The patient was healthy and underdoing an uncomplicated procedure. All went well – actually very well – the case went faster than normal and the patient was in the PACU quickly, woke up slowly, and that’s where the trouble began.
The patient noticed she could not move arms or legs, and then breathing became a problem. She could not call out for help, but could hear people around her. She had become either re-paralyzed in the PACU, or her muscle relaxant was not adequately reversed. The sequence of events that followed was not unusual, involving reversal drugs (both naloxone and neostigmine), a fair amount of excitement and a trip to the ICU. A “good outcome,” the patient suffered no physical issues. At least that is how it looked to the providers – to the patient it looked very, very different.
Awake, but cannot breathe, the patient describes the frantic thoughts. [Paraphrased from patient account]:
Oh no, I am going to die, and I cannot leave my children and spouse – they count on me. Final, desperate wishes for my family go through my head. I can’t cope much longer without breathing. How did this happen? What went wrong? When are those people going to realize I am in trouble? Finally I hear the nicest words of my life, when someone shouts, “She’s not breathing!”
This is of course a real life story, which as it turns out is not uncommon in PACUs across the country and around the world. We take neuromuscular blockade very lightly since we can reverse it and measure it, and we simply assume once reversed all is well. It is not. Not only do patients get “re-paralyzed,” but often our measurement of return of neuromuscular recovery is inadequate.
Lately there have been a number of studies looking at the incidence of this problem, and despite anesthesiologists’ clinical view that paralysis in PACU is very uncommon, it is actually quite common, when measured by adequately sophisticated machines and monitors. In fact, one expert claims[i] it happens regularly every day in both academic and private practice PACUs, despite the use of our common blockade monitors.
Now our patient did have an increased risk since no blockade monitor was used (still a common practice in the US) but appeared to be breathing quite well after a reversal dose.
So why am I writing about this? Is it to alert the anesthesia community to this issue? Partially I guess, but most of you have already read the articles and are aware of the problem. I am writing about this because of the other side of the issue – the human side, the “I am sorry” side.
This patient was kind enough to write out thoughts and feelings about what happened, partially and helpfully centered on the approach the facility and those involved took in explaining what happened, why, and apologizing.
The good news is that there was a nursing director who the patient felt was extremely helpful, the hospital medical director was a trusted source, the actual anesthesiologist involved apologized and explained the issue, and the patient felt the anesthesiologist was honest and understood mistakes happen. But she was not totally happy with the entire approach.
In fact, I believe she (and her spouse) were most unhappy with me (chief of service), because I offered to write this article to help others in the CSA prevent this problem – not that they thought the IDEA was bad, but they thought I was doing it as a way to have them not take legal action and to circumvent the entire issue itself. Clearly I did not find the human way to represent the concept and the reasoning. After a little discussion they understood and felt somewhat better.
But the issue then, is the human factor – how do we go about “apologizing” for events that are incredibly distressing? This patient continues to have some posttraumatic event issues, and it will take some time for this to resolve. What about for us? A recent article in Medscape (Medscape Medical News: Perioperative Fatalities Hit Anesthesiologists Hard: Caroline Helwick Oct 15, 2012) details the impact of bad things on the anesthesiologist.
This article of course is talking about the most severe complication, but it applies in the relative degree to lesser complications. And it applies and is true, because we are human beings, with a conscience, and well beyond our oath of “do no harm,” we have an innate sense of compassion. Yet we are told by legal counsel, “say nothing, do not apologize, do not talk about the case, speak only through your attorney, do not talk to the hospital about this, no one.” This is the exact opposite of what we want to do and need to do as human beings. Generally we want to get right next to that patient, hold their hand and say “I am so sorry – and I want you to know that in your heart, and I will do what I can to make things better.” (This was my reaction as chief when I heard about this situation, and my “what I can do” thought was to write this column and get people thinking about their approach to the human side of the equation.)
Google “I am sorry for physicians” and you get a long list of opinions, legal issues, laws passed that “allow” you to say I am sorry without fear of liability admission, etc. “Allow you” ?! Legally allow you to be human? This is just one example of how we have lost a bit of our humanity as we progress technically in our specialty (and we are not the only specialty experiencing this issue.)
This is going to become more and more important (the humanity side of our profession) as health care delivery systems force changes on patients. Physicians are intentionally thought of as commodities, replaceable and negotiable in price and service. We have a tendency to do this to ourselves. But we can, and must, stop this slide. We need to remember who is on the other side of the endotracheal tube – we need to know we have not been assigned a “case” – we need to know the assigned patient is a mother, father, son, daughter, best friend, etc., and what happens to that patient affects a very wide circle of life.
For this topic, distinguish yourself by remembering you and the patient are completely equal as human beings – feelings, thoughts and conscience. They trust you, and they want to trust you. When things go wrong, it is a sincere “I am sorry” that can make a huge difference – by the physician and the system. Patients are generally confused as to what happened and why, and sitting down looking them in the eye and saying and meaning “I am sorry” can do wonders for the patient’s healing, as well as the physician’s.
We really are all in this together – humans first…
[i] Glenn S. Murphy, MD, Moderator; Aaron F. Kopman, MD; Mohamed Naguib, MD; Matthew L. Kirkland, MD, FACS. “Reversal and Recovery from Neuromuscular Blockade: Examining the Science.” CME Lecture. Released: 11/06/2012.