Friday, 27 March 2009

When it all goes wrong

Some of the people that I work with have told me that I worry too much about things. Before anaesthetising a patient I check, check and check again. I do things that most deem unnecessary, and it’s been commented on a few times. I usually laugh it off and say that my paranoia keeps me sane. Sometimes it causes friction with my colleagues – I remember practically having a shouting match with the A&E charge nurse because one night I insisted on giving a general anaesthetic for emergency cardioversion in A&E resus rather than taking the patient to the Coronary Care Unit. I’m sure that as I become more experienced, I’ll “loosen the reigns” a little, but I think that I’ll always bring a healthy dose of paranoia with me to work.

The reason for this is that in anaesthetics, when things go wrong, they go BADLY wrong and they go badly wrong very quickly indeed. Yesterday, I was shown something that really crystallises this message.

“A mother who spent years undergoing IVF treatment died after a bungled birthand never saw the baby she longed for, an inquest was told yesterday.

Joanne Lockham had a Caesarean operation to deliver baby Finn but her brain was starved of oxygen for up to 30 minutes, it was claimed.

Within moments of the birth she suffered a heart attack and she died two days later after sustaining massive irreversible brain damage."

Reading a bit further into this story we learn that basically, the decision was made to give Mrs Lockham a general anaesthetic for her ceasarian section, after giving her the anaesthetic, the anaesthetist couldn’t put the breathing tube in the right place (couldn’t intubate) despite several attempts. By the time help arrived, she was already dead.

“…problems arose in the operating theatre. The jury heard that three attempts were made by anaesthetist Dr Prasad to insert a tube to give Mrs Lockham oxygen before it was eventually believed to have been successful.

Dr Prasad broke down in the witness box as he told how he repeatedly tried to intubate Mrs Lockham.”

It sounds like several things went wrong here but I’m not going to comment too much about the ins and outs of this case because I wasn’t there and don’t know all the facts, but I will say this. In situations like this, when things start to go a bit wrong, people start to panic. This is ESPECIALLY true on the labour ward. The midwives panic, the obstetricians panic, the scrub nurses panic and everyone starts telling you, as the anaesthetist to hurry up and get the patient to sleep. It’s noisy, the atmosphere is fraught and if the anaesthetist starts to panic, then things become INCREDIBLY dangerous. It sounds like Dr Prasad panicked.

“Dr Prasad said: 'I was doing my job, but I was in a complete state of shock, I couldn't think, I was trying to be useful in anything I could.

'I went in at that point in time with a particular plan and it didn't happen.

'It was completely out of the blue and the equipment was not giving way, so I didn't
know what to do, it completely numbed me, it was not what I was expecting.'"

This is a horrible situation for everyone and highlights the point that I’ve been told several times during my training – always be clear what your exit stratey is. The books say that Dr Prasad should have prevented the obstetricians from starting the caesarian section, woken Mrs Lockham up and waited for senior help to arrive. However, I can see that this is difficult to do when you have the consultant obstetrician and a room full of midwives yelling at you to hurry up and get the mother to sleep because “they need to get the baby out.”

This brings me back to my original point. I’ve not yet been in a situation like the one above by myself, but sooner or later, it’s goint to happen. Things are going to go wrong unexpectedly with one of my patients. At least if I’ve checked everything and know where everything is, when the panic starts to creep up on me, it reduces the amount of “thinking” I have to do and hopefully gives me more of a chance of sorting the situation out long before it gets to the stage that Mrs Lockham go to.

What happened to Mrs Lockham is truly tragic. Dr Prasad would have had to explain to her husband why he now has to bury his wife. What should have been a joyous occasion has become a horribly tragic one. Everybody involved will have to live with what happened for the rest of their lives. A child will grow up never knowing his mother.

My condolenses to Joanne Lockham’s family.

For more on this story, read here and here.


BenefitScroungingScum said...

Many years ago, prior to my diagnosis of EDS (so with a label of attention seeker) I was going through multiple shoulder surgeries. One of the (senior consultant)anaesthetists who put me to sleep a couple of times was considered to be paranoid in a similar way to that you describe by his colleagues. They also moaned frequently about how he spent too much time with patients, was too thorough etc, often making those complaints in front of patients.

