Uwe Klima v Singapore Medical Council

• Jurisdiction: Singapore
• Judge: Sundaresh Menon CJ
• Judgment Date: 13 April 2015
• Neutral Citation: [2015] SGHC 97
• Date: 13 April 2015
• Docket Number: Originating Summons No 113 of 2014
• Published date: 16 April 2015
• Plaintiff Counsel: N Sreenivasan SC and Lim Min (Straits Law Practice LLC)
• Hearing Date: 27 January 2015
• Defendant Counsel: Josephine Choo, Emily Su and Wong Shu Yu (WongPartnership LLP)
• Court: High Court (Singapore)
• Subject Matter: Professional conduct,Professions,Medical profession and practice

Andrew Phang Boon Leong JA (delivering the judgment of the court): Introduction

This is an appeal by Associate Professor Uwe Klima (“the Appellant”) against the decision of a Disciplinary Committee (“the DC”) constituted by the Singapore Medical Council (“the Respondent”). The DC convicted the Appellant of professional misconduct under s 45(1)(d) of the Medical Registration Act (Cap 174, 2004 Rev Ed) (“the MRA”) in respect of two charges brought by the Respondent. The allegation of misconduct contained in the first charge was that he had administered cardioplegia (“CPG”) solution to the patient (“the Patient”) without first diluting the CPG solution. The second charge was that he had failed to personally supervise an emergency operation performed on the Patient by another surgeon who was a conditionally registered medical practitioner (hereinafter referred to as a “conditional practitioner”).

Facts

The Appellant is a foreign medical degree holder who graduated from the Medical School of University of Vienna, Austria in 1988. He practiced General, Thoracic and Cardiovascular surgery at several medical institutions across Europe and the United States of America before joining the National University Hospital (“NUH”) on 6 April 2006 as a cardiothoracic surgeon. As mandated under s 21 of the MRA, his foreign medical accreditation and training only allowed him to practise in NUH as a conditional practitioner. Amongst other requirements, conditional practitioners can only work under the supervision of a supervisor approved by the Respondent. On 10 May 2006, Professor Lee Chuen Neng (“Prof Lee”) became one of the six supervisors assigned to the Appellant.

The proceedings before the DC concerned two separate but related surgical operations performed on the Patient on 19 December 2007. The first operation was pre-arranged but the second operation arose out of an emergency. The Patient was a two-year-old infant with a medical history of aneurysmatic right coronary artery with multiple fistulae at birth. In simpler terms, the right coronary artery of the Patient’s heart was diseased, resulting in an unequal distribution of blood which flowed into the right ventricle. On or about 15 October 2007, a panel discussion convened between paediatric cardiologists and cardiac surgeons identified the Patient’s condition as requiring surgical intervention. The operation was scheduled to take place on 19 December 2007. In the period leading up to the operation, Prof Lee requested that the Appellant take over as the principal doctor and surgeon in charge of the Patient to accommodate Prof Lee’s schedule. This arrangement was entered into with the consent of the Patient’s parents.

The first operation

The Appellant performed the first operation on 19 December 2007. He was assisted by two assistant surgeons. One of them was a cardiothoracic surgeon named Associate Professor Kofidis Theodoros (“Dr Kofidis”). The surgical team also consisted of an anaesthetist, Dr Sim Chin Keng (“Dr Sim”), a scrub nurse, Yiew Chin Thai, as well as two perfusionists. Tan Cheng Lee was the main perfusionist and Lim Kim was the assistant perfusionist.

The surgeons, anaesthetist and the scrub nurse were stationed at the operating table. Beside the operating table sat a heart-lung machine where the perfusionists were stationed. Their job was to set up and manage the heart-lung machine as well as prepare medication – including CPG – for the surgeon to administer to the patient. They were also in charge of monitoring the various parameters reflected on the heart-lung machine. Amongst other responsibilities, the scrub nurse served as a liaison between the surgeon and the perfusionists and would hand over medication prepared by the perfusionists to the surgeons.

At the commencement of the operation, the Patient was put on a heart-lung machine cardiopulmonary bypass and his heart was induced into a state of arrest in order for the heart to be safely operated upon – a process which involved the administration of CPG solution. CPG is procured and stored in concentrated form, referred to by some witnesses as “neat CPG”. However, when it comes to its administration, it is undisputed that cardiothoracic surgeons and perfusionists alike have been trained to never administer neat CPG (ie, CPG in an undiluted state). Undiluted CPG is potentially fatal due to the high levels of potassium found within the medication itself.

