Anaesthetic VignettesAnaesthetic Vignettes

40 years in USA and UK

Dr Bob Palmer

WOOLLEY AND ROE THE UNEXPURGATED VERSION

• MONDAY 13th OCTOBER 1947 CHESTERFIELD ROYAL INFIRMARY.

• CECIL ROE 45 MENISECTOMY.

• SECOND PATIENT LAPAROTOMY.

• ALBERT WOOLLEY 56 HYDROCOEL.

• DR J M GRAHAM ANAESTHETIST.

• SPINAL ANAESTHESIA WITH PLAIN CINCHOCAINE IN 10 ML AMPOULES.

• CECIL ROE SEVERE PAIN IN HEAD AND NECK DURING CASE AND POOR ANESTHESIA. SUBSEQUENTLY DEVELOPED DEEP ULCER AT INJECTION SITE.

• ALL THREE PATIENTS DEVELOPED CAUDA EQUINA SYNDROME WITH FLACCID PARALYSIS, LOWER BODY ANAESTHESIA AND INCONTINENCE OF URINE AND FAECES. IN MR ROE AND MR WOOLLEY THIS IMPROVED BUT WAS REPLACED BY A SPASTIC PARALYSIS OF UPPER MOTOR NEURONE TYPE CONSISTENT WITH ADHESIVE ARACHNOIDITIS.

• THE SECOND PATIENT DIED ON THE FIFTH POSTOPERATIVE DAY FROM SURGICAL COMPLICATIONS.

• CECIL ROE DIED OF PYELONEPHRITIS IN 1954.• MR WOOLLEY ALSO DIED PREMATURELY.

• MR ROE AND MR WOOLLEY SUED AND THE CASE WAS HEARD IN 1953.

• THE JUDGE RELUCTANTLY ACCEPTED THE OPINION THAT PHENOL HAD LEECHED THROUGH MICROSCOPIC CRACKS IN THE CINHOCAINE AMPOULES DURING STERILISATION.

• THERE WAS GREAT PUBLICITY AND SPINAL ANAESTHESIA WAS VIRTUALLY DISCONTINUED IN THE UK FOR 25 YEARS UNTIL SELWYN CRAWFORD USED IT IN OBSTETRICS IN THE LATE 1970’S IN BIRMINGHAM.

• DR CHRIS HUTTER INVESTIGATED THE CASE IN 1989.

• REUSABLE GLASS SYRINGES AND SPINAL NEEDLES WERE USED AND STERILISED IN WATER BOILERS.

• PERIODICALLY THE WATER BOILERS WERE DESCALED DUE TO THE HARD WATER WITH PROBABLY PHOSPHORIC ACID.

• DESCALING WAS PROBABLY PERFORMED ON THE SUNDAY, THE DAY BEFORE.

• PROBABLY THE PHOSPHORIC ACID WAS NOT FLUSHED OUT DURING THE DESCALING AND WAS THE CONTAMINANT.

• DR GRAHAM NEVER BELIEVED THE COURT VERDICT BUT KEPT QUIET AT THE TRIAL FOR PERSONAL REASONS.

• CECIL ROE’S SON ALSO CECIL ROE RECENTLY REFUSED A SPINAL.

Robbie Burns DayRobbie Burns Day

January 25 1977, McGill University January 25 1977, McGill University MontrealMontreal

• 41 yo woman with subarachnoid haemmorhage for carotid angiography

• Anaesthesiologists wife (ie my wife) having LSCS during this case

• Patient induced, paralysed, intubated and ventilated for case

• Monitoring: oscillotonometer and cardiogram

• At end of case pt reversed

• The neostigmine is in brown ampoules of 1mg each on rack with atropine ampoules, necessitating opening 3 neostig and 1 atropine ampoule

• After reversal patient develops serious bradyarrhythmia and severe hypertension above limit on oscillotonometer

• Surgeon who is still around unfortunately remarks ‘God damn it Palmer what the hells going on here’

• After 5 minutes off to quickly view my new daughter I carry on with list

• Later on that evening I go back and empty the sharps bin

• One of the neostigmine amps is actually phenylephrine

• It is the same colour and presumably been mistakenly placed on the reversal rack

• I go and see the patient and she doesn’t seem any the worse for my intervention

Getting On With Your SurgeonGetting On With Your Surgeon

The Johnny Carson ShowThe Johnny Carson Show

USA

• An anesthesiologist at a community hospital in Worcester came to fisticuffs with his surgeon while the patient was anaesthetised.

