Annals of the Royal College of Surgeons of England (1975) vol 56
'There, but W D Wylie Consultant
FRCP
for
the grace
of God .0.
.
FRCS FFARCS
An aesthetist, St Thomas's IHospital, Londo?n
Summary The number of deaths reported as associated with anaesthesia in England and Wales has fallen dramatically during the past 20 years. But the problem of cardiac arrest occurring while the patient is under the care of the anaesthetist, though small, remains a serious one because few such patients survive, even with serious complications, and the question of litigation may arise. A series of 66 cases reported to the Medical Defence Union during i964-73 and studied personally has been analysed and the probable primary causes determined. It is concluded that cardiac arrest might have been prevented in about 50% of cases, though there was clear evidence of negligence in only I2. A study of the medicolegal aspects of anaesthesia emphasizes the wide area of the consultant anaesthetist's re-
sponsibilities, extending from preoperative assessment to postanaesthetic recovery. While some degree of delegation is unavoidable and perhaps desirable, the close personal relationship between patient and anaesthetist must be maintained. Introduction My alma mater is famous for at least one historic fact, for the records show that on Ioth October I849 the first death during anaesthesia in any London teaching hospital occurred at St Thomas's. The details were From the i8th Joseph Clover Lecture delivered
on
revealed about 3 weeks later in a letter from a surgeon, Mr Samuel Solly, to the London
Medical Gazette'. The patient, John Shorter, aged 43 years, was an apparently fit person, though he drank a bit, who was admitted for the removal of an ingrowing toenail. The anaesthetic was chloroform. The hospital 'Dead Book' for I846-53 has the following unsigned comment written in the medical remarks column: 'Cause unknown as no inspection was allowed, died after taking chloroform'. No inspection refers to the absence of a postmortem, and at the subsequent inquest the verdict by a jury was 'natural death'. Mr Solly's description of the event tells us that death was accompanied by a dark face, small, quick, but regular pulse, laborious respirations, and struggling. Resuscitation was continued for i l h and included artificial respiration by 'a tracheo-tube and bellows and oxygen gas introduced into the lungs by some means.. .', and galvanism 'through the heart'. All somewhat surprisingly up-to-date for the I 84os and remarkably reminiscent in some respects of reports of death during anaesthesia that are made nowadays, including the verdict at the inquest. As a matter of fact the anaesthetic was administered by a surgery-man or lay helper and a positive result of this death was that from then on all anaesthetics at St Thomas's were administered by medically qualified people2. 20th March 1974
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Joseph Clover I intend to speak about cardiac arrest associated with anaesthesia, basing my remarks largely on my experience as a member of the Council of the Medical Defence Union, but first I want to pay my respects to the memory of Joseph Thomas Clover, whom we are all honouring here today. After all, Clover was himself intensely interested in the safety of anaesthesia and I dare say many younger members of the audience here know little of his personal history. When anaesthesia was first introduced in I846 Clover, then aged 21 years, was a senior student at University College Hospital and vcry probably witnessed the first administration of anaesthesia in Britain. He was born in I825 in Aylsham in Norfolk, almost certainly at a house called 'The Wood' or 'Aylsham Wood House' which was then the Clover family home. This house, built of brick in the early T 7th century, still stands, though it is now called 'Abbott's Hall'. The Clover family was in many vays remarkable and had established a place in history before Joseph Thomas was born. In the first Clover Lecture delivered in this College in 1949 A D Marston quoted Buckston Browne's description of Clover 'as a creator, an inventor-with a quality of mechanical invention which deserves to be called genius'3. It is interesting to speculate on the anthropological implications of that sentence in Clover's family tree. His father was descended from sound yeomen stock, the family having lived and worked as manufacturers and tradespeople in Norfolk for three generations at least. Clover's father, John Wright Clover, owned a successful (Iraper's shop in Aylsham. Clover's paternal uncle, Joseph Clover, was a noted artist and is best remembered in this College for the delightful portrait of Joseph Thomas Clover that hangs in the Council Chamber (Fig. i). This was painted in 1844 when Clover was I9 years old. Clover's paternal great uncle, also called Joseph Clover, started life as a village blacksmith but later became a veterinary practitioner and made so many contributions to his chosen field that he became known as the 'father of veterinary art'. Clover's ancestry has been described on many occasions, but it is vorth reflecting that these family attainments of practical ability, intellectual talent, original thought, and considerable common sense ultimately blended themselves so well in our Clover that for the relatively short period of his working life he became ihe dominant influence in our specialty.
