Monday, March 24, 2008
Death on the table
We recently had a death in the OR. Actually the patient died in the ICU afterwards but it was essentially a "table-death". This was a laparoscopic gall bladder in an octagenarian. She had an uneventful OR and then arrested in the recovery room. I didn't do the case but responded to the alarm, stayed for while until I figured there was enough help, so went on my way. Anyway she had a complex but no pulse which lead me to think she might be bleeding. After some rescuscitation they took her back to the OR where there was bleeding in the retroperioneum around the pancreas that nobody had noticed. She as I mentioned later died in the ICU.
This reminded me of a few things.
The first thing that came to mind was something that happened to a staff anaesthetist where I trained. This individual was not a very good anaesthetist. He however felt that he was the best anaesthetist around. This is a bad combination. He wasn't really fun to work with as a resident. (Aside from being a pompous twit, he had a nasty habit of poking you in the shoulder to make his point; nowadays laying hands on a resident would land you in the Dean' office.)The event in question however happened about 2 years after I finished. By that time I gather there had been a few other episodes.
He was doing a laparoscopic cholie around the time that surgeons started doing laparoscopic cholies and those of us who worked in that era remember what a dark time that was(3 hours of farting around followed by an open cholie). I gather during the case, the blood pressure continued to fall and fall. He asked the surgeon if there were any problems and of course the surgeon said no so on they went until the patient died.
My former "mentor" was told soon after that it was time he retired. This was before the autopsy showed a belly full of blood which the surgeon had failed to notice. Unfortunately my mentor had to keep retired while the surgeon is to my knowledge still working and hopefully learned something that day.
I have unfortunately over the years had a few deaths in the OR and few people that expired shortly after. Most of these have been predictable, ruptured aneurysms of both types, traumas and of course the ICU cases sent to the OR to be euthanized (this patient is going down the tubes and we can't think of anything to do so lets operate on him). Self flagellation comes naturally to anaesthesia and we always wonder if there was anything we could have done differently and looking back over the years, I don't think there was except maybe I could have run away.
The wierdest thing about a table death is that you usually have to start another case right after. Either you are on call or this case bumped into your elective list or it was in the middle of your elective list. So after an hour or so to clean up the mess and do the paper work, back in the saddle. Strange.
Several years ago, we had a province wide committee on peri-operative deaths and it was an interesting exercise. Essentially if a patient died within two weeks of surgery you had to come down to medical records, review the chart and fill out a form. Many of these were of course patients you knew died or you thought were going to die but you got the odd patient who just happened to die a few days post-op for no apparent reason. As I say it was interesting (and easier than reading the obits and looking for names you recognize.) This initiative stopped during our time of health care reform and downsizing in the mid 1990s when the province and hospital admins got worried that death might be attributed to their restructuring efforts.