10 Tragic yet Avoidable Anesthesia Errors (Part 2)

Doctors Performing an operationIn our last post, we saw how anesthesia awareness can cause a patient to be trapped during surgery, unable to move, but feeling all the pain; how children are more sensitive to anesthesia than adults; and how one careless anesthesiologist can blind five people in a day.

Here are three more horror stories due to the negligence or incompetence of medical professionals who should have known better.

5. Flash fire kills patient: In any surgical procedure where anesthesia is used, a fire hazard is always present, as various chemicals and gasses have the potential to combust. Within any operating room, many electrical and heat sources are present (such as electric scalpels and cauterizers), and one of these may act as a catalyst for combustion when chemicals or gasses are in close proximity. In one particular case, an Energy, Illinois, woman was seriously burned in a flash fire while on the operating table in Marion, Illinois. She died six days later. Surprisingly, such surgical fires still occur about 600 times per year, although the incidence used to be much higher because more flammable anesthetic chemicals were in use. But one trend has been common lately: Flash fires as a result of oxygen which ignites. In the past, surgical curtains were predominantly made of cloth. But in an effort to find easier, cheaper, and more disposable curtain solutions, synthetic fabrics have multiplied in the operating room. Unfortunately, these fabrics are often more combustible—they catch fire more easily—and flammable—they burn longer and stronger. While in surgery, anesthesiologists who are administering oxygen may unknowingly allow the oxygen to accumulate under these curtains. Especially when using pure oxygen (100% rather than diluted oxygen), a heat or electrical source may cause an instant flash fire or explosion resulting in extreme injury, or, as in this recent case, wrongful death.

6. Patient dies after anesthesiologist leaves room: Prior to undergoing lap band surgery, a 45-year-old woman needed to have an endoscopy. As part of that procedure, general anesthesia was required. Propofol (known as “milk of anesthesia” and best known as the drug that killed Michael Jackson) was administered through an IV line. It was at this point that the anesthesiologist exited the room and left the nurse anesthesiologist in charge for the rest of the procedure. In the past, anesthesiologists were present in the room from the very beginning of the procedure, as the patient drifted off into a coma-like sleep, until the patient was awakened afterwards. But these days, “anesthesia care teams,” which are comprised of an anesthesiologist with either an assistant or a nurse, are more common. Although some say this is a safer approach, many others contend that this is more dangerous, especially when the patient takes a turn for the worse (as in this case) and the only person on the team present is a less trained and less experienced nurse or assistant. In this particular circumstance, the patient stopped breathing within minutes of the administration of the anesthetic and, a short time later, her heart stopped. The nurse anesthetist tried to intubate the woman, but her jaw clamped down on the intubation tube and shattered her teeth. With only minutes before brain damage would begin, a code blue alarm was sounded, followed by chest compressions, use of a defibrillator, and doses of drugs including epinephrine. But by the time that her heart began to beat again, it had been without oxygen for over an hour. She never regained consciousness.

7. Anesthesiologist mocks sedated patient: When undergoing any type of procedure, it is normal to be concerned. After all, especially when sedated, a patient must depend fully upon the doctor to look out for his or her best interests. Few would ever expect that the anesthesiologist herself would be the one to victimize the patient. But this happened to one patient when he went in for a routine colonoscopy. The man had left his phone recorder on during the procedure to better remember the gastroenterologist’s care instructions afterwards. But when he later listened to the recording, he heard a number of alarming comments by the doctor and medical staff. The recordings captured comments that the patient was a “wimp,” a “retard,” that she wanted to punch him in the face, that he took far too long to get dressed afterwards, and that a rash on his penis might be an indication of syphilis or tuberculosis. As a result of this offensive conduct, the patient sued for defamation and medical malpractice. He suffered loss of sleep, embarrassment, and mental anguish, which required anti-anxiety medication. He later settled for $500,000 through his attorney.

But wait, there’s more. Keep following for part three of 10 Tragic yet Avoidable Anesthesia Errors.