FIG. I Joseph Thomas Clover, aged I9. From the portrait by his uncle, Joseph Clover. When John Snow died in I858 Clover became, as Nunn has phrased it, 'the leader of the second generation of anaesthetists-an expert clinician who laid the solid foundations for the safe practice of anaesthesia'4. He did not write extensively, but his contributions to anaesthesia and to surgery were many. The most important to anaesthesia were the researches he carried out for various committees investigating anaesthetic problems, including death, the major changes he made in the concept of anaesthetic apparatus, and the popularization of the sequence nitrous oxide-ether anaesthesia. This last made ether more acceptable to the patient and lessened the need for chloroform, thus increasing the safety of anaesthesia. In the surgical field Buckston Browne5 described Clover's equipment for evacuating stones from the bladder after lithotrity as 'unquestionably the prototype of all modern evacuators and in it lay the germ of the whole of modem lithotrity'. Bryn Thomas" reckons that Clover was 13 years ahead of Bigelow in the invention of a bladder evacuator. Despite his researches Clover4 was essentially a
'There, but for the grace of God . . .'
173
clinical aniaesthetist with an important private prac- 8000 tice, a fact wvhich in those days no doubt contributed to his personal influence and perhaps indirectly did much to ensure that anaesthesia 7000 started in the United Kingdom as a branch of medicine worthy of a medical practitioner's interest. He died in I882 aged 57 years and is buried 6000 ini Brompton Cemetery, where his grave is kept ini perpetuity by the Association of Anaesthetists of Great Britain and Ireland. Alas, there are no loniger any living direct descendants, and the last 5000 occasion when we anaesthetists were able to honour a Clover in person was in 1959, when Clover's surviving son, Dr Martin Clover, and his grand- 4000 (laughter, Miss Nancy Clover, attended the Faculty Anniversary Dinner. Judged by the standards of IOO years ago, Clover's 3000 contributions were immense, and we today, with the advaintage of hindsight, can honour him as one of the few who established our specialty. The very 2000 rapid progress of modern medicine sometimes makes it difficuilt for young doctors of today to uniderstanid, let alone appreciate, the contributions 1000 made by their older colleagues even a decade or so ago unless they have a sense of historic persj)cctive. One of the advantages of keeping green 100 the mcmory of Joseph Clover is to draw attention 1846 '50 '60 '70 '80 '90 1900 '10 '20 '30 '40 '50 '60 '10 to this fact and to remind us that sound principles FIG. 2 Deaths recorded as associated with are rarely, if ever, outdated. In 1871 Clover was able to write that he had anaesthesia in England and Wales by decades. giveni chloroform more than 7000 times in addi- (From Sykes9 and Registrar General's Antion to other anaesthetics in another 4000 cases anid 'never lost a patient from any anaesthetic'7. nual Reports.) This is a remarkable record of safety by any stanlard as he had been at that time practising anaesthesia almost from its beginnings. But in 1874 he me for the Registrar General's figures, to illushad a chloroform death" and subsequently at least trate very broadly the number of deaths associated with anaesthesia by decades onie other. Perhaps there is a moral herc.
