Sunday, May 27, 2012

Just a minor case

This is really sad. 

No I mean it, nobody should have to have gone through what this poor man's wife went thru; he shouldn't be a widower, his children should have their mother still.  And good for him for channeling his grief into trying to help others by educating and improving practices.

It does show something.

Surgery (and anaesthesia) are something to be respected.  From time to time I run into a patient who is scared shztless about his upcoming surgery.  These are for the most part ASA 1 or 2 patients having "minor" surgery.  I always tell them that it is quite normal to feel that way; surgery is something that should be respected.  Too many patients approach surgery with a cavalier indifference.  In the Pain Clinic I see a lot of people whose lives have been ruined as the result of surgery.  Without exception they all want another operation. We all see the patients in the Pre-assessment clinic or in the holding area who just can't seem to understand why we are asking them all these questions.  After all it is just a minor case.

We also get this response from surgeons when we suggest that the patient's diabetes needs to fixed or that the chest pain they have been having needs to be investigated, "Oh its just a quick case."

It is interesting watching the video, seeing what went down.   It appears as if she was having sinus surgery; a shared airway we all learned to respect very early in our residency.  I would have to question using a laryngeal mask although I realize many respected anaesthesiologists advocate this.  I like to have the airway secured while the ENT surgeon is messing around (while I know that they can and do accidentally extubate the patient).  Not that I don't like LMAs.  I use them for over half my cases but almost never in a head and neck case.  I suspect what happened in this case was that they couldn't intubate the patient so decided to go with a LMA, converting a Can't Intubate Can Ventilate airway to the much feared Can't Intubate Can't Ventilate airway.  I have never understood the logic of pushing a large LMA blindly down an airway you have already traumatized although I have done this myself and "got away with it". 

I have fortunately never been involved in a can't intubate, can't ventilate situation.  There has been the odd time when I thought I might be headed down that road but something intervened.  It is surprising that with an ENT surgeon in the room and the nurses even bringing in a trach set, nobody thought of doing a trach.  Of course I remember watching an ENT surgeon at the C of E doing a trach and thinking, "I hope my life never depends on you doing a trach on me!"

It is interesting that her widower works in the aviation industry, one industry that takes safety seriously (as I like to reassure myself before every take-off and landing.)  When it suits their agenda our administration is always exhorting us to imitate the aviation industry in our "quality" practices.  This is why we now have our safe surgery checklist.  There is a lot to learn from the aviation industry except that there is one huge difference.  If a pilot screws up badly, he dies along with his passengers. Therefore everybody, in the plane at least, has a real big incentive to make sure everything goes smoothly.  That doesn't include the ground crew or the air traffic controllers of course and we hear of the the odd suicidal pilot.  In contrast if you screw up in the OR, at the worst you may get a rough ride at M+M rounds, you might face an unpleasant interview with your chief, you might get a College complaint or you might get sued.  The bottom line is that in most cases you will be back to work.

But we have to remember that patients die during and after routine surgery from other causes.  They can succumb to an infection with sepsis, they can have a myocardial infarction or a pulmonary embolism.  These are for the most part unrelated to anaesthesia.  The difference is that there is usually very little hand-wringing when a patient dies from these causes although I would bet they are far more common than any direct anaesthetic related mortality.  It is however not possible to have most surgeries without an anaesthetic so why do we treat any anaesthetic death related or not related to competency differently.  Not that we shouldn't feel remorse or empathy when a patient has a bad outcome.  (Unfortunately the first thing most of us think about when this happens is "well at least it wasn't my fault".)

When people ask me what the risk of dying during anaesthesia is; I have a pat answer.  I tell them it is the same as being killed in a car accident on the way home.  One very anxious patient when I told her that replied, "Oh that is really high".  To which I replied, "You must be a really bad driver."

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