Midnight Angels

It was many years ago, but I remember it like yesterday.

I was an eager young registrar, on call for the maternity theatre. No doubt things have changed now, but back then it entailed literally 24 hours of c/sections. On any given day, about 15 howling little miracles could be delivered via the vaginal bypass route.

Most of us dreaded the maternity call ... it was endless ... and extremely painful both literally and figuratively. The gynaes were also in training and usually tended to struggle through the surgery. The patients were usually so exhausted, or so sick, that any form of communication was restricted to the bare necessities. The change over time was way too long. The maternity hospital was situated about 2 km from the main hospital so as an anaesthesiologist you were on your own. Help was at least 5-10 minutes away (and any fresh registrar with half a brain cell knew, that that was way too long ) You knew upfront that you were screwed on that day, but as is the nature of the human race ... against all odds, you still hoped, and hoped, and hoped for some divine intervention and at least an easy night. Or that all your spinals worked perfectly.

Despite all of that, I loved the maternity theatre! I enjoyed the spinals and most of all loved those little babies!! Nothing cuter than a newborn looking around , eyes alert, mere seconds after being delivered, with a know-it-all expression on its little face!! Yep the c/sections were definitely my favourite.

On this particular day it was busy as usual. It was around midnight and the endless stream of pregnant fairies seemed to ease up a little. I was tired, but the current patient was intelligent, friendly and really nice for a
change. I didn't need much convincing to have an enjoyable conversation with her.

Now in those days I used to draw up all the drugs needed for a general anaesthetic (in the event that my spinal didn't work), and have them all ready and labelled. I also had, and still sort of have, this obsessive compulsive notion of always drawing them up in the same way. So I always drew the tracrium up, diluted, in a 10ml syringe and the syntocinon in a 5 ml syringe. Tracrium is a muscle relaxant with a relatively short duration of action, which doesn't need to be reversed. Syntocinon is used to contract the uterus after delivery.

But not on that day .... No, on that day I drew up both the tracrium and the syntocinon in 5 ml syringes. Heaven knows why ... But at least I did have the syringes correctly labelled, although it didn't help me much.

So spinal was working perfectly, the patient was communicating nicely and the baby was out! Time for syntocinon. In our institution we gave 30u in the vaculiter and 10u IVI, so a total of 4ml. ( One ampoule of tracrium was exactly 5ml.)

I warned the lady that the medicine could give her a feeling of pressure on her chest, but reassured her that it would pass quite quickly. Then I took the syringe (labelled and all), wondered for the briefest of seconds why there was 5ml in it and proceeded to add 4mls to the bag of ringers and 1ml slowly IVI.


For a minute or so, all was well. Then it started ... she complained of a heavy feeling on her chest. I told her it was normal. She complained of difficulty to breathe. I started some mental checks. When she broke out in a sweat and started slurring her words, a light flash exploded in my brain! The syringes!!!!! I had mixed them up and instead of giving syntocinon, I had given tracrium!!!! I checked, and low and behold, the synto's was innocently lying on the trolley. No wonder I was perplexed by the 5ml, instead of the usual 4ml!! Faster than the speed of light I ripped off the contaminated vaculiter and replaced it with a clean one. Then I supported the patient with gentle mask ventilation, all the while talking to her softly, telling her not to worry, that all was well and that she was doing fine. Luckily the gynae was quite fresh too so the op took about 20 minutes longer than usual, which was more than enough time for the little bit of muscle relaxant to wear itself off.

Soon she was back to her chatty self as if nothing untoward had taken place, and I was calling myself every kind of fool. How could I make such a mistake?? Why didn't I read the label?? Why did I draw the drugs up differently??

The gynae never noticed and I never mentioned it. I repeatedly asked the patient if she was fine, and when she eventually sighed and said: Ok, if you must know, I am absolutely starving and would love a cup of coffee!! I finally relaxed. Still felt like a dog though ...

When I discussed it with the prof, and told him that perhaps I wasn't cut out for this job, he told me that at some point we all make mistakes but that the important thing was to recognise it quickly, deal with it correctly, and learn something from it. Also, never ever to underestimate the power of the midnight angels watching over us...