நோயாளிக்கு என்ன வகையிலான மயக்கவியல் மருத்துவம் கொடுக்க வேண்டும் என்பதை மயக்கவியல் மருத்துவரே தீர்மானிக்க வேண்டும்

நோயாளியின் நலன் மற்றும் அவரது உடல் நிலையை கருதி அவருக்கான அறுவை சிகிச்சையில் என்ன வகையான மயக்கவியல் முறை பின்    பற்றப்படவேண்டும் என்று தீர்மானிக்கும் அதிகாரம்    மயக்கவியல் மருத்துவருக்கே உள்ளது.

Decided on 18.12.2009

NATIONAL CONSUMER DISPUTES

REDRESSAL COMMISSION, NEW DELHI

M.C. KATARE  Vs. BOMBAY HOSPITAL AND MEDICAL RESEARCH CENTRE & ORS.

Original Petition No. 167 of 1995

        Anaesthesiologist has contended that the choice of anaesthesia, whether general or spinal, is the professional discretion of the Anaesthesiologist which he has to take keeping in view various factors like pre-anesthesia checks, the condition of the patient and best suitability/acceptability of the patient for the same. A perusal of the medical record dated 28.12.1994 would show that the suitability/acceptability of the patient for surgery under general anaesthesia was verified by the physician, Dr. Tiwari who, based on clinical examination as well as ECG report, etc., declared the patient fit to undergo surgery under general anaesthesia.

We may also examine this question from another angle, viz., whether the decision to administer general anaesthesia in preference to spinal anesthesia was fraught with greater risk/complication(s). In order to show that both these types of anaesthesia carry more or less similar risk factor, a reference has been made to the medical treatise on the subject of Anaesthesia and Preoperative Complications by Jonathan L. Benumof and Lawrence J. Saidman. In Chapter 3 of the said treatise, it has been observed, “I do not want anybody messing with my spinal cord”. This is based on the apprehension that in spinal anaesthesia, there is a fear of messing up with the spinal cord. The complications of the spinal anaesthesia are given as under:

•     Spinal hematoma

•     Epidural abscess

•     Neurologic injury

•     Postdural puncture headache

•     Backache

At page 56 of the said treatise, under the heading “Complications of Anaesthetic Agents”, it has been opined, “Central nervous system complications, cardiovascular complications, neurotoxicity, respiratory depression, nausea, pruritus, herpes reactivation, urinary retention, etc., are the incidents”. At page 57, based on a study of 14 patients, it was observed that these patients experienced apparently sudden cardiac arrest during otherwise uneventful and hemodynamically stable spinal anaesthesia. Even though these patients were young and healthy and despite evidence that their caregivers maintained appropriate standards of care, only one of the patients had functional neurologic recovery. The authors further noted that spinal anaesthesia conducted under routine conditions and in a standard manner carries a poorly understood potential for sudden cardiac arrest and severe brain injury in healthy patients. At page 62, under the heading “Conclusion”, it is observed as under:

“Our understanding of the complications associated with neuraxial anaesthesia has grown greatly since Bier and Hildebrandt experienced the postdural puncture headache. Along with this understanding has grown the popularity of neuraxial techniques and the application of these techniques to an increasingly broad segment of patients. Today, the practitioner of neuraxial anaesthesia requires the knowledge to avoid rare, serious complications. Perhaps no area of anaesthesiology creates as passionate a controversy as does the choice between regional and general anaesthesia. Arguments for the preferential use of regional anaesthesia (instead of general anaesthesia or in combination with it) emphasize diminished interference with circulatory and pulmonary function and beneficial influences on stress responses induced by extensive surgery.

Detractors of regional anaesthesia point out that modern general anaesthesia can be safely administered to almost any patient and emphasize the risks of regional blocks. A balanced decision ultimately requires an appreciation of the nature and frequency of adverse outcomes from regional anaesthesia. The calculation of risks and benefits is particularly critical when blocks are added to general anaesthesia because this subjects the patients to the risk of both techniques.

A further burden for anaesthesiologists who perform nerve blocks is the still-common notion among physicians and patients that because general anaesthesia is free of risk (except when bungled), why should one be subjected to the clear risk for needle-induced injury to nerves, vessels, and orders? This relative risk can be put into perspective by the information in other chapters in this book.”

20. In another article published in the well-known Internet-based “Wikipedia”, the authors have enlisted the risks and complications of spinal anaesthesia as under:

Spinal shock

Cauda equina injury

Failed Spinal

Total Spinal

Cardiac arrest

Hypothermia

Broken needle

Post-operative complications like the following are also listed:

Postdural puncture headache (PDPH)

Backache

Sixth cranial nerve palsy

Urinary retention

Meningitis”

Thus, on a thorough consideration of the question on the basis of the above referral/authoritative expert medical opinions, the irresistible conclusion is that both types of anesthesia—general and spinal—are fraught with one or the other kind of risks. In any case, the discretion to administer the anaesthesia, whether general or spinal or local, has to be left to the Surgeon and Anaesthesiologist concerned depending upon various factors, viz., requirement of the procedure, general and clinical condition of the patient, etc. The evidence and material produced on record do not establish that the administration of general anaesthesia to the deceased patient in this case was incorrect or contraindicative having regard to the medical parameters of the patient. We are, therefore, unable to hold that the Anaesthesiologist committed any negligence by inducing general anaesthesia to the deceased in the present case.

.

குறிப்பு - இன்றும் பல அறுவை சிகிச்சை மருத்துவர்கள்  மருத்துவ ஆவணங்களில் “ Fit for Spinal Anaesthesia' என்று எழுதுவதை வழக்கமாக வைத்துள்ளார்கள். மற்றவரின் துறையைப்பற்றி தேவையில்லாமல் மருத்துவ ஆவணங்களில் பதிவிடக்கூடாது. உதாரணமாக 'Fit For General Anaesthesia' என்று எழுதி, மயக்கவியல் மருத்துவர் நோயாளியின் நலன் கருதி “Spinal Anaesthesia'-ல் அந்த கேஸ்யை எடுத்து அந்த கேஸில் ஏதாகிலும் மருத்துவ சேவை குறைபாடு ஏற்பட்டால், முறையீட்டாளர் அறுவை சிகிச்சை மருத்துவர் General Anaesthesia-ல்தான் கேஸை எடுக்க சொல்லி ஆவணங்களில் எழுதியிருக்கின்றார் ஆனால் மயக்கவியல் மருத்துவர் Spinal Anaesthesia-ல் எடுத்ததால்தான் இந்த மருத்துவ சேவை குறைபாடு வந்தது என்று வாதிடலாம். அவ்வாறான சூழ்நிலையில் மயக்கவியல் மருத்துவர் அறுவை சிக்சசை மருத்துவர் சொன்னது சரியல்ல என்று கூறவேண்டும். அங்கு ஒரு internal conflict உருவாகும். அதுபோன்ற  சூழ்நிலை முறையீட்டாளருக்கு சாதகமாக அமையும். குறைதீர்க்கும் மன்றங்களும் ஏதே ஒரு குறை நடந்துள்ளது அது விஸயமாக இரு மருத்துவர்களுக்கு இடையே தர்க்கம் உள்ளது என்ற நிலைக்கு வந்துவிடும். ஆகவே, மருத்துவர்கள் தங்கள் படித்த துறையில் தங்களுக்கு உள்ள அதிகாரத்தை மட்டுமே பயன்படுத்தி மருத்துவ ஆவணங்களை உருவாக்க வேண்டுமே தவிர மற்றத்துறையைப்பற்றி எதையும் பதிவிடுவது என்பது சரியல்ல.