Anaesthetic mortality The mortality of anaesthesia has been much discussed. The late Stanley Sykes drew up a table to illustrate the incidence and total number of deaths associated with anaesthesia in England and Wales from I8469. The figures were culled from various sources, including the Annual Reports of the Registrar General when these became available in relation to anaesthesia in I 9 I I and onwards. I have used Sykes's original figures and brought them up to 1970, the last year available to
(Fig. 2). The rise in the number of deaths up to 1940 and with only a small fall through to 1950 is of course paralleled by a rise in the number of surgical operations and by their increasing complexity, but the peaks of the decades of 1940 and I950 also coincide with the early days of modem anaesthesia and of specialization as we now know them. Scurr, in his Hewitt Lecture here in I 97I10, also quoted the Registrar General's figures to show that the decline in the number of deaths associated with anaesthesia relative to the number of anaesthetics adnministered started in the
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middle 1930s, and he tentatively suggested that the subsequent fall could owe something to the institution of proper education and training in anaesthesia. Both Sykes and Scurr-and indeed all who have looked at the Registrar General's figures-are at pains to point out the danger of reading too much into them, as the problem of deciding what is an anaesthetic death for inclusion in the -figures is a difficult one. Nonetheless the figure illustrates two facts. First, the number of deaths can now be seen to have fallen dramatically, particularly during the last decade recorded; indeed the figures for each individual year since I 950 show a steady decline, and for each of the last 2 years of the decade I961-70 there were fewer than 100 deaths. Second, this decrease must be viewed in relation to the enormous increase during the past 2 decades in the actual number of anaesthetics administered. There are now probably more than 4 million given each year in England and Wales. No one can seriously doubt that nowadays death is an uncommon complication of anaesthesia and that the quantitative use of anaesthetic deaths as an indication of anaesthetic risk is of very limited value. Anaesthesia is very safe indeed. However, it is of interest to look at this side of the story from the point of view of a medical defence organization and then to consider the picture presented by an analysis of some of the few patients who die or develop complications short of death.
The Medical Defence Union My source is the Medical Defence Union (MDU), which was originally founded in I885. I have looked up the available records of those early years of the Union in an attempt to follow any reference to anaesthesia, whether it is non-specific or detailed. In fact right up to the I930S claims by patients of alleged negligence on the part of a doctor practising
60. 000
50, 000 40. 000
i954 55 '56 57 '58 '59 '60 '61 '62 '63 '64 '65 '66 '67 '68 '69 '70 '71 '72 '73
3 MDU, I954-73. (A) Number of members on register of the Union. (B) Reported complications associated with anaesthesia. FIG.
in any field of medicine were rare, most of the work of the Union being related to reporting laymen masquerading as qualified doctors, to libel, and to 'covering'. From I937 to 1952 each year a number of anaesthetic problems of some significance were reported to the Union, and from 1953 onward some details are available. I have charted (Fig. 3) figures for the past 20 years to show the small number of significant anaesthetic problems that are reported each year to the Union in relation to the increasing membership. These figures are not restricted to the United Kingdom, although the membership is predominantly in these islands, and for various reasons I cannot claim that the totals recorded each year for significant complications are completely accurate. The systems of recording used over the years by the MDU have been related to the needs of the individual doctor rather than to the production of med-
'There, hut for the grace of God . . .
ical data-in this case anaesthetic complications-for statistical purposes. However, I think that the total figures are sufficiently comparable from year to year to show the trend, and that the figures for cardiac arrest which are shown in Fig. 4 are accurate
TOTAL SURVIVAL TOTAL CARDIAC ARRESTS
20 t
10 0
601
0
30
[
nmmmmm n .
1954 '55 56 '57
'58 '59
11
ml
I
1 75
l-X
'60 '61 '62 '63 '64 '65 '66 '67 '68 '69 '70 '71 '72 '73
FIG. 5 MDU, I954-73. Reported cases of cardiac arrest and of survival with complications for a week or longer.
1954 55 5657 585960b6 6263 646566768697671 7273
FIG. 4 MDU, I954-73. Reported com plica-
tions associated with anaesthesia. enough to illustrate the smallness of the problem when judged quantitatively. Of course these figures represent only cases reported spontaneously to the Union, and presumably reported because the doctor concerned was worried that there might be repercussions. Even so the number of cardiac arrests is small-in the decade ending 1970 there was an average of approximately I8 a year, whereas the Registrar General reported for England and Wales alone an average of about I00 a year. The difference is large, but there are other defence organizations and the cases referred to the MDU are likely to have occurred in circumstances requiring investigation, while most cases reported by the Registrar General, though associated with anaesthesia, were not necessarily unexpected or avoidable. Fig. 5 shows the relationship between reported cases of cardiac arrest with death and reported cases with survival for
a week or longer. The influence of resuscitation begins to show itself in the early I96os. Now to preserve some relevance to presentday anaesthetic practice the number of cases of cardiac arrest reported to the Union during the past decade and the number of cases of survival for a week or longer are set out in Table I. It is not the total number that needs to be noted here but the small percentage of survivors with or without complications. The importance of this figure will become more obvious when a few of the factors associated with some of these cardiac arrests are considered. I have been able to study personally 66 of these cases and have set out some of the relevant details in Tables II and III. All these cardiac arrests occurred during or after the induction of anaesthesia or in the immediate postoperative period-the distribution being pretty equal between all those periodsand nominally at least when the patient was still in the care of the anaesthetist. In summary, there are three points that arise. First,
TABLE I Cardiac arrest associated with anaesthesia (MDU, I964-73). Total reported cases Patients surviving I week or loniger Patients surviving without complications
204 45 (22.0%) I
(0.4%)
I 7(
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'TABLE
II Cardiac arrest associatecI with an- delay in recognizing cardiac arrest and hence in commencing resuscitation. But there is no aesthesia (MDU, personal series, iu single common pattern in their probable 66 Total number of cases 20 (30.3 %) causation, while the number of cases is too Paticits surviving I week or longer Paticents surviving small and far too selected to make detailed 0 without complications conclusions worth while. A number of cases Type of operation be grouped together to illustrate 49 (74.2 %) can, though, Elective some of the probable primary causes (Table 17 (25.8%) lI'mergceicy IV). The headings are based on my opinion Physical state of patient Fit 40 (6o.6%) Poor I7 (25.8%) TABLE IV Possible primary causes of cardiac Vcry ill 9 (13.6%) arrest (MDU, personal series, I964-73) Degrec of operation 10 Major 37 (56.i %) Postoperative airway problems
)64-73).
Minor Status of aniaesthetist Conisultant or scnior registrar Registrar Senior house officer Other
29 (43.9%)
27 (40.-9 ',) i6
(24.2 %)
'3 (19.7%) I0 (15.2 %)
TABLE III Cardiac arrest associated with an(lesthesia (MDU, personal series of 66 cases, i964-73) Physical state of patient Fit Poor Very ill Degree of operation Major Minor Status of anacsthetist Consultant or scenior registrar Registrar Scnior house officer Other
22 i8
I0 7
20
4
3
6 7 7
6 5 2
4 I I
5 4
a large number of cardiac arrests occurred in fit patients, a high proportion of whom were undergoing minor elective procedures. Second, a relatively small number of patients survived, even with permanent complications. Third, most of the anaesthetists concerned were trained and experienced. There are some factors in this series that occtur relatively frecluently, such as the apparent
Errors of technique Hypotension Unexpected Deliberatc Technical failure Difficulties at induction Oxygen failure Others Total
I0
9 4 8 7 5
13 66
of the primary cause of cardiac arrest, but they reflect Sir Robert Macintosh's oft-quoted view that the causes of anaesthetic death are all too often mundane and obvious and rarely require much, if any, scientific investigation to establish them, provided a truthful account of the facts can be obtained. 'Others' in Table IV includes some patients who were seriously ill and had cardiac arrest despite everything being carried out correctly and some who died for no apparent reason and were seemingly perfectly fit. The facts suggest that approximately 50% of the cardiac arrests might have been prevented had a proper preoperative assessment been made by an anaesthetist or had the anaesthetist concerned maintained direct responsibility in the immediate postoperative period.
