Monday, July 16, 2007

I Got Sued Part 1

A few weeks ago while channel surfing I came across the movie "The Verdict" with Paul Newman. I first saw this movie in 1984.

The movie is about a lawsuit against an anaesthesiologist.

The "facts" in the movie are that the plaintiff came into hospital to have her baby and was "given the wrong anaesthetic". Essentially the patient had eaten just before she came into hospital to have a baby and was given a general anaesthetic with a mask during which she vomitted, aspirated, had a cardiac arrest was rescuscitated but was left in what we call a vegitative state.

The movie doesn't say what type of operation she had.

Assuming she had a caesarian section, there was no right or wrong anaesthetic in 1983 or now. The standard of care for a caesarian section under general since the 1960s would have been to intubate the patient. A mask anaesthetic would have definitely been the wrong anaesthetic. Pregnant patients are assumed to have a full stomach regardless of how long they have fasted and stomachs empty much more slowly in pregancy.

Now up until the 1960s or later, it was fashionable to give women heavy sedation approaching or exceeding general anaesthetic for labour and this is what may have happened. Judging from the clothing and hairstyles however, the movie is set in the early 80s/late 70s.

I am constantly amazed that producers are prepared to spend millions on a film without asking a specialist in the field, "Is this a plausible scenario?"

This however is not about reality in the film industry, it is about my brush with the medico-legal system.

Actually it was 14 years ago and I believe it was settled at least 10 years ago. I was reading Dr. Sid Schwab's blog and he talked about how he got sued years ago so I thought I should relate my experience.

Firstly I fully admit that while there were extenuating circumstances which I will detail, there were actions that had I followed them, the whole mess would not have happened. The bottom line is I have always accepted full responsibility for what happened.

It happened a few months after I joined the staff at the centre of excellence. I have been in practice for just over 2 years at the time. Statistically anaesthetists are at their most dangerous in their first 3 years of practice. (Some people think that more experienced anaesthetists are just better covering up their mistakes.)

Anyway as I have mentioned in a previous post, I had already by then realized that I did not fit in at the centre of excellence and that I would probably never fit in.

When I was a resident and in my first years of practice, when a patient needed to stay in hospital after their surgery, they were admitted the night before and they were seen the night before by the anaesthetist assigned to the room. This meant up to an extra hour of (unpaid) work after your list had finished not to mention the Sunday night visits. This was we all belived the cross anaesthetists had to bear. Now it was around that time, the hospitals in the name of saving money decided that patients could be admitted on the day of surgery. This meant that they were seen in advance of their surgery at a Pre-operative Assessment Clinic (PAC) by one anaesthetist who was assigned there that day. That lucky person would see all the patients, review the lab work and fill out the anaesthetic form. Hopefully if there was a potential problem, that would be relayed to whoever was supposed to do the case. At that time a copy of the anaesthetic form would be faxed to the office the day before so you had some idea of what you were doing.

Anyway, the day before I looked at the slate and saw that one of my cases was a "Laparoscopic Heller's Myotomy". Even with a medical degree, five years of medical training and over two years clinical practice, I had no idea what that was. Nor did anybody in the office. I suppose I could have gotten a surgical textbook and looked it up (I did several months later and even some surgical texts didn't use that term). Or I could have phoned the surgeon's office and talked to him. But I didn't. I figured I could talk to the patient the next day, read the chart and I would be able to figure out what I could or couldn't do. (Nowadays I would just Google Heller's Myotomy but back then Al Gore had only just invented the internet).

Complicating matters was that the surgeon was probably the most clumsy incompetent surgeon at the CofE. There are many clumsy and incompetent surgeons and many of them know their limitations and stick to hernias, lumps and bumps. Then there are those who don't know their limitations. This surgeon, widely known for his incidental splectomies was one of the later group. Worse still, he had jumped onto the laparoscopic bandwagon well in advance of many of his colleagues.

