DEATH on Operation Table (DOT) by Dr. Sharda Jain


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DEATH on Operation Table (DOT) by Dr. Sharda Jain

  1. 1. DEATH on Operation Table (DOT) Director s: Dr. Sharda Jain
  2. 2. I Dedicate this PPT to my Colleagues & Patients Review this lecture at slide
  3. 3. “ 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
  4. 4. • 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”
  5. 5. 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
  6. 6. DOT
  7. 7. A surgeon is caught at least once in lifetime in this tragedy !!
  8. 8. 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 ?
  9. 9. DOT is Always Possibility in any surgery
  10. 10. 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.
  11. 11. 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.
  12. 12. 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
  13. 13. Risk of Death  Caesarean Section 1 in 12,000  Hysterectomy 1 in 4000  Laparoscopy 1 in 8000  Minor Procedure 1 in 15000 Gross Underestimation !!
  14. 14. • 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
  15. 15. INFORMED CONSENT is vital both for surgeon and Anesthetist & liability need to be fully understood by them.
  16. 16. 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
  17. 17. 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.
  18. 18. 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.
  19. 19. 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.
  20. 20. 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
  21. 21. 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
  22. 22. Case of D & C In Anand Hospital 3.Real Life Incidents - Shifted to post operative Room - Given TT/ dose antibiotic by nurse
  23. 23. 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
  24. 24. Hysteroscopic removal of small submucous fibroid polyp (air embolism) died in “5” mts 5.Real Life Incidents
  25. 25. 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
  26. 26. What Happens After Death ?
  27. 27. Handling a Death on OT Table (support system)
  28. 28. 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
  29. 29. 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
  30. 30. Breaking some BAD NEWS for us! Is the MOST DIFFICULT TASK !!
  31. 31. 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”
  32. 32. Help Yourself Not to be Beaten Up INFORM Superintendent of hospital Police Station Security Guards Keep Emergency Exit available
  33. 33. • 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….
  34. 34. 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:
  35. 35. 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
  36. 36. Anticipate Reaction of Relatives & handle it well  Shock  Pain  Anger  Guilt  Depression
  37. 37. • 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
  38. 38. 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
  39. 39. • 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
  40. 40. 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
  41. 41. 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
  42. 42. Arrest of a Doctor • Postmortem report • Opinion of police surgeon • Discretion of the Investigating Officer after taking opinion of expert panel
  43. 43. 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
  44. 44. • 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.
  45. 45. • 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.
  46. 46. 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
  47. 47. 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
  48. 48. 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 ?
  49. 49. Left you with many Qunanswered