Litigation It has been said by Ilarman1' that patients' traditional attittude to a surgeon's mistake is tolerant because they believe that he is fight-
'There, ing for life and accelt that solnetiiries lie will be defeated. Death and other complications associated with anaesthesia are uncommon and therefore, to the patient or the relatives, totally unexpected. This perhaps accounts for the fact that anaesthetic complications are often followed by litigation. Many of the 66 cases I have briefly described have in fact been the subject of litigation, but I do not intend to imply that all the anaesthetists concerned were necessarily negligent. There was clear evidence of negligence in 12 of the cases. It is possible to make the wrong clinical decision for the best of reasons and have a patient die, and it is equally possible to carry out all the correct procedures and yet have an ill or difficult patient die-without in either instance being negligent. These are examples of misadventure. A young doctor in training mav have problems where a more experienced colleague would have none. This may be misadventuire too, yet it may also b2 negligence on the part of the consultant who delegates the case and is personally and vicariously responsible. I doubt whether there are a handful of hospitals in the United Kingdom in which all the very junior anaesthetistTI refer to the house officers-are continuouslv responsible to a consultant anaesthetist who knows what they are doina and who is free, if required urgently, to assist them. I also doubt whether all consultant anaesthetists appreciate just how vulnerable they are in legal terms for the mistakes of their most junior trainees. This is a problem in some ways peculiar to a service specialty which is often overstretched in its clinical commitments and in which practical, and potentially dangerous, things are done to patients. It is my experience that the defence organ-izations look with increasing frequency to the responsible consultant when something goes wrong in the hands of a junior doctor.
buit for the grace of God .
177
.'
TABLE V Some approximate costs of cardiac arrest (MDU, personal series, i964-73) £ 6750 Deceased 1965 Female adult £I5 000 Alive I966 Male child I 967
Male adult
1968 Female adult
1i969 1971
Male adult Female child Male youth Female youth Male adult Female adult
Female adlult
1972 Male adult
Deceased Deceased Deceased Alive Alive Alive
Deceased Deceased Deceased Alive
£ 6oo £ 7500 £ 1300 £ 7300
£69000 £39 000 £13 000 £ II00 £
700
£12 000
Trhe couirts in Britain expect a very high standard of care from medical practitioners, yet traditionally thev demand strong proof of negligence by a plaintiff before condemning a doctor. In recent years the pendulum has tended to swing against the doctor. When a defence against an allegation of negligence is difficult or impracticable, or wvhen negligence is clear, damages are paid. The financial cost of a cardiac arrest may be very high indeed, but the costs to the relatives of those patients who die, or of those patients who survive with permanent and terrible complications, can never be matched bv a sum of nmonev. Nonetheless the cost to the defence organization is considerable and is increasing. Table V shows the round figures for damages paid for 12 cases, all of which are amongst the 66 cases I have discussed. Responsibility During the past decade there has been and continues to be a steady erosion of the personal responsibility of medical practitioners for their patients, a trend that is particularly anparent within the National Health Service. Shared responsibility under the name of team work, delegated responsibility to junior doctors (and by them to more junior doctors), responsibility for somne traditional medical
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duties entrusted to nurses, clinical factcollecting by social workers and others, and recently, within the hospital complex, the delegation of some nursing duties to technicians and other ancillary staff-all these delegations of responsibility have weakened the direct personal relationship between patient and doctor to the extent that in some instances once a policy of management for a patient has been agreed the doctor's direct responsibility becomes nominal. Many factors contribtute to this state of affairs, but those which predominate are specialization, nmedical and other staff shortages coupled with an increasing work load, and a desire by those at the top of each level to do that which interests them most and consequently to do less of that which does not. As there are always more of the less interesting cases it does not take long before some of this less favoured work is delegated to the upper echelons of a lower grade. Mluch of this pattern of change is rational-increasing knowledge and technological advances have made many