Personal Views Personal views

Deaths on the operating table

BMJ 2000; 320 doi: http://dx.doi.org/10.1136/bmj.320.7238.881 (Published 25 March 2000) Cite this as: BMJ 2000;320:881
  1. Mel Jones, consultant orthopaedic and trauma surgeon
  1. Bangor

    The consequences of a patient dying during surgery have made headline news in the medical press recently. The message appeared unequivocal in the BMJ, Hospital Doctor, and BMA News Review. An operating list should stop if a patient dies on the operating table, and the surgeon should not operate for the rest of that day.

    The BMJ reported Professor Sir Alfred Cuschieri as saying, “My own view is that the death on the operating table of the patient is a harrowing experience for a surgeon. In my view, the surgeon is emotionally and mentally not in the frame of mind to continue to operate that day.” It was also stated that the sheriff conducting the inquiry agreed with this view. The president of the Royal College of Surgeons of Edinburgh was also quoted as saying, “We can understand the pressure that single surgeons are under, but I think there would be a very strong feeling that, when a surgeon loses a patient, he should not continue operating that day.”

    It is illogical to differentiate between elective and emergency surgery

    I was recently involved in treating two severely injured patients from a road traffic accident. The first died during emergency surgery in the small hours of the morning. The second needed emergency surgery for four open long bone fractures. I can recall several deaths during surgery in the 17 years since I qualified. I cannot honestly say that I was unable or unfit to continue working after any of these unfortunate events.

    The cause of death may be multifactorial and unrelated to the actual surgical procedure

    In view of the media comments, however, I sought advice from a medical defence organisation at about 5 30 am. Both my registrar, also a member of the same defence organisation, and I were advised not to operate further and to inform our trust accordingly. Fortunately, a colleague was available to carry on operating. This advice has been considered “totally untenable” and setting “a very dangerous precedent” by Sir Alfred (personal communication) as his comments applied only to elective surgery. This was not made clear in the selective reporting of the case. Subsequent advice from another medical defence organisation, based on the same set of facts, was to continue operating; a clear dichotomy of opinion.

    In this age of evidence based medicine, is it logical to stop operating after any death on the operating table? As far as I am aware, there is no evidence either way. Perhaps there should be before issuing any guidelines or getting the counsellors in. If surgeons are found to be traumatised after a death on the operating table are the anaesthetists unaffected? The cause of death may be multifactorial and unrelated to the actual surgical procedure.

    What would happen if the patient arrested as the drapes were being put on the patient immediately before the incision was made? Surely the anaesthetists would feel more traumatised than the surgeons: the subject has been described as one of the greatest taboos of modern anaesthesia literature. Nursing and other staff may be similarly affected. How susceptible individuals would be under such circumstances would become apparent only after the event. Some individuals may require more time off work than others. The day off suggested so far is hardly based on any science.

    As the effect of a death in theatre on the team involved is currently unknown, surely it is illogical to differentiate between elective and emergency surgery. Research in the future may discover that any such death may cause significant dysfunction in individuals. If so, then the consequences of preventing the surgical and anaesthetic team from working are profound. How would military field hospitals function during armed conflicts? The same logic would apply to NHS staff after major civilian disasters.

    Every major hospital dealing with emergency surgery would require at least two on-call teams in susceptible specialties just in case a death occurred during surgery. As this is an uncommon event, it will have no significant impact in terms of the European Union working time directive. However, the increase in the on-call workload is likely to have a detrimental effect on waiting times for our patients.

    The issue clearly requires urgent and reasoned discussion so that sensible conclusions can be reached. The consequences of rashness are immense.

    Footnotes

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