BMJ  2004;329:1086 (6 November), doi:10.1136/bmj.329.7474.1086

Filler

Understanding risk

I spent the afternoon before the Rugby Union world cup with a patient liaison group, fine tuning our anaesthetic literature for distribution to preoperative patients. An essential part of this sort of information is a risk-benefit explanation. Patients increasingly seem to expect that low risk is equivalent to no risk and that if something goes wrong it is a consequence of "fault" and lack of care. The only time people turn this perception of risk-benefit on its head is with the lottery: people regularly buy into the 1 in 14 million chance of winning the jackpot, but none would expect to be hit by lightning or die under anaesthesia—both of which are more likely.

I was healthy—a low risk for occlusive vascular events. I was 51 years old, a non-smoker for 20 years, body mass index 24.5, blood pressure a reasonable 135/85 mm Hg, blood cholesterol 5.6 mmol/l. I am not diabetic, and I exercised more than most (on the Thursday before my event I spent 90 minutes in the gym with my heart rate up to 150 beats/min without any problem), ate healthily, took multivitamins and minerals, and took aspirin 75 mg most days on the basis of the "big pill for the over 50s." (I hadn't got round to the ACE inhibitor, statin, and blocker.)

It was then with some disbelief that, after walking back from our local shop (150 metres round trip), I felt a little "funny" and realised rapidly that I could not articulate. My left side became weak, and I could not stand up. By two days later, I had had a third occlusive vascular event that left me bewildered, exhausted, and bed bound.

Only two years previously, I had undergone an emergency appendicectomy. I chose my anaesthetist with care, and it was uneventful. However, I believe that if I had had my occlusive vascular event during the anaesthetic, there would have been an implication that my anaesthetist had done "something wrong." And yet he did not, but how else could one explain a fit man undergoing uncomplicated anaesthetic and surgery who had an occlusive vascular event?

After 25 or more years in anaesthetics, I think I had a reasonable understanding of the risks of my anaesthesia and surgery. I have accepted that my occlusive vascular event was independent of the anaesthesia—but how to explain that to the lay public if the interval between anaesthesia and adverse event had been two minutes rather than two years? I suspect that most would not believe it. I can imagine the soul searching of the anaesthetist and the hospital complaints procedure. And yet the adverse event was completely unpredictable; an act of God.

So it is a wonderful thing to share with a patient the risks of the procedure proposed. But how realistic is the understanding that goes with it?

A week after my occlusive vascular event, I underwent transoesophageal echocardiography, after being told the risk of oesophageal perforation was 1:1000 or so. Despite my experience of long odds less than a week previously, I underwent the procedure more worried about the effects of midazolam on my injured and confused brain. I went into the "1:1000 is not very high, it will be alright" mode.

And so hundreds of thousands of others, some far fitter than me, many less so, undergo anaesthesia and surgery having had the risks "explained" and having "understood" them. And none of them would seriously expect an adverse outcome to accompany the end of surgery. The most common adverse event related to anaesthesia is dental damage. People are most relieved to wake up to find their crowns intact, rather than appreciating that their intact brain is more important and less easily correctable.

Warwick Hospital (dr.derbyshire{at}ntlworld.com)

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Any help with how to expalin risk?

David G Taylor
bmj.com, 7 Nov 2004 [Full text]

Re: Any help with how to expalin risk?

Peter Bruggen
bmj.com, 22 Nov 2004 [Full text]