supply to the lungs. 

"The chances of the patient surviving a massive pulmonary embolism would be very low," said the tribunal.

The tribunal added that the patient's chances of survival may have been further lowered by Dr Islam's delay in recognising the changes in the patient's vital signs and the consequent delay in initiating supportive and resuscitative treatments.

HIGH CULPABILITY

The tribunal — comprising Professor Sonny Wang, Dr David Ong Eng Hui and Mr Lim Wee Ming — said they were prepared to accept Dr Islam’s evidence that he had informed the AU nurse before he stepped out of the operating theatre. 

However, they were concerned that he left a high-risk patient undergoing high-risk surgery, under the care of the AU nurse and it did not appear to be clear — even from the anaesthetist's own evidence — that he had informed the AU nurse on every occasion. 

While the tribunal accepted that there was no delay in the blood transfusion to the patient, it was concerned that Dr Islam was giving instructions from the induction room when there was a "massive blood transfusion" to be carried out. 

The tribunal said the lack of contemporaneous records showing whether the doctor had administered any medication to raise the patient’s blood pressure was troubling. 

While the tribunal accepted that it was common practice for anaesthetists to leave patients who are stable with nurses, the SMC raised that the patient was “not stable on at least four separate occasions”. 

The medical council said that the harm caused was at the highest end of the moderate range. 

It was not disputed that the doctor’s misconduct may have lowered the patient’s chances of survival, said SMC. 

When a patient is under general anaesthesia, the patient’s basic bodily functions such as breathing, are largely dependent on the anaesthetist, the council added. 

It said Dr Islam demonstrated a "reckless or wilful disregard for the patient’s welfare and interest in leaving the patient’s side repeatedly, despite knowing that it was a high-risk operation on a high-risk patient, whose parameters were deteriorating". 

LENGTH OF SUSPENSION

SMC asked for a suspension of 36 months.

Dr Islam submitted that only slight harm was caused, as his misconduct caused "little to no direct harm to the patient". 

He added that the eventual harm was caused by the massive pulmonary embolism and that the patient's chances of surviving such a complication were "very low".

He said that there are no official guidelines or notices regarding making phone calls while anaesthetists are taking care of their patients.

The anaesthetist raised that Parkway Pantai, which runs Gleneagles Hospital, had already suspended him for six months from March 1, 2017. He submitted that his level of culpability was medium and asked for a shorter period of suspension of seven-and-a-half months.

The tribunal disagreed and found that Dr Islam's level of culpability was high and that the level of harm was within the highest end of the moderate range.

They found that Dr Islam did not stop his practice of taking phone calls during operations and said it had "serious misgivings" about Dr Islam's contention that he was unlikely to reoffend.

Although Dr Islam was suspended by Parkway for six months, he continued to work with other hospitals during that period.

Besides being suspended for two-and-a-half years, Dr Islam was also censured and has to refrain from "engaging in the conduct complained of, or any similar conduct, in future".

He was also ordered to pay costs for the hearing and for SMC. The suspension started 40 days after the date of the order on Nov 30, 2022.