Complex comorbidities and anaesthesia

Case History

Ms X is a 40-year-old patient with multiple co-morbidities. She is married with young children and works full time.  She has type 2 diabetes, sleep apnoea, and is categorised as morbidly obese with a BMI of 45. She also has history of ischaemic heart disease and suffered a myocardial infarct at age 35. 

She suffers from left-sided sciatica and has seen a neurosurgeon and an orthopaedic surgeon. She has no neurological signs but has considerable pain.  She is keen to proceed with surgery to relieve her symptoms. Dr A runs a regular anaesthetic list for the patients of the orthopaedic surgeon. As per her normal practice, she sees Ms X in her rooms the week before surgery.

Dr A obtains a detailed history. She notes the patient’s current medications and her treatment for sleep apnoea. She also notes that the patient sleeps routinely sitting up in an armchair, and she has been unable to lie flat in bed for several years. Dr A views the pre-operative blood tests and physical measurements including the patient’s collar size. 

After considering this information, Dr A is concerned that the patient is at very high risk for an anaesthetic. She explains to the patient the increased risks from anaesthesia for morbidly obese patients, indicating that they have a higher potential for difficult mask ventilation, laryngoscopy and intubation. She also explains that she would like a pre-operative cardiology review. The anaesthetist indicates that she would like to refer the patient for further investigation before making a decision about whether she is willing to proceed with anaesthetising her.

The complaint

A few days later Dr A receives a letter from the patient who is very annoyed that she was not able to go ahead with her surgery as she had organised time off work and childcare. She also described feeling humiliated and insulted during her consultation and demanded an apology. The patient says Dr A used offensive language such as “morbidly obese” and focused on this as an excuse not to proceed with anaesthesia.

Dr A is surprised by this as she felt she had dealt with the patient in a sensitive manner. She writes to the patient, explaining this, and declines to refund the consultation fee as requested by the patient. Subsequently Dr A receives a notification from AHPRA indicating that the patient has lodged a formal notification against her.

At this point, Dr A contacts MDA National and receives assistance to respond.  The investigation takes some time, and requires expert reports to be obtained regarding the assessments made and the anaesthetic risk the patient presented. Ultimately, the conclusion reached is that Dr A carried out the consultation in an appropriate manner. She was dealing with an extremely difficult presentation and it was not unreasonable for her to decline to proceed with the anaesthetic until further investigations were undertaken. 

Discussion

If you have reason to believe it is too risky to proceed with treatment, you can decline and advise your patient of this. In this case, the anaesthetist was placed in a difficult position of assessing the patient after she had already agreed to and booked for surgery. Assessing patients with significant co-morbidities or complex medical conditions may benefit from a team approach between the specialists involved so that patient expectations are not raised before all aspects of the clinical presentation are considered.