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Three Anaesthetic Deaths
581
Medicine and the Law Three Anaesthetic Deaths LEAVING THE ANAESTHETISED PATIENT
THE letters column of Anaesthesia News is the platform for a debate on how far it is safe and good practice for an anaesthetist to leave the room (eg, to have a quick cup of coffee) when the patient is stable and being monitored by a competent operating theatre assistant or nurse. Dr John Sear (John Radcliffe Infirmary, Oxford), whose reply has been accepted for publication, has little doubt that the British legal system would sympathise with a doctor who had left the theatre to go to the toilet when misadventure occurred but not if his reason was a coffee. (Trained anaesthetic nurses are scarce and the "nurse" referred to may be a theatre nurse allocated for the day to learn how anaesthetic monitoring is done.) Common sense suggests that Dr Sear must be right for it cannot be responsible for a doctor to have a coffee break while his patient lies anaesthetised and there is no fully skilled anaesthetic back-up. Events following the death of a 34-year-old man being operated on at the Mayday Hospital, Croydon, for a detached retina suggest that such a practice could be not only negligent but also criminal. The inquest had to be halted following claims that Russian trained Dr John Adamoko, the anaesthetist, had left the operating theatre to make a cup of coffee. Dr Adamoko denied the accusation, but colleagues testified that he had been seen making himself a coffee and that he had privately admitted that he was absent. The man’s blood pressure had fallen dangerously low and Prof James Payne, an expert witness, said that the patient had probably been deprived of oxygen for five minutes, which had led to brain damage. The coroner postponed the inquest hearing and handed the files to the Crown Prosecution Service. The doctor may now face
manslaughter charges. INCORRECT PLACEMENT OF ENDOTRACHEAL TUBE
On Aug 4, 1987, a woman of 57 was admitted to Selly Oak Hospital, Birmingham, for a cataract operation. Dr Kirit Tana, a locum anaesthetist, inadvertently inserted the tube into the oesophagus. The patient collapsed, and a consultant anaesthetist had to leave his own patient to try to save the woman’s life until the senior registrar arrived. By then it was too late and the patient had been deprived of oxygen for 14 min. She had severe brain damage and died 2 months later from bronchial pneumonia. Dr Leslie Groves, a consultant anaesthetist, investigated the accident. He said that difficulty with endotracheal intubation was an almost daily occurrence but misplacements were usually noticed long before any damage was done. The coroner recorded a verdict of accidental death.
When the operation was over the anaesthetist could not wake the patient with 100% oxygen. He said that her pulse had been strong throughout the operation but, on its completion, the pulse began to fade. At this point, the anaesthetist thought he detected cyanosis from observing the pharynx; cyanosis is difficult to detect in dark-skinned people and it was apparently not noticeable elsewhere. The anaesthetist could not explain the patient’s cyanosis and collapse and he immediately summoned a consultant anaesthetist. The consultant arrived a minute later. The patient was by then lying flat. Her chest was moving normally but she was pulseless with a very slow heart rate. The consultant found that the tube was lying in the oesophagus and she repositioned it. Efforts at resuscitation were unsuccessful. The coroner returned a verdict of misadventure. He found that the patient had died of hypoxic brain damage when the endotracheal tube used for anaesthesia had become displaced. He said that it seemed highly probable that the tube had become displaced when the patient was being transferred from the anaesthetic room to the operating theatre, and that she had not received anaesthetic gases, including oxygen, during the operation. The medical evidence at this inquest showed that where a patient is dark skinned, the onset of cyanosis will be difficult to detect at a glance, so the anaesthetist should regularly check on this-for example, by observing the pharynx or using a transcutaneous oxygen monitoring device (not available in Dewsbury). Obesity in a patient may add to the anaesthetist’s difficulties, and thus to the risks. Here the patient had had to be intubated. The anaesthetist had been unable to view the vocal cords but had noted that the tube went in front of the visible part of the larynx. Even when the patient was cyanosed and had collapsed there were none of the usual signs to indicate that a misplaced tube was in the wrong place. The anaesthetic gases were going into the stomach, pushing the diaphragm, and when this happens gas usually escapes up the pharynx, causing a characteristic noise. Here, distension was not visible because the patient already had a protuberant abdomen, and there had been no "mouth noises". In cross-examination the consultant anaesthetist agreed that there were several points during which the tube could be pulled and dislodged, especially when a patient is moved from the anaesthetic room to the operating table. DIANA BRAHAMS, Barrister-at-law
International Diary 1989
2nd international conference on Health Law and Ethics: London, UK, 16-21 (Sharin Paaso, American Society of Law and Medicine, 765 Commonwealth Avenue, Suite 1634, Boston, Massachusetts 02215, USA).
July
DISPLACEMENT OF ENDOTRACHEAL TUBE AND CYANOSIS IN DARKSKINNED PATIENT
On March 30, 1988, a 41-year-old Asian woman with dark skin admitted as a day case to Staincliffe General Hospital, Dewsbury, for cystoscopy and urethral dilatation. However, because the patient was very obese, though otherwise reasonably fit, the anaesthetist, Dr Melvyn Robinson, a senior house-officer 8 years qualified with 4 years in anaesthetics, thought that a mask was contraindicated; obese people do not breathe well on their own under anaesthesia because of the weight of fat on the chest, especially when the patient is in the lithotomy position required for a cystoscopy. Metoclopramide and atropine were administered intravenously followed by etomidate and suxamethonium. A mask was then put over the patient’s face and anaesthesia induced by manual ventilation with 66% nitrous oxide, 33% oxygen, and 1 % enflurane. Shortly afterwards an endotracheal tube was introduced. The patient was then moved on to the operating table. An ECG monitor was attached, the tube was checked, and the patient’s pulse and colour continuously monitored.
1st international congress on Therapy with Amino Acids and Analogues: Vienna, Austria, Aug 7-12 (Barbara Bartosch, department of paediatrics, University of Vienna, Wahringer Gurtel 18, A 1090 Vienna).
was
2nd meeting on Paediatric Surgical Research and 4th South-EastEuropean symposium on Normal and Disturbed Esophageal Function in Childhood: Graz, Austria, Sept 6-9 (Dr H. Sauer, department of paediatric surgery, University of Graz, Heinrichstrasse 31, A-8010 Graz).
Centenary congress of the Polish Surgical Association: Krakow, Poland, Sept 17-20 (Organizing Committee, Secretariat, ul. Kopemika 40, 30-501 Krakow). 17th international congress of Rheumatology: Rio de Janeiro, Brazil, Sept 17-23 (Swami Jose Guimaraes, Secretariat, JZ Promocoes e Assessoria De Congressos, Rua Visconde da Silva 52/505, 22271 Rio De Janeiro). International symposium on New Trends and Developments in Occupational Health Services: Espoo, Finland, Oct 3-6 (Secretariat, c/o Institute of Occupational Health, Mirja Kallio, Topeliuksenkatu 41 aA, SF-00250 Helsinki).
Medicine and the Law Three Anaesthetic Deaths LEAVING THE ANAESTHETISED PATIENT
THE letters column of Anaesthesia News is the platform for a debate on how far it is safe and good practice for an anaesthetist to leave the room (eg, to have a quick cup of coffee) when the patient is stable and being monitored by a competent operating theatre assistant or nurse. Dr John Sear (John Radcliffe Infirmary, Oxford), whose reply has been accepted for publication, has little doubt that the British legal system would sympathise with a doctor who had left the theatre to go to the toilet when misadventure occurred but not if his reason was a coffee. (Trained anaesthetic nurses are scarce and the "nurse" referred to may be a theatre nurse allocated for the day to learn how anaesthetic monitoring is done.) Common sense suggests that Dr Sear must be right for it cannot be responsible for a doctor to have a coffee break while his patient lies anaesthetised and there is no fully skilled anaesthetic back-up. Events following the death of a 34-year-old man being operated on at the Mayday Hospital, Croydon, for a detached retina suggest that such a practice could be not only negligent but also criminal. The inquest had to be halted following claims that Russian trained Dr John Adamoko, the anaesthetist, had left the operating theatre to make a cup of coffee. Dr Adamoko denied the accusation, but colleagues testified that he had been seen making himself a coffee and that he had privately admitted that he was absent. The man’s blood pressure had fallen dangerously low and Prof James Payne, an expert witness, said that the patient had probably been deprived of oxygen for five minutes, which had led to brain damage. The coroner postponed the inquest hearing and handed the files to the Crown Prosecution Service. The doctor may now face
manslaughter charges. INCORRECT PLACEMENT OF ENDOTRACHEAL TUBE
On Aug 4, 1987, a woman of 57 was admitted to Selly Oak Hospital, Birmingham, for a cataract operation. Dr Kirit Tana, a locum anaesthetist, inadvertently inserted the tube into the oesophagus. The patient collapsed, and a consultant anaesthetist had to leave his own patient to try to save the woman’s life until the senior registrar arrived. By then it was too late and the patient had been deprived of oxygen for 14 min. She had severe brain damage and died 2 months later from bronchial pneumonia. Dr Leslie Groves, a consultant anaesthetist, investigated the accident. He said that difficulty with endotracheal intubation was an almost daily occurrence but misplacements were usually noticed long before any damage was done. The coroner recorded a verdict of accidental death.
