Last December, there was a morning when many doctors, myself included, who heaved a sigh a relief at a High Court judgment.

An anaesthetist, who had been accused of causing neck injury while he was administering general anesthesia for a patient, had his case dismissed.

The case had taken 39 days.

When the incident happened, the patient was 35 years old and pregnant with her sixth child.  She was undergoing surgery to deliver her baby.

She alleged that the doctor caused her neck injuries when he inserted a breathing tube down her airway ahead of the Cesarean delivery.

Since the delivery, she said, she continued to suffer pain in her neck and back, numbness in her hands and feet, and often lost her balance.

She sued because she said that the anaesthetist had failed to obtain her informed consent for the general anaesthesia procedure.

In medicine, this issue of informed consent almost invariably comes up when things go wrong, or when the outcome is not what the patient had expected. In every procedure, and indeed, in most treatments, there are risks.

But is it really possible, or desirable, for doctors to cover all the possible complications with each procedure and every drug administered?

Siok Hwee, a 50-year-old lady, has been under my care since 1995.

Her problem was that of stage four malignant lymphoma (also called non-Hodgkin’s lymphoma), not unlike the type which late President Ong Teng Cheong had.

There are many types of malignant lymphoma (a primary cancer of the lymph nodes).  These can be broadly classified as low grade (slow growing) or high grade (fast growing).

When Siok Hwee first saw me in July 1995, we confirmed at that time that the lymphoma was low grade but at an advanced stage because her bone marrow had already been invaded by the cancer cells.

Although the cancer cannot be cured, it is a highly treatable disease and compatible with a long life in the majority of patients.

One of the problems with low grade lymphoma is that it can transform into a high grade lymphoma.  This is believed to occur in up to 25% of patients.

Indeed, in January 2002, Siok Hwee’s lymphoma transformed and a biopsy of a newly-discovered liver tumour, confirmed that the lymphoma had changed into an aggressive form.

We had to embark on an aggressive chemotherapy program for four months and this successful cured her of the high grade lymphoma.

In 2007, biopsy of a lymph node in her right armpit confirmed that the low grade lymphoma was still lurking around.

Two months ago, we discovered another lymph node inside her abdomen.  In my explanation to her, I simply told her that we needed to stick a needle into the lymph node and extract some cells for examination by the pathologist.

I did not go into the details of the procedure.  After all, she had several biopsies before – when she first saw me in 1995 and also in 2002 and 2007.

The biopsy was to be done by the interventional radiologist under the imaging guidance.  In other words, the radiologist would be able to “see and localize” the lymph node using the CT scan, before sticking the needle into it.

With so many recent medico-legal cases centering on informed consent, the interventional radiologist painstaking described all the possible complications – puncturing the lung, spleen or intestines, bleeding, infection, need for emergency surgery and – possible death.

He did the perfectly correct thing.

But after hearing the spiel of things that could go wrong, Siok Hwee had a fright and quickly called me on the phone.

“Dr Ang, what should I do?” she asked.

“Just do it!” I replied.

She happily hopped onto the procedure table and the biopsy was carried out uneventfully.

The result turned out to be low-grade lymphoma and she did not need to have any treatment. We were most relieved – and that’s when I remembered the court’s judgment in December – what if things had gone wrong?

I guess my head could possibly have been on the chopping board. But I had been caring for Siok Hwee since 1995, and over the course of 27 years, I think she would trust me to make the right choice for her.

True, this trust has been earned in her case, over a few decades, but I do not think I would do any different for a new patient, and I hope the trust would be there too.

I truly believe that as doctors, we need to practice good clinical medicine – remembering always to comfort and heal, and not the defensive medicine that the times dictate.

Written by Dr Ang Peng Tiam



Tags: