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Opinion of HCFI Legal Team (Ira Gupta Advocate)
New Delhi, August 18,2018 :
About spinal epidural hematoma
Spinal epidural hematoma (SEH) is an uncommon complication of neuraxial anesthesia. Patients who have received medications affecting hemostasis (e.g., anticoagulant or antiplatelet agents), particularly those having vascular surgery, are at highest risk. Risk is very low in obstetric patients.
Since epidural catheters are often placed just prior to induction of anesthesia, presence of an epidural hematoma may not become apparent until the effects of anesthetics and sedatives have worn off.
The most common presenting symptoms for neurologically significant SEH are progressive motor block, sensory block, or bowel and bladder dysfunction; back pain is a less common presenting complaint.
If an epidural hematoma is suspected, emergent magnetic resonance imaging (MRI) is performed (or CT scan if MRI is contraindicated).
If SEH is detected, urgent consultation with the neurosurgery or orthopedic spine surgery service is necessary for possible decompressive laminectomy since neurologic recovery is more likely if decompression occurs within eight hours of symptom onset (Source: Uptodate.com).
Defence arguments
- Epidural hematoma is an uncommon complication, but a known complication. The incidence is < 1 in 1.5 lakh in epidural and 1: 2.2 lakh in spinal anesthesia. A known complication is not medical negligence. This can be an error of judgement at most.
- Neurologic recovery is more likely if decompression occurs within 8 hours of symptom onset. The emphasis is on the words recovery is “more likely” and not necessarily.
- If an epidural hematoma is suspected, emergent MRI is performed. Being uncommon, it is often missed in differential diagnosis. In the said case, even the consulting neurologist did not suspect an epidural hematoma on clinical examination and did not advise an “urgent” MRI. The neurologist advised steroids and advised an MRI if there was no response.
- Since epidural catheters are often placed just prior to induction of anesthesia, the presence of an epidural hematoma may not become apparent until the effects of anesthetics and sedatives have worn off.
- A survey can be done to find out how many obstetricians would think of this complication in the first few hours. Gynecologists and obstetricians are not expected to diagnose epidural hematoma.
- Rare complications may not be a part of the informed consent process. In Samira Kohli vs Dr. Prabha Manchanda & Anr. Appeal (civil) 1949 of 2004, date of judgment: 16/01/2008, the Supreme Court of India said, “The consent must be real: that is to say, the patient must have been given sufficient information for her to understand the nature of the operation, its likely effects, and any complications which may arise and which the surgeon in the exercise of his duty to the patient considers she should be made aware of; only then can she reach a proper decision. But the surgeon need not warn the patient of remote risks, any more than an anesthetist need warn the patient that a certain small number of those anaesthetized will suffer cardiac arrest or never recover consciousness.Only where there is a recognized risk, rather than a rare complication, is the surgeon under an obligation to warn the patient of that risk. He is not under a duty to warn the patient of the possible results of hypothetical negligent surgery.”
This view is opposite to that held by the UK Supreme Court in the Montgomery case (Montgomery v Lanarkshire Health Board), which ruled that the doctor has a duty “to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.” But, the Montgomery judgement is not applicable in India.
Video to watch: Modern day doctor-patient relationship: TEDx Talk by Dr KK Aggarwal
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Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
President HCFI