When the operation was over the anaesthetist could not wake the patient with 100% oxygen. He said that her pulse had been strong throughout the operation but, on its completion, the pulse began to fade. At this point, the anaesthetist thought he detected cyanosis from observing the pharynx; cyanosis is difficult to detect in dark-skinned people and it was apparently not noticeable elsewhere. The anaesthetist could not explain the patient’s cyanosis and collapse and he immediately summoned a consultant anaesthetist. The consultant arrived a minute later. The patient was by then lying flat. Her chest was moving normally but she was pulseless with a very slow heart rate. The consultant found that the tube was lying in the oesophagus and she repositioned it. Efforts at resuscitation were unsuccessful. The coroner returned a verdict of misadventure. He found that the patient had died of hypoxic brain damage when the endotracheal tube used for anaesthesia had become displaced. He said that it seemed highly probable that the tube had become displaced when the patient was being transferred from the anaesthetic room to the operating theatre, and that she had not received anaesthetic gases, including oxygen, during the operation. The medical evidence at this inquest showed that where a patient is dark skinned, the onset of cyanosis will be difficult to detect at a glance, so the anaesthetist should regularly check on this-for example, by observing the pharynx or using a transcutaneous oxygen monitoring device (not available in Dewsbury). Obesity in a patient may add to the anaesthetist’s difficulties, and thus to the risks. Here the patient had had to be intubated. The anaesthetist had been unable to view the vocal cords but had noted that the tube went in front of the visible part of the larynx. Even when the patient was cyanosed and had collapsed there were none of the usual signs to indicate that a misplaced tube was in the wrong place. The anaesthetic gases were going into the stomach, pushing the diaphragm, and when this happens gas usually escapes up the pharynx, causing a characteristic noise. Here, distension was not visible because the patient already had a protuberant abdomen, and there had been no "mouth noises". In cross-examination the consultant anaesthetist agreed that there were several points during which the tube could be pulled and dislodged, especially when a patient is moved from the anaesthetic room to the operating table. DIANA BRAHAMS, Barrister-at-law
International Diary 1989
2nd international conference on Health Law and Ethics: London, UK, 16-21 (Sharin Paaso, American Society of Law and Medicine, 765 Commonwealth Avenue, Suite 1634, Boston, Massachusetts 02215, USA).
July
DISPLACEMENT OF ENDOTRACHEAL TUBE AND CYANOSIS IN DARKSKINNED PATIENT
On March 30, 1988, a 41-year-old Asian woman with dark skin admitted as a day case to Staincliffe General Hospital, Dewsbury, for cystoscopy and urethral dilatation. However, because the patient was very obese, though otherwise reasonably fit, the anaesthetist, Dr Melvyn Robinson, a senior house-officer 8 years qualified with 4 years in anaesthetics, thought that a mask was contraindicated; obese people do not breathe well on their own under anaesthesia because of the weight of fat on the chest, especially when the patient is in the lithotomy position required for a cystoscopy. Metoclopramide and atropine were administered intravenously followed by etomidate and suxamethonium. A mask was then put over the patient’s face and anaesthesia induced by manual ventilation with 66% nitrous oxide, 33% oxygen, and 1 % enflurane. Shortly afterwards an endotracheal tube was introduced. The patient was then moved on to the operating table. An ECG monitor was attached, the tube was checked, and the patient’s pulse and colour continuously monitored.
1st international congress on Therapy with Amino Acids and Analogues: Vienna, Austria, Aug 7-12 (Barbara Bartosch, department of paediatrics, University of Vienna, Wahringer Gurtel 18, A 1090 Vienna).
was
2nd meeting on Paediatric Surgical Research and 4th South-EastEuropean symposium on Normal and Disturbed Esophageal Function in Childhood: Graz, Austria, Sept 6-9 (Dr H. Sauer, department of paediatric surgery, University of Graz, Heinrichstrasse 31, A-8010 Graz).
Centenary congress of the Polish Surgical Association: Krakow, Poland, Sept 17-20 (Organizing Committee, Secretariat, ul. Kopemika 40, 30-501 Krakow). 17th international congress of Rheumatology: Rio de Janeiro, Brazil, Sept 17-23 (Swami Jose Guimaraes, Secretariat, JZ Promocoes e Assessoria De Congressos, Rua Visconde da Silva 52/505, 22271 Rio De Janeiro). International symposium on New Trends and Developments in Occupational Health Services: Espoo, Finland, Oct 3-6 (Secretariat, c/o Institute of Occupational Health, Mirja Kallio, Topeliuksenkatu 41 aA, SF-00250 Helsinki).