• It subsequently featured on the Johnny Carson Show.

• Same anesthesiologist • Same hospital • Anaesthetising for the same surgeon • Two separate occasions • Both for laparoscopic procedures on young

women • Unrecognised oesophageal intubations both

times

• One patient died

• One developed locked-in syndrome and is still institutionalised in Boston.

An Anaesthetists NightmareAn Anaesthetists Nightmare

• Friday 13th February 1979, Worcester Memorial Hospital

• 42 yo morbidly obese female for diagnostic laparoscopy

• Induced with thiopentone and succinylcholine

• Intubated and ventilated with nitrous oxide, oxygen, halothane and a succinylcholine infusion

• Monitoring: oscillotonometer and ECG

• The surgeon threw the drapes over the patient

• I didn’t attach them to the IV pole so I couldn’t see the patients face

• I was filling in the anaesthetic sheet when I noticed from the sound of the ECG monitor bradycardia and ectopics

• I pulled the drape off the patients face and she was navy blue

• I pulled out the ET tube

• Inserted a guedel airway

• Bagged and masked the patient with 100% oxygen

• Intubated the patient

• Stopped the sux infusion

• Called for help

• As a colleague arrived the patient exhibited decerebrate rigidity

• The patient was given 500mg of thiopentone for cerebral protection, and transferred to the intensive care unit where she was hyperventilated overnight

Personal consequences of a bad Personal consequences of a bad near miss or disaster, esp when near miss or disaster, esp when you know you have been at faultyou know you have been at fault

• Self doubt

• Loss of confidence for many weeks or months

• Excessive attention to every aspect of clinical care

• Depression, sometimes worse

• Never forget and change clinical practice

BOTTLE OF WINE QUESTIONBOTTLE OF WINE QUESTION

Dr Ellison Pierceand

Jeffrey Cooper

Dr Ellison PierceDr Ellison Pierce

• Anesthesiology graduate of University of Pennsylvania

• Attending anesthesiologist at New England Deaconess Hospital in Boston

• Elected vice president of the American Society of Anesthesiologists in 1982

• His particular interest was patient safety in anaesthesia

Jeffrey CooperJeffrey Cooper

The great leap forward

• 36 year old bioengineer at the Massachusetts General Hospital

• Ellison Pierce recruited him to look into anaesthetic mishaps and develop technologies to reduce them

• He watched anesthesiologists at work and studied in depth 359 anaesthetic disasters

• Many potential problems with anaesthetic machines

• Most mishaps occurred in the middle of anaesthetics due to poor vigilance

• Most were airway or breathing circuit related

• Problems associated with long working hours

What he found….What he found….

He was the catalyst for the He was the catalyst for the introduction of:introduction of:

• Capnography

• Pulse oximetry

• Redesigning of anaesthetic machines e.g. with the oxygen nitrous oxide interlock

• Shortening of residents working hours

• Following widespread adoption of these, anaesthetic mishaps dropped to 1/20 of their previous level.

THE WRONG SIDE AGAIN

• 2007 QA TRAUMA LIST.• YOUNG LADY FOR FOREARM SURGERY.• AT PREOPERATIVE VISIT PATIENT OFFERED

AXILLARY BLOCK AWAKE FOLLOWED BY GA WHICH SHE ACCEPTS.

• IT IS MY PRACTICE TO ALWAYS DO BLOCKS WITH THE PATIENT AWAKE AND BEFORE I START CONFIRM WITH THE PATIENT I AM BLOCKING THE CORRECT SIDE.

• SHE STARTS CRYING AND SAYS SHE WANTS TO BE ASLEEP FOR THE BLOCK.