Anyway on arrival in the room, I asked the nurses if they had any idea what our second case was. They too had no idea. So we asked the surgeon when he came in. He mumbled something like, "just like a laparoscopic cholie, no problem". Our first case was a breast biopsy which unfortunately needed a frozen section which took much longer than planned, so we were already running late. All this time I was thinking no problem, I'll talk to the patient and read the chart and I can do this next case.

On dumping my first patient in the recovery room, I went out to the receiving area but my second patient wasn't there yet. Quite often I will see the patient in the operating room but I distinctly remember telling the nurse in receiving, " call me when the patient gets there". Then I went to have coffee.

The next call I got was from the room telling me that the patient was in the room. No problem, I can read the chart and talk to the patient there. Except.....

Because patients don't come in the night before, the surgery residents also don't get a chance to read the chart and the surgery resident had taken the chart somewhere to read it. And...

The patient was deaf-mute and no family member had accompanied her.

No problem. One of my colleagues must have been able to talk to the relatives, read the chart in the PAC. So I got the anaesthetic record (which hadn't been faxed over the day before). She had been seen by the chairman of the department, an eminent academic anaesthetist. To be honest there wasn't much on the chart just a couple of meds, no allegies and a note that the patient was deaf-mute. Nothing to get the spidey senses tingling. Now I have learned since and probably knew then that the more eminent an academic anaesthetist is, the less competent they are. But I figured, okay we're dealing with something like a laparoscopic cholie in deaf-mute but otherwise health person.

So we set up to induce anaesthesia. I had a student with me that day, somebody I had worked with for a couple of days. This was a smaller room and we had the two monitor towers on each side of the bed so there was only room for one person at the head of the bed. Since my student was going to intubate,that was him. When we start anaesthesia, there is supposed to be a nurse whose only responsibility for those few minutes is to help us. There was a female nurse-looking person standing at the side of the bed where the nurse usually stands.

So I inject the drugs and after waiting a few seconds, my student goes to intubate. First thing he says is "I think we need suction". So I ask him to get away from the head of the bed because there is not room for two of us because of the monitors and I take a look and her entire mouth is full of some gross whitish material. That was when I discovered that my lovely assistant was a student nurse who had never helped start a case and that she had not got a suction ready. (The nurses get the suction ready for each case, but I admit it is my responsibility to check for its presence).

At this point, the surgery resident wandered into the room with the chart, looked into her brimming oro-pharynx and said, "Isn't achalasia gross?"


Achalasia is a condition where the muscles in the esophagus that are supposed to propel food down towards your stomach don't work. This results in solid food accumulating in your esophagus where it basically decomposes leaving you with a massively dilated esophagous full of rotten food. This patient I learned later had a particularily bad case to the point where she had to sleep sitting up or else all this rotten food would go down her lungs.

Usually patients like this are admitted to hospital several days in advance and all the rotten food is sucked out and they kept on a liquid diet.

Now when you screw up like this, no matter how extenuating the circumstances are, when you should be thinking, "how can I help this poor person?", your first thoughts are, "boy am I in shit!"

So I pushed the student aside waiting for the real nurse to set up a suction, sucked out the oro-pharnynx and intubated. Fortunately the patient's oxygen saturation remained okay and she was not broncho-spastic. I called for a broncho-scope and looked down into her lungs. There was a little bit of "staining" in the parts of the lung I could get to with the bronchoscope which I tried to suction out as best I could.

At that point I should have cancelled the case. The patient had aspirated she was stable but she could get worse during the case and once we started, it might be difficult to stop. I didn't do that though. I felt so bad that my telepathic powers had failed to pick up what the patient had and what the surgeon planned to do that I felt I had to make things up by continuing on with the case. This is very irrational but that is how you think when things like this happen.

At the very least, I should have suctioned out the 2 or so litres of rotten food in her esophagous to keep it out of her lungs. (An endotracheal tube is only partial protectiona against aspiration.)

After that, the case went pretty good.

1 comment:

Sid Schwab said...

Actually, assuming it was my blog you were referring to, it's Sid. Be that as it may, your candor and descriptive powers make this a pretty gripping post. Feels sort of familiar; how a cascade of little things can end up in a disaster.