erstwhile testing or difficult procedures relatively simple and within the capacities of personnel who are not trained to a very sophisticated level. But it may be a dangerous philosophy. The problem is to know how far the process of fragmentation of the direct care and responsibility for an individual patient can go before the advantages are outweighed by the inherent risks. Now let me consider anaesthesia. Amongst a variety of factors that attract some doctors to our specialty is a desire, not necessarily fuilly developed or consciously formulated at an early stage in a postgraduate career, to limit personal responsibility for patients. The consultant physician or surgeon who looks aftel 30 or 40 patients in hospital beds is continuously responsible for these patients so long as they remain in hospital, even though he may delegate as a matter of routine
much of the immediate care to others. For many anaesthetists, once the patient has left the recovery area responsibility ceases unless there are complications attributable to anaesthesia. Now the paradox of this situation is that for most of the past 2 decades there has been a gradual widening of the potential areas of the anaesthetist's responsibilities, not only to certain aspects of the pre- and postoperative care of the patient but to fields unassociated with surgical problems. Many anaesthetists, but not all, have taken this opportunity to increase their personal contact with individual patients. Not all anaesthetists appreciate that the attainment of a consultant position positively endows them with responsibilities which-at least in the ultimate legal sense-they cannot avoid. It is not sufficient to be satisfied with the minimum of practical care of the patient in the operating theatre, for a consultant anaesthetist's responsibility for matters pertaining to anaesthesia is considerably wider than that. There are two broad areas of responsibility; that which is clearly a doctor's but in which there is often overlap between the anaesthetist and the surgeon (or other doctor concerned) and that which is frequently, but not always, delegated to someone other than a medical practitioner. An obvious example of the former is the preoperative assessment of a patient for anaesthesia-to which I have already referred. My medicolegal experience stuggests that on occasion a patient is anaesthetized without adequate assessment by an anaesthetist, and with catastrophic results. Fitness for surgery and fitness for anaesthesia are still two separate entities, though most commonly in concert together. On the rare occasions when they are not, the anaesthetist's view of the patient's likely response to the anaesthetic may be of considerable importance. The current discussion about
hepatic damage following anaesthesia and
'There, but for the grace of God . . .'
surgery, particularly after multiple exposure to both over a brief period of time, illustrates the importance of the anaesthetist's personal responsibility. Some anaesthetists may not realize that they are responsible, at least in part, for complications not normally associated with the anaesthetic but occurring during it. I quote the example of the effects on the whole patient of the injection of carbon dioxide during surgical and gynaecological procedures or of air embolism during others. Anticipation, even of rare complications, may lead to a successful outcome provided treatment is speedy. Late recognition or failure to match the anaesthetic to reduce the risk could be considered negligent. An example of the second or commonly delegated type of responsibility is in the immediate postoperative and postanaesthetic period when a nurse is left to care for the patient. Recovery areas in operating theatre suites have saved many lives that might otherwise have been lost in open wards, yet the delegation of responsibility to a nurse in a recovery area does not absolve the anaesthetist from a continuing interest in his patient. Again my medicolegal experience suggests that the creation of a facility of undoubted merit is abused by some doctors who assume that, having transferred the patient to an area of special care, their responsibility ends. If responsibility is shared by too many people it ceases to exist"t. The traditional field of direct responsibility by the anaesthetist lies in the anaesthetic care of the patient in the operating theatre. There is already a system of delegation to theatre personnel for the provision and preparation of equipment and drugs used in anaesthesia. This is sensible provided the ultimate responsibility of the anaesthetist who finally administers the drugs and uses the equipment is fully appreciated, yet there is some evidence from recent enquiries that this
179
