Arctic Char

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hello everyone. i just read this piece from an anes. professor in Israel, thought you all would enjoy it. btw - this is the best forum on SDN. you guys are always considerate, humorous, informative and helpful. cheers

Why the anesthetist fell asleep on the job

By Yoel Donchin

Anesthesiology hit the headlines this week in the wake of an investigation by Channel 2's "Fact" into the death about a year ago of a toddler during an eye operation at Assuta Hospital. According to the investigation, the anesthetist fell asleep during the operation on Neta-Li Borovsky and nobody noticed the beeping alerts of the monitor until it was too late. In an ironic coincidence, this week there was an announcement about the first events designed to increase public awareness about anesthesiology, in an attempt to enhance the reputation of the clearly unglamorous profession and to attract doctors to it.

In fact, some people define the profession I have been practicing for over 30 years as a situation in which a doctor who is half asleep sits next to a patient who is half awake. It's no wonder that the Israel Society of Anesthesiologists wanted to change the name of the specialty to express the far-reaching changes that have taken place in the profession.

The anesthetist is very far from the spotlight, but is on the front lines. When there is a mishap related to anesthesia during an operation, the anesthetist is blamed automatically. Nobody asks how many consecutive working hours are necessary in order to earn a living. Nobody asks how well the facilities are maintained, whether the anesthetist is alone in the operating room with the patient and the surgeon or if there is an assistant to help monitor the patient.

The usual reaction of those chiefly responsible for every mishap is: Yes, the doctor has been transferred from his or her job. I have yet to hear - either from a hospital or from those who investigate the facts on the ground - of any intention to examine the system from top to bottom and to see where it can be improved. Just as superficial military investigations repeatedly discover the unfortunate gatekeeper, and punish him immediately (and harshly!), the anesthetist serves as the scapegoat of failing medical systems. If we try to get to the bottom of things, I believe that in the near future it will be possible to achieve anesthesia with zero mishaps.

It began in Boston

Some history: The term anesthesia was coined already in 1846, by a doctor from Boston named Oliver Wendell Holmes, who witnessed the first demonstration in the history of mankind of the ability to block the sense of pain and to bring about a temporary loss of consciousness, thus enabling the surgeon to treat the affected tissue without the patient feeling any pain, which obviated the need to operate quickly. The demonstration was performed by a dentist named William Thomas Morton who had discovered that inhaling ether fumes caused a loss of consciousness as well as of the sense of pain, and that as long as a person continued to inhale the fumes the painless condition could be maintained.

Enthusiasm for the possibility of inducing unconsciousness quickly swept the world. Months after the demonstration in Boston, there were reports of successful anesthesia performed in Australia, New Zealand and Africa. It was considered simple and safe, and it advanced all branches of medicine.

Some even suggested administering ether to criminals before hanging them to spare them from the terror of death.

But soon after the introduction of ether the journal of the British Medical Society reported a case in which a 14-year-old girl died while under anesthesia for a simple operation on her toes. As it turned out, it was not understood at the time that in addition to causing a loss of consciousness the ether also blocks the reflexes that protect the lungs against vomiting.

For several years after the discovery of the anesthetizing properties of ether, the surgeon or nurse would carry out the procedure, which was nothing more than a careful dripping of the ether solution onto cotton that was placed on the patient's nose. Later, specialist doctors began to provide the service, developing a new profession that was concealed from the public eye but familiar to anyone working in the operating room or hospital.

The advent of new methods and powerful drugs made it possible to develop daring surgical procedures, to invade the heart and lungs, to connect tiny blood vessels and to implant organs. Before anesthesiology the number of operations carried out in Boston hospitals was minuscule. Most were attempts to save lives by amputating a gangrenous leg or removing an external skin tumor. One could say that the discovery of anesthesiology was one of the most important turning points in the history of medicine.

Deadly risks

However, along with impressive pharmacological capabilities and the technology that made it possible to take an anesthetized patient to the verge of death and back came the mishaps during anesthesia. Most of these were during the first stage of the process. Thick tomes were written describing the risks of this condition, the effect of anesthesia on the heart muscle, the respiratory system and the formation of blood platelets. Thousands of studies were conducted. (Incidentally, to this day the secret of the miraculous mechanism remains a mystery.) And despite all the knowledge, mortality and morbidity from the very act of anesthetizing did not decline significantly. The marvels of surgery and the wonders of pharmacologically induced unconsciousness were shattered by three minutes of lack of oxygen, which caused irreversible brain damage. Hours-long operations to remove a tumor that had taken over the entire stomach cavity did not bring relief to the patient, because at the end of the operation his body temperature was so low that he could not be saved.


In the early 1960s, a group of anesthetists in Boston formed a research group to investigate the roots of the mishaps, the reason for the interruption in the supply of oxygen to the brain during surgery. The group studied the behavior of the anesthetists and the system in which they operated. It engaged in pure science, without fear of litigation. Their first studies indicated that the work environment provides fertile ground for mishaps. They recommended a series of actions, including supply systems for artificial respiration with failsafe mechanisms.

An agreed method for attaching the various tubes was determined to make it impossible to connect the oxygen supply tube to a different type of gas. Procedures were fixed, as were work hours, methods of communication and reporting. For the first time in medicine attention was paid to the human factor - to the connection between the person sitting for hours in front of a monitor and the physical environment. It was recommended to add devices to monitor the saturation of oxygen in the blood and the degree of release of carbon dioxide from the lungs of the patient receiving artificial respiration. And wonder of wonders, morbidity and mortality declined impressively.

When I began to specialize in anesthesiology, I was witness to many mishaps, to unimaginable complications. The mortality rate was one in 3,000. Today, death during anesthesia is very rare. Safety is at such a high level that earlier this year the medical insurance companies announced a reduction in premiums paid by anesthesiologists due to the small number of claims.

It is true that the price of a mistake in administering anesthesia is higher than in any branch of medicine, death or terrible disability. The damage is evident as soon as the operation is completed. The high price means we must be extraordinarily careful. But we should also remember that no anesthetist operates in a vacuum. The anesthetist works in a factory (the hospital) that tries to take advantage of its resources, on a team with people whose interests sometimes contradict safety rules. The anesthetist is exposed to the gases that flow from the malfunctioning machines (and can become drowsy as a result.)

Most patients who arrange for the services of renowned, prestigious surgeons take no interest in the anesthetist. In the operating room where I work, patients often request to speak to the surgeon to ask one more question before losing consciousness. I usually tell them the surgeon deals with their internal organs, while I am merely responsible for their lives.

Prof. Yoel Donchin, a specialist in anesthesiology, is the head of the Patient Safety Unit at the Hadassah University Medical Hospital, Ein Karem in Jerusalem.


first surgical anesthetic -Dr. Crawford Williamson Long, MD, Jefferson, Georgia.

I'm sure you all know that. Boston has enough medical history without stealing some from Jefferson, Georgia.
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I routinely fall asleep during cases due to gases leaking from my malfunctioning machine. Especially when there is a toddler on the table.
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