We pause to observe that there are, in general, two ways to dilute CPG. The first method is to dilute CPG with the patient’s blood. This variant of diluted CPG is commonly referred to as “blood CPG”. The second method is to dilute CPG with another chemical known as Hartman’s solution or Ringer’s solution (hereinafter referred to as “Hartman’s solution”). This variant of diluted CPG is commonly referred to as “crystalloid CPG”. It is undisputed that the dilution of CPG is almost always performed by perfusionists.

Returning to the present operation, about 23 minutes after the Patient was put on cardiopulmonary bypass, on the Appellant’s instructions, the perfusionists administered CPG in its concentrated form into the heart-lung machine. Dilution occurred when the CPG solution mixed with the Patient’s blood as it made its way through the machine before entering the Patient’s aortic root in the form of blood CPG. The use of the heart-lung machine to administer blood CPG is known to the witnesses as the “Calafiore method” or the “syringe-pump method”.

The Appellant chose to employ a semi-closed system for the operation. This was because he did not expect the operation to take more than 15 to 20 minutes and the system was “easy to control”. The limitation of a semi-closed system was that the perfusionists were unable to draw sterile blood from the Patient to dilute the CPG solution. It is, however, disputed whether the Appellant himself was able to draw sterile blood from the operating table – a point to which we shall return later in this judgment.

The operation turned out to be longer than expected. About 30 minutes into the operation, the heart had to be “re-cardiopleged”. The left coronary artery was re-cardiopleged by running the blood CPG via the heart-lung machine through the aortic root. As the proximal right coronary artery anastomosis had not been completed, blood CPG administered to the left coronary artery could not reach the right side of the heart. Unlike a multi-tail system which utilises a “Y-connection”, the semi-closed system uses only one single line to release CPG into the left coronary artery, leaving no free end for the Appellant to perfuse the other side of the heart. As a result, he decided to manually administer CPG to the right side of the heart.

The Appellant asked the perfusionists for “cardioplegia solution” (or according to some witnesses “cardioplegia”). According to the perfusionists, it was unusual for a surgeon to request for CPG solution using such terms. Unsure of how the CPG was to be administered, Lim Kim opened an ampoule of CPG and passed it to the scrub nurse (in its original concentrated (ie, neat) form). She claimed to have mentioned twice that it was “neat” and the scrub nurse testified that she had echoed the same when Lim Kim passed the ampoule to her. However, the scrub nurse admitted that the Appellant was engrossed in suturing when that remark was made and so she could not be sure whether he had heard her. The scrub nurse then drew the contents of the ampoule into a syringe and passed it to the Appellant.

According to the Appellant, he was expecting the perfusionists to prepare crystalloid CPG (as opposed to blood CPG) in the manner set out in the NUH Protocols & Guidelines for Perfusion Practice. He was given a clear solution in a syringe. Thinking that it was crystalloid CPG (as it takes the form of a clear solution), he administered the solution directly into the right coronary vein bypass to protect the right side of the Patient’s heart. According to the Appellant, he confirmed with the scrub nurse and the perfusionists thrice that the syringe contained “cardioplegia solution” before administering it to the Patient. It turned out that the syringe actually contained neat CPG. At this juncture, it is important – for reasons that will be apparent below – to note that, like crystalloid CPG (which the Appellant had thought he was administering), neat CPG also takes the form of a clear solution.

At the end of the operation, a routine check of the Patient’s blood showed a high concentration of potassium at 10.01 mmol/L, when the usual reading would be 3.5 to 4.5 mmol/L. The Patient was started on haemofiltration to bring down the level of potassium in his body and was then sent to the Paediatric Intensive Care Unit (“PICU”) ward. However, his condition continued to deteriorate. The administration of neat CPG formed the subject of the first charge preferred against the Appellant.

The second operation

When the Patient was in the PICU ward, a Paediatric Intensivist named Dr Graeme MacLaren (“Dr MacLaren”) found him to be in an extremely unstable condition. A meeting was convened between Dr MacLaren, the Appellant, and two other doctors, and a decision was made to perform a second operation on the Patient to save his life. They decided to deploy an Extracorporeal Membrane Oxygenation Device (“ECMO”) in order to support the Patient’s cardiac and respiratory functions. It is not disputed that deploying an ECMO was a lifesaving procedure for the Patient.

The second operation was to be conducted by the Appellant on the evening of the same day. However, he did not carry out the intended operation. Due to a migraine attack which he had allegedly suffered shortly before the commencement of the operation, he requested Dr Kofidis, who had assisted him in the first operation, to conduct the operation on his behalf. Even though the notice given (approximately 30...