TABLE VI Death or permanent complications associated with problems with the gases supplied to or from anaesthetic apparatus or with the apparatus itself, including connections (MDU, I964-73) 17 No oxygen-various causes Apparatus disconnected Equipment incorrectly used Carbon dioxide excess Contaminiated initrous oxide Total no. of cases
5 3 2 2
29
degree of delegation is believed by some anaesthetists to absolve them from any responsibility for equipment failure or incorrect drug usage that results in harm to a patient whom they anaesthetize. Some hazards of equipment failure are illustrated in Table VI. Contamination of the nitrous oxide can be fairly eliminated as being out of the control of the anaesthetist, but the remainder are less easily disposed of. Three of the 17 cases in which there was no oxygen arose because of failure or mistakes in piped oxygen supplies to the operating theatre, but the remaining I 4, though arising in a variety of ways, were under the immediate control of the anaesthetist concerned. In some cases simply disconnecting the patient from the anaesthetic apparatus and substituting air might well have prevented cardiac arrest. There are many anaesthetists who advocate the delegation of anaesthesia for routine straightforward procedures on fit patients to specially trained assistants, provided a medically qualified anaesthetist is available in case of need, and there are others who advocate the delegation of continuing care in the operating theatre but short of the actual administration of the anaesthetic. Delegation in some degree would give more time to the anaesthetist for other consultant duties, and some of the routine of protracted operating
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lists, particularly when the work load is heavy in relation to the number of anaesthetists available, would be avoided. Indeed such a dilution of the personal responsibility of an anaesthetist for a patient may be dictated on economic and logistic grounds. But this is hardly an ideal way in which to decide about the quality of patient care, and the factors that make a few anaesthetists less safe than their colleagues are not necessarily going to be solved by someone with a less comprehensive training and a far narrower knowledge of the problems involved when something unexpectedly goes wrong and experienced help is not immediately available. There is little dotubt that non-medically-qualified workers can be trained to carry out medical procedures, certainly at a technical level, though sooner or later some want to think for themselves and then their limited background has disadvantages. Whether thev should do thesc things is another matter. I have made no attempt to marshal all the arguments for or against a system of delegation of the administration of anaesthetics; certainly I have no objective evidence from my medicolegal experience that convincingly supports either view. But subjectively I fear for the personal relationship between an individual patient and an individual doctor. That patient whom Lytton Strachey described as 'the quintessential pivot around whom the whole magnificent machine revolves'. It is becoming increasingly easy to treat disease but increasingly difficult to treat patients, to safeguard their interests, and to maintain that degree of personal relationship with them which affords mutual satisfaction and reassurance'2. This personal relationship is often the best buttress against an action for negligence. We mtust consider the value and the disadvantages of delegated responsibilitv in ouir partictular field of active medicine. If it can- paradoxically perhaps-assist anaes-
thetists to increase their personal relationship with patients, then we must not be frightened of it. Whatever we do we must not be complacent about these matters nor let them evolve-as seems to be the case-without proper control. I believe that Joseph Clover would have favoured this approach, for in i882 a colleague wrote of him that 'he showed always a critical and careful spirit in examining and applying all new knowledge'. I am grateful to the following who have made this lecture possible: Miss F J Allatt, Mr J Banfield, Mr T W Brandon, Dr Charles Briscoe, Miss Jean Davenport, Miss Margaret Matthews, Mr Nevillc Ripley, Miss Gail Thomas, Mr F A Tubbs, and all those whose experience and knowledge have contributed over the years to my own understandinig of medicolegal matters.
References I
2
3 4 5 6 7 8
Solly, S (I849) Londont Medical Gazette, 9, 757. Tubbs, F A (1946) St. Thomas' Hospital Gazette, 44, '47Marston, A D (I1949) Annals of the Royal College of Surgeons of England, 4, 267. Nunn, J F (I968) Annals of the Royal College of Surgeons of England, 43, 200. Browne, G B (190I) Twenty-five years' experience of urinary surgery in England. Harveian Society Lectures. Thomas, K B (I972) Anaesthesia, 27, 436. Clover, J T (187I) British Medical Journal, 2, 33. Clover, J T (1874) British Medical Journal, i, 817.
