The first time I witnessed the death of a patient on the operating table as a junior anaesthetist will always remain with me.
Mr Clark* was 60 and remarkably well. He lived at home with his wife and walked his dog twice each day. He required the removal of one kidney due to an aggressive tumour. My consultant, Dr Roberts*, expected a large blood loss and was well prepared: additional large drips, invasive monitors and plenty of cross-matched blood available.
The surgery was painstakingly difficult; the surgeon meticulously dissected out the kidney avoiding the tumour and vessels. When the vein was clamped, a tie was slung around it and pulled tight.
The bleeding started immediately as the tie cut through the wall of the vein with the ease of a cheese wire. Another tie was requested and hurriedly passed to the surgeon. Slowly and carefully, despite continual blood spillage, noisy suckers and soaked swabs, the surgeon again tried to tie off the bleeding vessel.
But the same thing happened again, the vein wall had been weakened by the infiltrating tumour. The bleeding intensified. At the head end we could see the surgeon’s arms raised at the perplexity of it. “It’s just disintegrating,” he said.
What do you do when the usual treatment compounds the problem? We actioned our plan. Opening drips on both sides, clear fluid poured into the circulation. The atmosphere changed: now a sinister quiet, punctuated only with requests and instructions. We gave two bags of blood. Then another two. “Phone the lab and ask for six more bags fast,” I was instructed.
We were lagging behind so the surgeon packed the bleeding area with swabs to temporarily dam the flow, buying us some time to replenish the circulation. The swabs turned quickly red and were replaced. Haemostatic gauze was called for and placed over the bleeding vein. The blood continued to spill. A vein cannot contract as an artery would.
We used all the blood. More was 30 minutes away. “Get the O negative,” my consultant said. I nodded, realising the gravity of the situation.
A nurse wiped the blood from the surgeon’s visor. Another put absorbent pads on the floor where blood was accumulating, the drapes long since saturated. An adrenaline syringe was now running and I could feel my own adrenaline levels increase too.
The battle continued: more stitches, more swabs, more hands in Mr Clark’s abdomen, more blood, more instruments, more tension and more failure. I began to administer large doses of potent syringe jets of adrenaline.
The numbers on our screen were dropping, flashing, alarming: the blood loss was relentless. The monitors dwindled. Mr Clark was grey, his face waxy. The bleeding continued to outpace us and culminated in cardiac arrest. Dr Roberts commenced futile cardiac compressions. Their purpose to confirm everything had been done and allow time for a consensus opinion. It was time to stop.
The surgeon left the operating table, ripping off his gown and slamming it into the bin. The door to the scrub room banged shut. A pause as silence momentarily blanketed the theatre.
I closed the drips, unsure of protocol. The surgeon’s assistant closed the abdomen with coarse sutures lacking precision or planning. Dr Roberts turned off the anaesthetic gases and with reluctance, the ventilator. I felt a morbid finality, never before experienced. It was over. The procedure, the anaesthetic, the life.
My overriding thoughts at that moment were not for Mr Clark, not for the surgeon nor Dr Roberts. They were for me and they were mostly of relief. I was glad I was not in charge, was not required to make the big decisions nor standby their outcomes. I was glad for once that I was a trainee with responsibility only to learn.
No one had done anything wrong. No vital step forgotten yet the patient died. I was not ready to carry that weight.
It was 14 years later that I found myself in charge of a similar case. I was experienced and confident in my practice, yet still, the outcome did not sit comfortably. I doubt it ever will.
* Names have been changed.
- Ellie May is a consultant anaesthetist and author of Adventures in Anaesthesia and How To Pass Exams
If you would like to write a piece for our new series Blood, sweat and tears, read ourguidelines and get in touch by emailing healthcare@theguardian.com.
Join our network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.
.png?w=600)
