The document discusses death on the operating table (DOT) from various perspectives. It begins by outlining WHO surgical safety protocols to prevent wrong procedures. It then notes that DOT is always a possibility in surgery despite precautions, and shares real life cases of unexpected DOT. The document emphasizes the importance of informed consent, documentation, communication with relatives and police, and providing support after a DOT to address medico-legal issues and prevent litigation. Overall, it examines DOT as an occupational hazard in surgery and strategies for managing its aftermath.

1. DEATH
on
Operation Table
(DOT)
Director s:
Dr. Sharda Jain

2. I Dedicate this PPT to my
Colleagues & Patients
Review this lecture at
slide share.net

4. “ W.H.O.” Surgical Safety
Universal protocol for preventing wrong side ,wrong
procedure, and wrong person (Joint Commission ,2009)
1. Preprocedure verification of all relevant documents
2. Marking the operative site , and
3. Completion of a “TIME OUT” Prior to procedure
initiation.
* procedure are correctly identified.
* prophylactic antibiotics
* Length of procedures
* Anticipated complications
* Special Instruments

5. • Surgery is a combination of good
training experience and just common
sense.
• People don’t want a Top
GOOD surgeon;
They want a
“LUCKY SURGEON”

6. The 100%successful performance of
surgery is impractical….
unexpected Complications strike literally
like
A BOLT FROM THE BLUE
While in 60% in is anticipated
and
In rest totally unexpected

7. DOT

8. A surgeon is caught at least once in lifetime
in this tragedy !!

10. The most serious surgical complication
“Death On Table”
which means that the patient dies before the
surgery could be completed or
Just at the end of an otherwise technically perfect
and “Successful” operation!
What is DOT ?

11. DOT is Always Possibility
in any surgery

12. Any surgical operation has the potential to surprise
the Great surgeon by sudden occurrence of DOT
This may occur in spite of taking all pro-active
precautionary measures.
Although awareness and readiness to face and tackle
all possible mishaps would minimize complications,
to a large extent.
However it cannot always be eliminated all together.

13. Dr. Sharda Jain
I become a Gynae surgeon I, realized that
despite a bad prognosis some patients
survive and despite good chances some
payients die.
I have never found out why this is so.
I have now stopped taking CREDIT for a
successful surgery. Before every surgery
I pray to god to help me do my best.

14. In complicated surgeries I often regret
operating on patients who don’t survive.
The thought that perhaps an alternative
palliative therapy would have suited them
keeps nagging me.
Prof. PK Devi
A living soul on chair is far better than dead

15. Risk of Death
 Caesarean Section 1 in 12,000
 Hysterectomy 1 in 4000
 Laparoscopy 1 in 8000
 Minor Procedure 1 in 15000
Gross Underestimation !!

16. • Life
• During every action and situation in life, some
unexpected problem or accident may arise;
sometimes it may end in fatality. This is normal
risk and we take it every day in our day to day
activities.
• Surgery
- “Standard Risk”.
- High Risk (Co-morbidity)
“Standard Risk” & High Risk
in Surgery

17. INFORMED CONSENT is vital both for
surgeon and Anesthetist & liability need to
be fully understood by them.

18. Lawsuits Scare US
Most surgeons take an insurance cover
When case is bad & have No choice but to
Operate.
I tell a patient and his family
members about the possible risk. At times,
even record it on video for risk of DOT & this helps
to avoid litigation
Dr. Sharda Jain

19. DOT is fortunately not a common accident,
but its rarity makes it all the more difficult to
obtain any definite information regarding its
causation & how to tackle it.
It is like death in police custody where
there is no help for patient & nobody knows
the facts except doctors & their team.

20. One of the major concerns for medical personnel is
being accused of malpractice during treatment,
as it is an obvious presumption on the part of laymen
that death
was directly related to the medical
treatment as compared with other
in-hospital deaths.
DOT Raises a Number of Special
Medico - Legal Questions.

