Saturday, May 23, 2009

During the operation the anesthesiologist went to sleep

----- Original Message -----
From: Docv
Sent: Saturday, May 23, 2009 10:01 AM
Subject: [ai] Sentence of Anesthesiologist

A couple of days ago on consultant level anesthesiologist was sentenced  8 years of prison after the death of a child during an general anesthesia for strabismus .( Killing by negligence)

During the operation the anesthesiologist went to sleep , forgetting the inhalational anesthetic vaporizer to induction level and in the same time “muting “ the monitors , including alarms..  The child died after about 30 minutes and nobody noticed for several minutes , surgeon included.( The surgeon got 4 month of correctional work for society - meaning shuffling papers in a Government office or voluntary work with handicapped etc )

I have no intention of commenting on the case and sentence  but someone  in our department suggested that we should  urgently have a “protocol” forbidding reducing the volume of the ECG monitor under a certain level  and forbidding closing the alarms as well .

I wonder if some of you have something like this as a” protocol” in your departments.

Best :


Virgil

1 comment:

painpop said...

When I did my post graduation in anesthesiology in 1982-84, there were practically no electronic monitors and the color of blood on incision and monitoring of radial pulse (and heart beat with a precordial stetho in children) were the guiding stars. But our chief's instructions were that no anesthesiologist will sit (leave aside sleeping) inside the OR when a case was going on. I think he had a feeling that some day some anesthesiologist would sleep off during surgery. And that has happened. I see no reason for a monitor alarm to be switched off. If a monitor is giving alarm without any clinically valid reason, it should be changed rather than silenced.