• OUT OF CHIVALRY I AGREE.• ONCE ASLEEP I CANNOT VERIFY THE

SIDE TO BE BLOCKED WITH HER.• I PREP THE WRONG AXILLA.• TWO NURSES IN THE PREP ROOM

STOP ME IN TIME.

Worcester, Mass, USAWorcester, Mass, USA

BOTTLE OF WINE QUESTIONBOTTLE OF WINE QUESTIONGregory Pincus

The Same Old MistakeThe Same Old Mistake

(not RJP)

• Male patient 85 yo laparotomy for bowel resection for Ca

• 1 litre plastic bag of crystalloid hanging, 500 cc run through

• Surgeon asks anaesthesiologist to give 500mg metronidazole IV

• Anaesthesiologist takes down IV bag and props it upright on anaesthetic machine

• After metronidazole has run through anaesthesiologist reattaches IV bag

• There is a sudden episode of bleeding

• Anaesthesiologist attaches pressure bag to IV crystalloid and pumps it up

• Hears strange bubbly noise

• Patient arrests and can’t be resuscitated

• Only the anaesthesiologist realises the reason for the arrest

• What should he/she do?

• What did he/she do?

Skating On Thin IceSkating On Thin Ice

Anaesthetic TrainingAnaesthetic Training

USA vs UK

USAUSA UKUK

• 4 yrs uni degree• 4 yrs med school• 1 yr anaes intern• 3 yrs anaes resident• ABA exam + work• Typically aged 30-31• 80 hrs week• Same hospital• Won’t discuss longer

• 5 yrs med school

• 2 yrs foundation dr• 7 yrs anaes trainee

• Typically aged 32-33• 48 hrs week• Many hospitals• Worry if ready

BOTTLE OF WINE QUESTIONBOTTLE OF WINE QUESTION

PortsmouthPortsmouth

FLKFLK

Portsmouth, UK

1994

• 11 yo physically handicapped girl for bilateral release of tight heel cords

• Apart from appearance and apparent mild cerebral palsy, history and examination essentially normal

• No further investigations felt to be needed

• Surgeon agreed to do operation in supine position

• After siting of cannula, patient induced with propofol

• LMA, spont resps on circle with N2O, O2, isoflurane

MonitoringMonitoring

• NIBP

• Capnography

• Cardiogram

• Pulse oximetry

• Nasopharyngeal temperature probe

25 minutes later25 minutes later

• Patient develops a tachyarrhythmia with multifocal ventricular ectopics

• Shortly followed by desaturation

• Decreasing pulmonary compliance

• What was happening?

• Any questions?

• I had a trainee with me and at the start of the case we had discussed the association of MH (and hyperkalaemia) and FLKs

• Therefore this possibility was uppermost in our minds

• We immediately called a consultant anaesthetic colleague who got the dantrolene from recovery

• Dantrolene reconstituted, given IV

• Arterial line sited, bloods sent

• Dantrolene had a rapid effect on what had been a deteriorating and somewhat desperate situation

• O2 sats improved, pulmonary compliance improved

• Bloods showed hyperkalaemia, metabolic acidosis and very high CPK

• Patient transferred to ICU

• Bilateral forearm swelling, nearly requiring fasciotomy

• Several months residual problems with one arm but eventual complete recovery

A Good SniffA Good Sniff

• 1984

• I am chief of anaesthetic department in community hospital in USA

• I am approached by a member of staff complaining about a surgeon who has been seen on more than one occasion breathing the nitrous oxide from the anaesthetic machine in one of our theatres

• I am reminded of the case of the anaesthetist whose life was saved when a junior anaesthetist happened to go into theatre and found him obstructed and blue on the floor after sniffing

• The department was sworn to secrecy

• How do I deal with this?

To Tell Or Not To Tell, That Is To Tell Or Not To Tell, That Is The Question ?The Question ?

• 1978 Worcester, Massachusetts

• Another epidural

• Commit cardinal sin of pulling epidural catheter back through Tuohy needle which way back then had a sharp end

• End 1 cm of catheter shears off and is left in patients epidural space

• I am the only one who knows

• The 1 cm of portex catheter left in the epidural space is probably innocuous

• Surgical removal would not be indicated

• If I tell the patient she may develop a back neurosis and/or sue

• Clearly if the patient has been harmed a full explanation and apology is the correct course

• However one could argue she has not been harmed

• What should I do?

