According to findings released today, the woman, who was a doctor by profession, had hip repair surgery at a private hospital in April 2020.
Before the surgery, she specified that an inhaled general anaesthetic, sevoflurane, was not to be used because of the family history in the context of this medication.
A week after surgery she ended up back in hospital with an acute kidney injury.
Months later she was diagnosed with myalgic encephalomyelitis/chronic fatigue syndrome – a severe fatigue that does not improve with rest, and can last for at least six months.
The HDC found that while there were failings, it had been appropriate for Dr B to administer the drug because there was a risk of the woman regaining consciousness during surgery. Photo / Santiago Nunez
When researching possible causes she reviewed her surgical clinical records from her hip surgery and discovered she had received sevoflurane during the operation.
The anaesthetist who administered it said he had not told her about it because he “did not consider it to be important” in light of the operation, and postoperative recovery having gone smoothly.
Doctor complains about doctor
The woman complained to the Health & Disability Commissioner about the anaesthetist, who was found to have breached a section of the Health Consumers’ code, related to patient rights to information.
The anaesthetist retired from medical practice in December 2021.
Commissioner Morag McDowell agreed with independent clinical advice gathered during the investigation that failure to disclose what had occurred was a “severe departure from accepted standards”.
Before the operation, the woman emailed her surgeon’s secretary, asking that information be added to her anaesthesiology form.
Her email noted concerns about a family history of complications following general anaesthesia, including that her mother had possibly experienced malignant hyperthermia – a severe reaction triggered by certain gaseous general anaesthesia medications.
Symptoms included fever, muscle rigidity, and increased heart rate.
Accordingly, the woman requested that propofol was used as her general anaesthetic.
She recalled the anaesthetist was “initially apprehensive” because he considered that complications with sevoflurane were rare, but he ultimately agreed to use propofol.
The woman told the HDC that on the day of surgery, the anaesthetist confirmed the use of propofol and that he would not use sevoflurane.
Troubling sign
Shortly after surgery started, monitoring suggested the woman could regain consciousness.
The IV line administering propofol was found to be obstructed.
Without a functional IV line, and while it was being troubleshooted, the anaesthetist administered a low dose of sevoflurane to deepen Dr A’s anaesthesia.
He later told the HDC that the maintenance of anaesthesia during the ongoing surgical procedure was his priority.
He said it was the only option in the situation and that following administration of sevoflurane, there was no indication that the woman had reacted poorly or exhibited any symptoms to suggest malignant hyperthermia.
The anaesthetist said that the IV line was restored and the rest of the procedure was completed without any further issues, or need to administer additional sevoflurane.
He said he would not usually document such events but acknowledged in his response to the HDC that he did not adequately document the event in the clinical notes and that making a note regarding the IV line would have been appropriate.
Documentation lacking
McDowell said the automated anaesthetic record documented that sevoflurane had been administered, but no reason was recorded as to why, nor was there documentation of the IV-line having been obstructed.
Health and Disability Commissioner Morag McDowell.
She was however satisfied, based on an independent clinician’s advice, it was indicated and appropriate for the anaesthetist to administer sevoflurane, notwithstanding the plan it was not to be used.
“This action was necessary because of an IV-line obstruction that temporarily prevented her from receiving IV anaesthetic, resulting in a risk of her regaining consciousness during surgery,” McDowell said.
She said Medical Council guidelines stated doctors must keep clear and accurate records that report relevant clinical information, options discussed, the proposed management plan, and decisions made and the reasons for them.
McDowell said it was evident that the anaesthetist’s documentation was lacking and was critical of its incomplete standard.
Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.