Routine operation results in death
Dr Kevin Fong, a Consultant in Anaesthesia at University College London Hospital has recently been in the news with his article considering what we can learn from fatal mistakes in surgery
. To highlight this issue, Dr Fong analysed the case of 37 year old Elaine Bromley who suffered catastrophic brain damage
after unexpected complications occurred at the start of a routine operation on her nasal air passages.
In 2005, shortly after the anaesthetic drug had been injected an emergency arose, Elaine’s airway- the path from her mouth to her lungs through which normal air flows – had become obstructed, this is a rare event which occurs in fewer than one in 50,000
The medical team had persisted for 20 minutes trying to assist Elaine’s breathing however they were unable to remedy the situation
, Elaine’s brain became starved of oxygen, and she was transferred to the intensive care unit, but unfortunately died several days later
After the death of his wife, Martin Bromley focused his energy on trying to understand what had gone wrong
during the operation and the reasons why. Martin was a commercial airline pilot and was familiar with how the world of aviation would have responded to a similar catastrophic event. There would have been an independent investigation
to try and discover the root cause of the incident, the focus of this would not be to apportion blame or determine legal liability but in fact would have been to learn lessons which may save lives
in the future.
An independent investigation was carried out into Elaine’s death due to her husband's persistence, it revealed many elements of the incident in which those present could have performed better
. Whilst reading the report Martin came to the conclusion that the system had let Elaine down and the members of the team were insufficiently protected
from their own fallibility.
In the airline industry, steps are taken to standardise operational procedures
, leaving as little as possible to chance or the frailties of human psychology, whilst examining the events surrounding his wife’s death Martin noticed that such measures were often absent from the practice of healthcare
as it stood in 2005.
As a result of this Martin took it upon himself to advocate for improved safety culture in medicine
, by doing this he has succeeded in forcing a radical rethink amongst healthcare workers particularly those who are involved in the frontline anaesthetic practice.
Martin believes that in healthcare there should be greater standardisation of procedures
and more use of checklists to ensure that vital tasks are not omitted, this is not to say that all healthcare should be run the way airports and commercial liners are, however, this is no reason to completely ignore the lessons we might learn from other organisations as there are important aspects of airline safety which the health service would benefit from.
The investigation into Elaine’s death identified elements which could have been dealt with differently, however it also stresses that even if the management of Elaine’s care had been perfect her life may still have been lost. Even though this may have been the case Martin feels as though the healthcare profession has learned the important lessons
which stemmed from his wife’s death.
There are 3 main types of anesthesia, general, regional and local. All 3 carry their own unique risks and it has been suggested that up to 2% of intensive care unit admissions at any one time are related to anesthetic problems. Although general anesthesia is not without risk, it should be remembered that it allows necessary procedures to be performed
- without which the patient might otherwise die.
There are many important complications of general anesthesia which are well documented and whilst Dr Fong is correct when he says that the loss of control of a patient's airway during anesthesia is a rarely experienced event
, and it is hard to prepare for situations which may arise only once in a career lifetime, it is also true that doctors are trained to recognise such medical emergencies.
There are a number of complications that can occur as a result of an anesthetic and if there is a failure by the doctors to recognise and/or act promptly then there is an increased risk that you could suffer irreversible brain damage
which could result in you becoming wholly dependent on other people to take care of your daily needs in all aspects of your life as a result of a medical mistake.
Some well recognised complications of a general anesthetic are listed below:
- Nausea and vomiting - up to 30% of patients
- Damage to teeth - 1 in 4,500 cases
- Sore throat and laryngeal damage
- Anaphylaxis to anesthetic agents - figures such as 0.2% have been quoted
- Cardiovascular collapse
- Respiratory depression
- Aspiration pneumonitis - up to 4.5% frequency has been reported; higher in children
- Hypoxic brain damage
- Nerve injury - 0.4% in general anesthesia and 0.1% in regional anesthesia
- Awareness during anesthesia - up to 0.2% of patients; higher in obstetrics and cardiac patients
- Embolism - air, thrombus, venous or arterial
- Idiosyncratic reactions related to specific agents, eg malignant hyperpyrexia with suxamethonium, succinylcholine-related apnoea
- Iatrogenic, eg pneumothorax related to central line insertion