Bad Outcome I

Sometimes no matter what we do, a situation cannot be salvaged. Despite all the preparation in the world, anticipation of difficulties, immediate diagnosis and treatment, and timely intervention, there are surgical misadventures for which we cannot compensate. In any endeavor, there is the possibility of mistake, failure, unforeseen obstacles, and we hope that in some realms - nuclear power plants, airplane control towers, pediatric surgery - these never happen. But they do.

I was involved in a situation where a healthy child had an elective surgery. The operative plan changed mid-course due to unexpected anatomic abnormalities. In fact, the surgeon talked to the family and consented for additional procedures that had not been planned. Things progressed well for a few hours until the surgeon suddenly encountered a brisk arterial bleed. The surgical field welled up with blood, and the lesion was so deep they could not get surgical hemostasis. I managed it as anesthesiologists do: obtaining large IV access, arterial access, calling for blood, resuscitating aggressively. The vital signs were always stable. Since the bleeding would not stop, we rushed the patient down to interventional radiology to see if the vessel could be embolized. That in itself was a learning experience; I had to quickly pack up my emergency airway equipment and drugs, all while resuscitating this actively bleeding patient. Unfortunately, the cath showed a devastating lesion that extended into the brain. Neurology was consulted and placed EEG leads while the neurosurgeons embolized the lesion, but the damage had been done. Even without anesthetics on board, the patient had little brain activity. Imaging was consistent. The patient never woke up.

Anesthesiologists like to banter that our job is to protect the patient from the surgeon. Lamentably, we don't always succeed. There is so much that goes through my mind and heart after experiencing a case like this. Everyone focuses first on the medical points. Was this purely a surgical mistake? Could it have been avoided? Should we have aborted the procedure when we came across the first obstacle, ordered more tests, asked for another consult, decided to plan things for another day? It's easy in retrospect to say so, but it's not uncommon for surgeries to run into minor hiccups, and how do you decide when something is minor or major? Could there have been anything else we could have done to stop the bleeding, or could we have gotten to the cath lab faster? Was there anything more we could have done for the anesthetic and resuscitation? As I ponder this case, I feel that there wasn't much more I could have done from my perspective, and that this injury was simply non-survivable to start.