Deaths on the operating table
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7238.881 (Published 25 March 2000) Cite this as: BMJ 2000;320:881
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Editor - I agree with Mel Jones referring to this as one of the
greatest taboos of modern anaesthesia literature(1). Searching the
literature there seem to be only very few articles relating to this
subject. Our anaesthetic training centres virtually exclusively on the
prevention of potential disasters, whereas nothing really prepares us
for how to deal with them when they occur(2). Anaesthesia related deaths
are extremely rare, but they do happen, often unexpectedly, leaving the
individual anaesthetist feeling devastated. The emotional effects on
anaesthetists are seldom discussed and debriefing after a death is often
haphazard. Plans of how to handle such a situation only exist in very few
anaesthetic departments. We all assume that this will happen to somebody
else, rather than ourselves, leaving the anaesthetist it happens to often
feeling isolated and with little support(3). The surgeon and nursing
staff are likely to be equally affected, especially if children or young
otherwise healthy adults are involved.
I think that there is a clear need to include the management of
anaesthetic disasters into the curriculum of our anaesthetic training.
Anaesthetic departments should have action plans on how to deal with
anaesthetic catastrophes to reduce the suffering for all those involved.
This should include guidelines on breaking the news to the family, the
format of the interview, hospital paperwork, preparation for possible
civil proceedings and the debriefing of the theatre-team involved(3). In
an environment of best practice, clinical evidence/excellence and an
increasingly litigious society the question remains if the remainder of
the operating list should be continued by a completely new team including
surgeon and nursing staff.
On a background of anaesthetic suicide rates that are ten times higher
than those of the average population it is important that we all support
each other and help new generations of anaesthetists with guidance and
open discussion rather than maintaining this taboo.
Chris Seifert specialist registrar in anaesthesia
Princess Margaret Hospital, Swindon SN1 4JU
10 The Bartletts
Hamble
Southampton SO31 4RP
Tel/Fax: 023 80454896
E-mail: chris.jenny.seifert@lineone.net
1 Jones M. Death on the operating table. BMJ 2000;320:881.(25 March)
2 Aitkenhead AR. Anaesthetic disasters: handling the aftermath.
Anaesthesia 1997;52:477-482.
3 Bacon AK. Death on the table. Anaesthesia 1989; 44:245-8.
Competing interests: No competing interests
Although on operating table is a most distressing event, not
just for the surgeon but the whole team, there are events and compications
that can be no less stressful than on the operating table.In my
specaility of Ophthalmology, the expulsive choroidal haemorrhage is one
such complication. The sudden occurance of this devastating complications
is the most distressing situation that can confront an ophthalmic surgeon.
The next operation to be performed on the list can prove a real
challenge and test one's nerves. I faced this problem once as a Senior
Registrar, and I shall always remain grateful to my Consultant, who
ensured that I faced up to the reality of medicine and did continue with
the next Cataract operation.
I think it is rather unfortunate that we are becoming too preoccupied
with guidelines and are slowly loosing the will and ability to face up to
the unpredictability of events surrounding the delivery of health care,
that life itself is made of.
Competing interests: No competing interests
I read with great interest Mr Jones article. I would agree with Prof
Sir Alfred Cuschieri that "a death on the operating table of the patient
is a harrowing experience for a surgeon". From this one can only draw the
conclusion that such an experience will blunt the concentration of the
surgeon and may in some way adversely affect the care of any subsequent
patients on that operating list.
Three years ago I was working as an Obstetric Senior SHO in a similar
district hospital. On a particular Monday morning, the department was very
sombre and the "weekend team" very quiet. On Saturday afternoon there had
been an induced labour, an emergency caesarian section and, after a
prolonged resusciatation attempt, a fetal death. The inquest apportioned
blame and made recommendations; these events happen on labour wards.