21. DOT Raises a Number of Special
Medico - Legal Questions.
As patient’s relatives have no access
whatsoever to OT during procedure.
The onus lies on the doctors in the O.T.
to explain the events that had happened
there. It is the duty of the doctors to
prove or rule out the cause of death for
which they’re allegedly held
responsible.

22. 1 Real Life Incidents
PGI Chandigarh
52 years, Doctor's aunt came with PM
bleeding. Patients had no co-morbidity
All tests were normal from pre OT area
patient was shifted on trolley and before
she could be transferred on
OT table - she was NO MORE

23. A surgeon was operating on his own wife, doing a “minor” operation
under LA. His dear wife was fully awake & alert at the start of a
surgery expected to last 20-30 minutes. The surgeon was an
experienced doctor with thousands of surgeries over a period of 20
yrs under his belt. His wife was healthy & did not have cardiac
problem, hypertension or diabetes. Hence she was considered as
having “standard risk” in undergoing this relatively small surgical
procedure after injecting Xylocaine solution around the lump in the
breast to be biopsied. Hypersensitivity to Xylocaine was tested
before the start of surgery. Surgery was performed easily without
any hitch & at the completion of surgery, the surgeon called the
patient by name & asked her how she was. There was no
response! Then it was found that she was not responding to any
stimulus! There was no pulse palpable at the wrist; no breathing; no
heart beat! She was dead! All attempts to revive her by immediate
cardio-respiratory resuscitation measures were of no avail!
2.Real Life Incidents

24. Case of D & C
In Anand Hospital
3.Real Life Incidents
- Shifted to post operative Room
- Given TT/ dose antibiotic by nurse

25. Suction Evacuation – 28wks molar
pregnancy with 5gm Hb ,bleeding
profusely (PGI Chandigarh 1972)
(Inspite of 4,BT she died on table)
4.Real Life Incidents

26. Hysteroscopic removal of small
submucous fibroid polyp
(air embolism)
died in “5” mts
5.Real Life Incidents

27. Ruptured ectopic came with shock had DOT
In medical college in Delhi
• 1 case before start of surgery
• 1 case during surgery
6.Real Life Incidents
In
In 3/7 cases consent of DOT was taken

28. What
Happens
After
Death ?

29. Handling a Death on OT Table
(support system)

30. What are we worried about…?
• Breaking the news
• Facing questions of relatives
• Fear of mob violence
• Handling police enquiry
• Medico-legal issues – arrest,
courts, case, judgment…
• Compensation amount
• Damage to reputation
• Loss of confidence
• Stress in future cases

31. Loss of Reputation
What we fear most is the loss of our
reputation, which we build on hundreds of
good surgeries. If one case goes against us
in the court, and it gets publicized, we may
lose our hard – earned reputation.
Dr. Yogesh Agarwala

32. Breaking some BAD NEWS for us!
Is the MOST DIFFICULT TASK !!

33. How to Handle The Situation…
 Gather
 Ask for help in OT
 Relax
 Review sequence of events
 Do not adopt a “Blame Culture”
 Proper documentation
 No discrepancies in records
 No comments by junior staff
Never worry, “Be concerned”

34. Help Yourself Not to be Beaten Up
INFORM
Superintendent of hospital
Police Station
Security Guards
Keep Emergency Exit available

35. • During intra-operative procedure keep relatives
informed if patient is serious and collapsing.
• Complete all relevant documents such as case paper with
detailed anesthesia and surgeon notes, resuscitation notes,
any visiting consultant notes.
• Notes should tally among consultants and there should
not be any contradictions.
• Preserve all the broken ampoules of injections, no expired
drugs should ever be found in OT.
• Leave things as they are, do not clear up the OT.
• Take back all prescriptions if any, from relatives especially
for emergency drugs.
Before Declaring to Relatives
& Informing Police….