Thing is, from a patient perspective, despite what other medical staff said it was the safest I ever felt being given a general. He wasn't prepared to let anything go as 'just one of those things' and in hindsight I realise, that unlike all the other doctors 'treating' me, this anaesthetist knew there was an underlying problem and was well on his way to finding it.

The point being, that from a patient perspective we all want the person who likes to check and recheck (so long as it's not an obsessive problem preventing action of course!) Bendy Girl

Nasty Nurse said...

I've seen many F1's do really silly diagnostic tests for things their SHO's wouldn't necessarily do themselves- simply because they're more confident.

That story is hurendous though- but, i guess the patients like a thorough doctor, keeps them from moaning to the nurses!

Anonymous said...

You have absolutely no idea what you are talking about.

You state that you do not know all the facts, then you imply criticism of a named colleagues actions. That is unprofessional.

Incidentally, for the benefit of lay people, the description of "the consultant obstetrician and a room full of midwives yelling at you to hurry up and get the mother to sleep because “they need to get the baby out” is rubbish. All obstetricians and midwives appreciate that their duty of care is to the parturient. In 27 years of practice, I have never witnessed obstetricians or midwives pressurising anaesthetists in the manner described. This simply does not happen in the UK. If the risks (to a woman) of operative intervention outweigh the intended benefit, obstetricians and midwives will always act in the best interests of the parturient.

The media reports of the inquest do not include all the relevant details of this case. Any suggestion that the ST3 anaesthetic trainee failed to check equipment is factually incorrect. The ST3 anaesthetist summoned help when it emerged that he was unable to intubate the woman.

It might be helpful if the author of this blog didn’t jump to stupid conclusions, on the basis of limited reports from tabloids. Junior trainees can find lots of algorithms about the management of unplanned LSCS and difficult intubation. These are suggested guidelines.

This thread should be deleted.

Dr Michael Anderson said...

You appear to have completely missed the point of my post which is basically, when anaesthesia goes wrong, bad things can happen and this is why we are so focused on the safety side of the job.

In the example I used to highlight this point, I didn't jump to any conclusions or imply criticism at anyone - read it again.

You claim to have 27 years of experience in obstetrics but have never felt the panic in the labour ward theatre or seen an obstetrician or midwife pressure an anaesthetist to hurry up and put a patient to sleep? I must say, I've very jealous of your department because this hasn't been my experience or that of my junior colleagues. I have less than a year's obs experience and have been in that exact situation already, and seen it happen to one of the registrars.

As for my "jumping to stupid conclusions," maybe you could tell me what that conclusion is meant to be?

Anonymous said...

I am an anaesthetist with a reasonable amount of obstetric experience, and would like to take issue with the comment that the previous anonymous poster made about anaesthetists never being hassled by midwives/obstetricians - please let me have a job at your hospital! This is simply not the case. There is a considerable amount of pressure put upon anaesthetists (especially juniors) to "get the tube in" mostly born out of self-induced panic and insecurity, and it is this pressure which can lead to inexperienced anaesthetists failing to intubate the parturient with the potentially disastrous consequences demonstrated in the Stoke Mandeville case.

Anonymous said...

I completely agree about the 'flapping' that goes on in LW/Maternity theatre. Anaesthetists are highly skilled and knowledgeable and should be able to get on with their job without the added pressure of other members of staff hurrying them along.

As a student midwife I find it much harder to learn anything when midwives panic in emergencies; it teaches us very little of how to handle an emergency situation and could make the more impressionable student more likely to act similarly in an obs emergency when they qualify.

The Neonatal staff where I train seem to be the best at handling difficult situations(compared to midwives). They appear calm and focused on the job in hand... far better for everyone involved I think!

(Student Midwife and medical student hopeful for 2011)

Anonymous said...

Late comment, I know. I've been in exactly this situation. Can't intubate can't ventilate in an urgent section.
Of course there is huge rush and Time pressure. You have to resist. My patient started breathing again just in time. Very blue. Woke her up and gave a spinal. Baby ok. A few months later I waited about 5 minutes for the bp to come down in a preeclamptic before I started the anaesthetic and the baby was stillborn. Horrible. Mother comes first but the only right answer is to have a senior person on the spot.

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