A sad reminder about over-reliance on machines

Being a leader in my field means I am often contacted by colleagues for advice, or support. Last week I had one such call from a senior VN who was understandably upset because a patient had died under anaesthesia while in her care. The case was a tragic convergence of events, the wrong things happening at the wrong time, and resolving any one of those events could have changed this outcome from death to a survival.

The case began with the senior VN going to lunch and thinking that the planned orthopaedic surgery would be started after her return. As soon as she left, the new vet decided to start the surgery immediately, but didn't realise the implications of having only two junior VNs working at the time. Once the patient was anaesthetised, a medication was given into the drip line under the veterinarian's instruction, and the patient started to have an anaphylactic reaction to the medication, but the signs weren't obvious until it was too late. The patient's temperature began to drop, but the junior VNs didn't notice it because they weren't taking the temperature more than once every 30 minutes. The patient's respirations decreased, but they didn't notice because the ap-alert monitor continued to make reassuring beeping noises every so often. The patient's oxygen saturation began to drop, but only by a couple of points and the type of monitoring sheet they were using didn't allow them to see the trends very easily. You can see where I'm going with this…I don't need to tell you about the assisted ventilation, faulty blood pressure probe, or insufficiently cuffed endotracheal tube. Suffice it to say, when the senior VN arrived back to work and found the patient near death, immediate resuscitation began, but it was too late.