Inflated, deflated
This week I read a coroner's report from the UK regarding a man who died under anaesthesia:
The man was having an operation to repair an injury to his little finger, for which he requested a general anaesthetic. A general anaesthetic is not entirely necessary for a finger operation, however perhaps the patient didn't understood the other options.
The anaesthetist taking care of him had difficulty intubating him (putting an endotracheal 'breathing' tube through his throat into his lungs), possibly because he weighed 124kg. After trying several different strategies the doctors ended up putting a Cook catheter in- a narrow, pointy tube, which can deliver small amounts of oxygen. The endotracheal tube can be threaded over the narrow Cook catheter.
That's when things really started to go wrong. The Cook catheter wasn't held in place properly, and it slipped down through his lungs and ended up in his chest wall. At the same time, the nurse was asked to connect the oxygen, which was turned to 15 litres per minute. At this point, the coroner notes, the patient "began to swell up extremely rapidly...The delivery of high pressure oxygen in these circumstances would have caused [him] to inflate."
Some moments later the doctors heard a loud crack- which turned out to be the man's scrotum exploding. He died.
I had several reactions to this report. First, a horrible 'there but by the grace of god go I' fear: it is SO EASY to make horrible mistakes in my job. Second, compassion for the poor man's family. Not least of their traumas is that their loved one's death is detailed for all the world to read on the interwebs!
It's the first time I've properly read a coroner's report and I have to say I really like the way they describe the events both plainly and meticulously. At times it reads like a tragi-comic pantomime: the senior anaesthetist racing into the room at the call of the emergency buzzer, the nurse on hands and knees trying to find the oxygen source whilst a doctor scrambles over her trying to reach to patient's airway.
And finally, if I'm honest, a Roald-Dahlian wonderment in the grotesque: he inflated!! But instead of floating up to the roof like a character from Charlie and the Chocolate Factory, he popped and then he died.
The man was having an operation to repair an injury to his little finger, for which he requested a general anaesthetic. A general anaesthetic is not entirely necessary for a finger operation, however perhaps the patient didn't understood the other options.
The anaesthetist taking care of him had difficulty intubating him (putting an endotracheal 'breathing' tube through his throat into his lungs), possibly because he weighed 124kg. After trying several different strategies the doctors ended up putting a Cook catheter in- a narrow, pointy tube, which can deliver small amounts of oxygen. The endotracheal tube can be threaded over the narrow Cook catheter.
That's when things really started to go wrong. The Cook catheter wasn't held in place properly, and it slipped down through his lungs and ended up in his chest wall. At the same time, the nurse was asked to connect the oxygen, which was turned to 15 litres per minute. At this point, the coroner notes, the patient "began to swell up extremely rapidly...The delivery of high pressure oxygen in these circumstances would have caused [him] to inflate."
Some moments later the doctors heard a loud crack- which turned out to be the man's scrotum exploding. He died.
I had several reactions to this report. First, a horrible 'there but by the grace of god go I' fear: it is SO EASY to make horrible mistakes in my job. Second, compassion for the poor man's family. Not least of their traumas is that their loved one's death is detailed for all the world to read on the interwebs!
It's the first time I've properly read a coroner's report and I have to say I really like the way they describe the events both plainly and meticulously. At times it reads like a tragi-comic pantomime: the senior anaesthetist racing into the room at the call of the emergency buzzer, the nurse on hands and knees trying to find the oxygen source whilst a doctor scrambles over her trying to reach to patient's airway.
And finally, if I'm honest, a Roald-Dahlian wonderment in the grotesque: he inflated!! But instead of floating up to the roof like a character from Charlie and the Chocolate Factory, he popped and then he died.
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