What I found most difficult to understand is how the two doctors
involved with that delivery had been expected to continue to provide acute
obstetric care for a further forty hours on call. No relief was offered
after such a damaging experience. Surely when something goes dramatically
wrong, there must be a facility to allow that doctor to step aside and
recover. If we do not then patients will be treated by a doctor drained
and blunted emotionally and physically and the doctor left damaged by
being unable to escape the distressing environment. Such a release may not
always be necessary, but it should always be possible.
Competing interests: No competing interests
I read this article and the responses with interest. Why are we
limiting this debate to surgeons? As an on call paediatric registrar, the
experience of a death is every bit as distressing to me as it must be to a
surgeon. The fact is that I cannot just "down tools" and wander off to
deal with my feelings; sometimes I've got to get on and deal with the next
problem that comes up. I can't see a way in which I can have the proper
time to debrief, to reflect, and, sometimes, have a bit of a cry, if I'm
working in a real hospital. I work in an area of medicine where machismo,
if not extinct, is becoming endangered. People are very supportive of the
devastating consequences of some of the things we witness. But sometimes
you've just got to carry on working, haven't you?
Competing interests: No competing interests
I believe Jones raises the important issue of deaths during elective
vs emergency procedures. My own experience, necessarily anecdotal will
surely be familiar to many.
Relatively newly "Calmanized" I spent my first weekend as the "Senior
Registrar" at a London Teaching Hospital supervising 5 other junior
doctors. My Consultant was immediately available, and supportive. Of the
six operative procedures with which I was directly involved (ie in the
Operating Room for all or most of the case) as compared with the twenty or
more of which I was "aware", three died either on the operating table or
within a few hours in the ICU.
All were ASA (American Society of Anesthesiologists) grade 5E, ie not
expected to survive 24 hours without surgery. The on call consultant was
informed of each case, and was present for several of them. Should the
anesthetists involved in these case not anaesthetise any other patients
that day? That weekend? Who was going to take over from us.
Since necessarily the two most senior doctors on call were involved
with the sickest patients, not carrying on was not an option. I am still
grateful for the professional and personal support I received from my
colleagues, surgical, anaesthetic and nursing, that weekend. Taking the
rest of the day off was not an option - neither was it for the surgeons
who operated on two of the three patients who died.
I agree with Jones that advice on when not to continue operating (or
anaesthetising) must pay due regard to the circumstances, and that a
distinction between elective and emergency work must be made
Competing interests: No competing interests
The writer makes valid points. Cookbook medicine is seldom
good medicine. Individual circumstances in medicine
frequently defy the textbook. Making rules based on someone
else's personal recipe is courting a dangerous precedent.
The final decision should be left up to the captain of the
ship; this policy has worked well in the past and will be a
good guiding light for the future
Captain of the ship.
Competing interests: No competing interests
What about the death of a baby?
Dear Sir
I found the discourse of the consequences of a patient dying during
surgery interesting (Personal View, BMJ vol.320 pp881). Having rotated
through various surgical specialities in my SHO and Registrar posts during
my training years, (including cardiothoracic, trauma, vascular and gastro-
enterological), before entering obstetrics and gynaecology, I experienced
a fair number of cases of death on the table for a variety of unrelated
causes.
We all know that observing a death, affects different people in
different ways, much an individual personal reaction. Even the same
surgeon would react differently if, for example, the patient was expected
to die anyway but the operation was to try and given him/her that bit of a
chance, compared to a healthy young patient who was having a minor non-
life threatening procedure.
If the advice of the President of the Royal College of Surgeons of
Edinburgh is to be followed that “……… when a surgeon loses a patient, he
should not continue operating on that day”, should this apply to a surgeon
who carries out a Casearian section and for some unfortunate reason the
baby dies? What about a midwife who, in the course of attending to a woman
in labour “loses” the baby – should she not look after another woman in
labour that day?
I shudder to think of the implications regarding medical and surgical
staffing on our labour wards. Or is the death of a new born child less
traumatic to the accouchier than the death of a patient to the surgeon?
Fortunately both are rare events.
Yours sincerely
A I KIWANUKA FRCS MRCOG
CONSULTANT GYNAECOLOGIST
Competing interests: No competing interests