Herding CatsHerding Cats

NSAIDS

• ADVERSE EFFECTS ON RENAL FUNCTION.• ANTIPLATELET ACTIVITY.• ADVERSE EFFECTS ON OSTEOBLASTS AND

FRACTURE SURGERY.• GASTRIC IRRITATION.• USE IN ASTHMATIC PATIENTS.• CARDIAC EFFECTS.• NEGATING EFFECT OF IUCD.

Dangerous To KnowDangerous To Know

Early 1980s

• Anesthesiologist in Massachusetts gave a young female patient a caudal anaesthetic

• Injected 20mls of an ester local anaesthetic 2,3 chlorprocaine (nesacine)

• Which contained the preservative sodium metabisulphite (later removed from the preparation by the manufacturers)

• He pushed the needle in too far

• Penetrated the dural sac at S2

• Deposited the entire 20 mls intrathecally

• The patient developed a permanent cauda equina syndrome

• The same anesthesiologist was subsequently involved in the infamous Massachusetts Institute of Correction (Walpole) affair.

jappenergy.mpg

MiscommunicationMiscommunication

““Another General Anaesthetic, Another General Anaesthetic, Doctor”Doctor”

• 1712 hrs, 12 Nov 2005, Portsmouth UK

• I am the anaesthetist on call for labour ward

• Category 1 LSCS for foetal distress

• RSI, GA

• Live infant, APGAR 1 and 4

• To neonatal ICU, does well

1725 hrs1725 hrs

• Trainee arrives (25 mins late) takes over case

• I wait until end of case

• Patient reversed and wakes up uneventfully

• After being recovered, sent to single room on post natal ward

0405 hrs, 130405 hrs, 13thth Nov Nov

• Trainee receives call from midwife who had gone to patients room to give prescribed 0400 hrs antibiotic

• “Your patient seems to have had another general anaesthetic, doctor”

• Trainee immediately goes to ward and finds patient deeply unconscious but fortunately not obstructed

• Does primary survey

• What do you think has happened?

• GCS 3

• Yellow sclera

• Blood sugar <1

• Gives IV dextrose

• Patient partially wakes up

• Transferred to ICU intubated and ventilated

• Diagnosis: acute liver failure due to acute fatty liver of pregnancy

• Transferred ventilated to Kings Hospital Liver Unit for possible liver transplant

• Eventually recovers and doesn’t require transplant

An Obstetric Anaesthetic An Obstetric Anaesthetic FeastFeast

1986 Worcester, Mass USA1986 Worcester, Mass USA

• Labour Ward on one floor

• 3 LSCS rooms adjacent to each other

• 6 labour/delivery rooms next to LSCS rooms

Clinical situationClinical situation

• 8pm weekday evening

• I am sole anaesthetic person

• No anaesthetic techs in USA

• Lots of obstetricians around including several OB residents, one of whom has done a brief anaesthetic attachment

Clinical ScenarioClinical Scenario

• 4 functioning labour epidurals running

• I am in OR 1 with a category 3 LSCS under epidural which is working well.

• The husband is next to me.

• I have the Wall Street Journal tucked away hoping for a suitable moment.

• The surgeon has started but the baby is not delivered

• They say there is a category 1 LSCS on one of my labour epidurals who is being moved to OR 2 now

• WHAT WOULD YOU DO?

• WHAT DID I DO?

• I am in OR 2 having done a rapid sequence induction on LSCS #2. There is a sux drip running. The surgeon has just started, but again the baby is not delivered yet.

• My friendly OB resident is with LSCS #1 which fortunately is going well

Suddenly pandemoniumSuddenly pandemonium

• There is a second category 1 LSCS from off the street being wheeled into OR 3

• WHAT WOULD YOU DO?

• WHAT DID I DO?

• WOULD I DO THE SAME NOW ?

• IS THE MACHO MALE ANAESTHETIST AN ISSUE?

• I am in OR 3 having done a rapid sequence induction on LSCS #3.

