anonymous

12th September 2018

TO ERR IS HUMAN (4)

TO ERR IS HUMAN (4)

DR G.S. AMBARDEKAR

Doctors, too, are human; they may occasionally commit errors. The emotional distress that a doctor undergoes as a result of errors committed inadvertently can be gauged from the following case.

A young Jewish lady, about 36 years of age and very closely related to a well-known gynaecologist was wheeled into the O.R. for a tubal ligation (family planning operation). After a detailed clinical examination, I deemed her fit for a spinal anaesthesia. In this form, a local analgesic solution is deposited, most commonly, in the lumbar subarachnoid space of the spinal cord. Our spinal cord contains a fluid called cerebrospinal fluid (CSF) which acts as a vehicle to carry the local anaesthetic drug to the spinal nerves. Thus, the drug when introduced in the lumbar region blocks all sensations below the waist so that surgery can be performed here without the patient feeling pain or any other son heat, cold or pressure.

After taking all aseptic precautions, I injected the local anaesthetic drug into the patient's spine, Under normal circumstances, the effect of this medicine becomes apparent within a couple of minutes or at the most in five minutes. To my utter surprise ten to fifteen minutes elapsed and yet the stubborn drug refused to act. At the end of about thirty minutes, when the injection still did not have the desired effect, the surgeon grew a little restless, as he had to attend to other patients lined up in his Out-Patient Department (OPD).

What had gone wrong, I wondered. There had been no error in my technique. I had waited for the CSF to come out of the spinal needle in drops and only then had I introduced the drug into the subarachnoid space. I rechecked the date of manufacture as well as the expiry date on the box that contained the local anaesthetic ampoules. The stock was fresh, hardly four months old. Suddenly a thought flashed across my mind and I ran towards the small bucket in the O.R. that received all the useless and unwanted articles. When I retrieved the ampoule discarded by me, the word FLAXEDIL stared at me and I almost froze.

For Flaxedil (gallamine triethiodide) is an intravenous muscle relaxant drug, given during general anaesthesia to block the conduction of electrical impulses from the nerves to the muscles thus paralysing the skeletal muscles of our body. The muscles of respiration, too, get paralyzed as a result of which the patient is unable to breathe on his own and is provided with artificial respiration by the anaesthesiologist. This method provides a relaxed tension-free operative field to the surgeon. At the end of surgery the action of this drug is reversed by another drug neostigmine or prostigmine, so that the patient's muscles recover from paralysis and the patient starts breathing on his own.

Instead of the local anaesthetic, Inj Xylocaine, someone had placed Flaxedil in the Xylocaine box. How it came to be there still remains an unsolved mystery. But the fact remains that instead of Inj Xylocaine, I had injected Inj Flaxedil in the spine! After my initial emotional distress, the anaesthesiologist in me soon took charge of the grave situation. I checked the patient thoroughly-she was absolutely pink and not only breathing but even flashed a smile at me. I felt relieved. The drug, after all, had not had any deleterious effect on my young patient.

In order that the surgeon could proceed with the surgery, I administered a general anaesthetic to her. The 30 minutes surgery was uneventful. General anaesthesia did not pose any problem and I ordered the patient to be transferred to the recovery room where she could be under close observation for any untoward effect of the drugs administered during surgery. As she was being wheeled out of the O.R, she suddenly started moving her limbs peculiarly and soon came down with full-fledged convulsions. I initiated the anti-convulsion therapy and immediately contacted an eminent neuro-physician. The latter opined that the iodide in gallamine triethiodide (or Flaxedil) which had been given by the spinal route was an irritant to the central nervous system and hence the convulsions. He advised Inj. Paraldehyde, an anti-convulsant to be given in case they recurred. He seemed rather reluctant to discuss the prognosis. After the physician's departure, my fears increased by leaps and bounds as the convulsions kept cropping intermittently without any sign of abating. The physician's presence had given me some courage. Now I began to suffer mental agony. I had messed up a young woman's life unwittingly. I continued to sit beside the patient, tending to her intermittent convulsions. A couple of hours later, the patient's relative, the eminent gynaecologist, telephonically expressed his surprise that the patient had developed tetanus so soon after surgery!

By then it was 02.00 a.m. I could not go to sleep. I had to keep watch over my patient. By early morning, the convulsions had decreased in intensity but they had not altogether abated. I thought it wise therefore to call a personal friend, a well-known general physician, Dr Motashaw and appraise him of my problem. Dr Motashaw was himself a severe diabetic and a hypertensive but he graciously agreed to come over at that early hour. He examined her and I thought I saw a trace of optimism on his face. However, I firmly believed that nothing short of a miracle could save my patient: Mentally I went through what a post mortem might reveal in case she died.

At 4 a.m. Dr Motashaw advised me to go home. I offered a brief prayer to the good Lord and tried to catch a wink or two—but in vain. The convulsions of my patient haunted me. Suddenly around 6.00 a.m. I was awakened from my disturbed sleep by the shrill telephone ring. I shuddered to pick up the receiver. I guessed that the worst had happened and I did not wish to hear the ominous news of death. All the same I hesitantly picked it up and in the next few seconds, I was in seventh heaven! The nurse in her gentle voice wished me a very good morning and informed me that the patient was absolutely hale and hearty and had a ravenous appetite and wanted a sumptuous breakfast. Could she give it to her?

Exactly one week later, I suffered my first heart attack, on March 20, 1967! The purpose of relating this story in some detail is twofold:

One, I sincerely hope it serves as an eye-opener to my junior anaesthetic colleagues—they should check the labels on any medication, especially the lethal anaesthetic drugs, not just once, but twice and doubly confirm what they have seen with their medical or nun

In fact, in Copenhagen, Denmark. there is a law that makes it mandatory for both the doctor as well as the nurse, to read the instructions on an injection ampoule simultaneously before injecting its contents into the patient's body.

Two, contrary to the general opinion prevalent amongst the lay public, a doctor does get emotionally disturbed and distressed when something untoward happens to his patient.

This is the 3rd case of anaesthetic mishap, reported in International Medical journals, the other two cases reported were from U.K. and Teheran. But let me assure my readers that such an aberration occurs but once in a million and there is no reason to suspect every doctor. Thousands of operations are routinely carried out every day all over the world without any mishaps. I have recounted what happened to me only to make the point that doctors are only too human and not beyond tripping.

Compilation of professional reminiscences of specialists - edited by M.V.Kamath and Dr.Rekha Karmarkar.