My first loss ..

Ten years ago , on May 5, I was a fresh young registrar of 5 months, with a recently acquired Diploma in Anaesthesiology. My confidence was boosted by my success and I was starting to feel as though this weird and wonderful job, could, perhaps, just work for me.

Although I now adore my work, I am the first to admit that I was by no means a natural-born doper. I had no idea what I wanted to specialize in, but knew that a GP practise was out. My initial objective for joining the anaesthetic department was purely personal. For one, I had heard that the hours were not too bad, and most importantly, I needed to overcome my fear of anaesthesia. How ironic is that?? Scared, with a touch of laziness! Anyway, I figured that doing it over and over on a daily basis for a year, with a professor or two breathing down my neck, would do the trick. When I passed the Diploma exams, it just sort of went without saying that the degree would be next.

The day I signed my reg papers the prof pulled me aside, welcomed me to the task force and said, " 5 in 5 years." Needless to say, I misunderstood as per usual...
Well, I do love children, but 5 in 5 years whilst specializing was like begging to be institutionalised, or even worse, pure suicide!!
I was promptly corrected, " 5 DOTT's " .... Death on the table ...

My worst fears were confirmed, this species really was alien, and totally nuts, and I was signing up to join them!!! Was I nuts??? I was expected to kill 5 people in 5 years?? What about that wierdo Hippocrates??? What about my mental health??? What about being able to sleep at night??? What about getting out of this 5- year- stint in the same condition I got into it???

Some of my what about's must have been visible. No good to show a weakness, but hey, I never bragged about any superhuman powers. He explained. The only way to learn how to deal with the inevitable DOTT, was to actually experience it a few times. 5 Times seemed reasonable, it could be more .... but be assured, he said, it would happen.

Well, with the formalities out of the way, I pushed that conversation to the furthest recesses of my mind, and got on with my training. No point in harboring crap thoughts.

Back to 5 May....

I was blessed with the paediatric orthopaedic list. I was excited and ready for it!! All paeds lists were supervised by a consultant, so although I wasn't alone, it was still my list and I was responsible for all the preparations. The first case was a 5 month old baby for bilateral clubfoot manipulation. He weighed 5 kg. Anyone who has ever had a kid could tell you that at 5 months no baby weighed 5 kg unless it was seriously premature at birth. This one wasn't.

The theatre was prepped to perfection. From ambient temperature, to warming mattress, tiny paediatric equipment, all drugs drawn up, diluted to accommodate the child's weight, and clearly marked, warmed bubble-free infusion lines ... everything was exactly right. Even emergency drugs were drawn up and ready for use. I felt proud, and confident that the consultant would be satisfied.

With a skip in my step, I walked over to the mother and took the child from her, assuring her that the procedure wouldn't be long. I put him on the nicely warmed theatre table and he just lay there, looking around, but not moving. No premed had been given. He was soooo comfortable I thought to myself. I had definitely prepared well. Once again, anyone who's had a child knows that no 5 month old lies so utterly still without arms and legs kicking in all directions. Especially having just been taken away from their mother. I didn't have any then, so what did I know? The consultant arrived, and we started the inhalation induction. Unfortunately, in those days, sevoflurane was still scarce and expensive so we made do with halothane. Within minutes the IVI was up and running, then I intubated the little fellow with no difficulty at all. It felt good.

You are not in. No end-tidal CO2. You are definitely not in.

The gas we humans exhale is CO2, and by measuring it after an intubation, we confirm the correct placement of our endotracheal tubes. Because the entrance to the trachea and the entrance to the esophagus are in such close proximity, and even more so in little babies, it is possible for the tube to go down the wrong pipe, thus blowing air into the stomach instead of the lungs. This classifies as an anaesthetic disaster. End-tidal CO2 is also a very sensitive indicator of cardiac output. No cardiac output - no life.

I most definitely WAS in, I saw the tiny vocal cords, there was no way I wasn't in. But now was not the time to argue. I stepped aside for the consultant, a very well-respected and highly intelligent anaesthetist. Within seconds, he re-intubated the child himself. Still no end-tidal CO2. Heart rate was good, ventilation was good, but no end-tidal CO2. The consultant appeared totally calm, but a few beads of sweat had broken out on his brow, something was wrong. Horribly wrong.

Without being told I began administering the emergency drugs, closed the anaesthetic gas, gave 100% oxygen and sent the sister to get help. An intense resuscitation followed, probably the most intense one I have experienced to this day. Theatre 8 exploded with a flurry of activity. When things go wrong, the news spreads faster than the speed of light, and help appears out of nowhere. A reg was appointed to keeping time and recording everything that was being done. Another was appointed to cardiac compressions, another to the airway, another to all IV administrations and a last one was used as a runner. The professor himself, together with the consultant, was in charge. Even the orthopods helped.

One hour and forty five minutes later, the baby was declared dead..... DOTT ......

How could such a perfect day end in such a tragedy?? I was shattered, totally totally shattered. I felt a million things and absolutely nothing all at once. My life flashed before my eyes while I wondered what the hell had gone so wrong. Walking back to that mother, empty-handed, was one of my most horrible experiences. I was sent home that day ...... Sadly the post-mortem yielded no answers, and after expert investigation, the cause of death was given as halothane- induced cardiac suppression.

I still don't know why I didn't quit anaesthetics that day - God knows I wanted to - but the next day I was back at work, and the next, and the next ....
Out of the obligatory big 5 as I later began to call them, that first one was by far the most traumatic. I couldn't look at a baby for months afterwards without feeling ill. I have never used halothane again, no matter how expensive the sevoflurane. I'm particularly sensitive to paediatric cardiac patients whose stories more often than not, don't have happy endings ... and ...
I have not taken a child from it's mother pre-operatively since then.