36. o Communication with the bereaved family.
 Transparent chronological documentation of the
death circumstances
 Questions regarding certification of death
 Questions arising from autopsy to determine the
reason of death
 Questions about malpractice
 Legal requirements concerning confidential
medical communication and information about
what must be sent to the professional indemnity
insurance company are important.
Other important aspects such as:

37. Communication Skills
 Good communication by sr. Consultant
can prevent litigation
 It potentially offers the most rewarding
aspect of total patient care
 RELATIVES WANT TRUTH
 Sympathetic approach

38. Anticipate Reaction of Relatives
& handle it well
 Shock
 Pain
 Anger
 Guilt
 Depression

39. • Avoid aggression or putting blame on
relatives
• Staff should not contradict statements
made by consultants to avoid
misinterpretation by relatives.
• Do not refuse for postmortem,
rather suggest it from your side.
Communication Skills

40. Being Sensitive to the
Relatives
 While you proceed read the non-verbal clues;
face/body language, silence, tears
 Allow for “shut down” (when relatives turn off
& stop listening) give time & space: allow
possible denial
 Give opportunity to ask questions
 Arrangements for taking away the dead body.
 Registering the death

41. • Informing the police
• Police perform “Panchnama”
• Handing over the papers after numbering
• Information to police shall preferably be in
writing and the written acknowledgement should
be obtained.
• If the information is telephonic
one must note down name,
buckle number and
designation of the police.
Interaction with the POLICE

42. Inform the police:
• When cause of death is not known
• When cause of death is known but to show that we
are not hiding the facts.
When to inform police:
• Death linked with abortion
• Death on operation table
• Death within 24 hours post-operative
• Death related to medical procedure
• Death related to accidents or violence
• All deaths related to tubal sterilizations
(postmortem is mandatory)
• When there is allegation of medical mis-
management

43. Most important areas:
DEATH CERTIFICATE AND DEATH
RELATED EVENTS
• Death Certificate: To Be (given) Or Not To Be (given)!!
• Give it… may be sensed as “hush-hush” in the matter
• Not give it… sensed as “ended life but harassment
unending ”
• A doctor can give DC only if he knows the cause
of death and not otherwise

44. Arrest of a Doctor
• Postmortem report
• Opinion of police surgeon
• Discretion of the Investigating Officer after
taking opinion of expert panel

45. Important issues for general insurance if
treating doctor has indemnity cover and
patient is having a life cover
• Death due to medical negligence
• Death due to anesthesia
• Death on operation table
• Post-operative death

46. • A survey in the British Medical Journal reported
the attitudes of doctors towards the intra-
operative death of a patient………
• 84% response rate
• 92% of respondents had experienced a DOT
• Majority of deaths being expected by 60%
• 77% say these DOT are non-preventable
• 80% says occurring during emergency surgery
• In 41% of cases involving vascular surgery
• 87% had given repeat anesthesia in next 24
hours.

47. • The KARNATAKA HIGH COURT, while
proceeding a case of DOT held that in the
absence of postmortem, histopathology,
etc, the possibility of other causes of death
can’t be ruled out. The death on the
operation table by itself is not sufficient to
prove rashness or negligence against the
accused.

48. Anesthetists per se are likely to experience intra-
operative death more than surgeons, the consequences
of which can be extremely stressful.
Although the majority of doctors agree that it was
reasonable for medical staff not to take part in operations
for 24 hrs after an intra-operative death.
consideration should be given by all departments
towards the prevention of DOT, and the management of
its aftermath, including the provision of support for
psychologically traumatized staff, and relatives.
Support Systems

49. Last, But Not The Least…..
 Stop thinking about it constantly
 Take a break
 Keep your morale & self confidence
intact
 Learn the lesson it teaches
Even with simplest operation it
can not be
taken for granted that patient
will come out
Better of or even alive

50. We all make mistakes
How many of you have ever felt that
“I” should not be practicing medicine because
I am too dangerous for society
?

51. Left you with many Qunanswered