• There is a sux drip running.

• I have a friendly OB attending in OR 2 with LSCS # 2,

• And I have a second friendly OB attending with LSCS #3 in OR 3

• I am shuttling between OR 2 and OR 3,

• On an adrenaline high,

• Feeling pleased with myself,

• And thinking this is great, I’m going to get all the sections out of the way so I can get some sleep

• I have not called anybody else in because it all happened so quickly,

• I reason it will be over by the time they arrive,

• And I am thinking what a hero they will think I am

• WHAT WAS THE OUTCOME?

LSCS #1LSCS #1

• Everything fine, mother and baby well

• I speak to mother and husband after and they are very happy and understand the predicament, and liked the OB resident anyway who was more chatty than me

LSCS #2LSCS #2

• Baby has a 1 minute APGAR 9. Mother and baby fine

• I do not talk to them after about circumstances as she was asleep and father therefore was out of OR anyway

LSCS #3LSCS #3

• Baby has APGAR 0 at 1 minute.

• Resuscitated by attending neonatologist.

• APGAR 3 at 5 minutes.

• Ventilated on NICU.

• Ultimately makes full recovery

• Now presumably in early twenties driving a fast car and gobbling up worlds natural resources

• I do not speak to mother and husband after for the same reason as #2

LSCS #3LSCS #3

RumpelstiltskinRumpelstiltskin

• 0300 hrs called to maternity for category 1 LSCS

• Arrived within 90 seconds in maternity OR to be met with the following spectacle

1982 Worcester, Mass USA1982 Worcester, Mass USA

• 140 kg African American lady writhing in labour on operating room table,

• wheezing (asthmatic)

• OB attending jumping up and down like Rumplestiltskin saying “Get her asleep stat Bob”.

• Severe fetal distress

• No anaesthetic tech in USA

• No other anaesthetic person

• Circulating nurse available

• OB resident present

• All drugs and anaesthetic equipment available and ready

• No IV in yet

• Attending neonatologist standing by

• This was before the advent of capnography and pulse oximetry

• Could this be the end of my career?

• What are the options available to me?

• What would you do?

• What did I do?

• Did I do the right thing?

The Language BarrierThe Language Barrier

• Category 2 LSCS

• Brazilian lady, speaks Portugese, no translator, apparently good health

1978 Worcester, Mass USA1978 Worcester, Mass USA

• OB resident asks if he can do epidural

• We have informal arrangement with OB service regarding training OB residents in obstetric anaesthesia in case they go somewhere without anaesthesiologists

• I have poor attitude

• (I do not agree with the policy compounded by the fact that he is a Vietnam draft dodger)

• I supervise him• Catheter inserted ok• Negative aspiration• Test dose 0.5% bupivicaine with

epinepherine with monitoring of maternal ECG; no tachycardia

• Wait 5 minutes• Then slowly give 0.75% bupivicaine

(before FDA banned its use)

• Unable to converse with patient

• Patient has grand mal seizure

• What was the outcome?

• I was very lucky

• A colleague in a non obstetric situation has a similar problem. He was not so lucky. He gave up anaesthesia.

• Levobupivicaine is safer than bupivicaine.

• Epidural catheters can pose a risk.

How Not To Deal With A Serious How Not To Deal With A Serious ProblemProblem

• I am reluctant chief of department,

• Nobody else wanted to do it,

• Not my strong point,

• Chief rhymes with grief

• My predecessor has hired a new anaesthesiologist for the department without input from ourselves

• The head nurse from OB calls me down and says her staff are very unhappy about him

• Over the course of several weeks these are my observations

• He always wears a long sleeved gown

• He is always scratching his arms

• He requests regular coffee breaks

• He has twice had unrecognised esophageal intubations (on the second occasion the surgeon pulled the tube out)

• Some of the surgeons have asked not to have him in their OR

• What do I suspect?

• This is a very difficult issue to discuss with my colleagues especially if I am wrong

• Patient safety should be the first priority

• Will I get sued?

• What would you do?

• What did I do?

• Unloaded an unwanted colleague onto another institution with references.

• What should I have done?