Sykes, W S (1961) Essays on the first hundred years of anaesthesia, Vol. II, Chart I, p. 32. Edinburgh and London, Livingstone. io Scurr, C F (I97I) Annals of the Royal College of Surgeons of England, 48, 274. ii Harman, J B (I973) Therapeutic Accidents. Joint Meeting of the Medical Defence Union and Le Sou Medical. Private printing. I2 Thompson, A (I968) Practitioner, 201, 73.
9
'There, but W D Wylie Consultant
FRCP
for
the grace
of God .0.
.
FRCS FFARCS
An aesthetist, St Thomas's IHospital, Londo?n
Summary The number of deaths reported as associated with anaesthesia in England and Wales has fallen dramatically during the past 20 years. But the problem of cardiac arrest occurring while the patient is under the care of the anaesthetist, though small, remains a serious one because few such patients survive, even with serious complications, and the question of litigation may arise. A series of 66 cases reported to the Medical Defence Union during i964-73 and studied personally has been analysed and the probable primary causes determined. It is concluded that cardiac arrest might have been prevented in about 50% of cases, though there was clear evidence of negligence in only I2. A study of the medicolegal aspects of anaesthesia emphasizes the wide area of the consultant anaesthetist's re-
sponsibilities, extending from preoperative assessment to postanaesthetic recovery. While some degree of delegation is unavoidable and perhaps desirable, the close personal relationship between patient and anaesthetist must be maintained. Introduction My alma mater is famous for at least one historic fact, for the records show that on Ioth October I849 the first death during anaesthesia in any London teaching hospital occurred at St Thomas's. The details were From the i8th Joseph Clover Lecture delivered
on
revealed about 3 weeks later in a letter from a surgeon, Mr Samuel Solly, to the London
Medical Gazette'. The patient, John Shorter, aged 43 years, was an apparently fit person, though he drank a bit, who was admitted for the removal of an ingrowing toenail. The anaesthetic was chloroform. The hospital 'Dead Book' for I846-53 has the following unsigned comment written in the medical remarks column: 'Cause unknown as no inspection was allowed, died after taking chloroform'. No inspection refers to the absence of a postmortem, and at the subsequent inquest the verdict by a jury was 'natural death'. Mr Solly's description of the event tells us that death was accompanied by a dark face, small, quick, but regular pulse, laborious respirations, and struggling. Resuscitation was continued for i l h and included artificial respiration by 'a tracheo-tube and bellows and oxygen gas introduced into the lungs by some means.. .', and galvanism 'through the heart'. All somewhat surprisingly up-to-date for the I 84os and remarkably reminiscent in some respects of reports of death during anaesthesia that are made nowadays, including the verdict at the inquest. As a matter of fact the anaesthetic was administered by a surgery-man or lay helper and a positive result of this death was that from then on all anaesthetics at St Thomas's were administered by medically qualified people2. 20th March 1974
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Joseph Clover I intend to speak about cardiac arrest associated with anaesthesia, basing my remarks largely on my experience as a member of the Council of the Medical Defence Union, but first I want to pay my respects to the memory of Joseph Thomas Clover, whom we are all honouring here today. After all, Clover was himself intensely interested in the safety of anaesthesia and I dare say many younger members of the audience here know little of his personal history. When anaesthesia was first introduced in I846 Clover, then aged 21 years, was a senior student at University College Hospital and vcry probably witnessed the first administration of anaesthesia in Britain. He was born in I825 in Aylsham in Norfolk, almost certainly at a house called 'The Wood' or 'Aylsham Wood House' which was then the Clover family home. This house, built of brick in the early T 7th century, still stands, though it is now called 'Abbott's Hall'. The Clover family was in many vays remarkable and had established a place in history before Joseph Thomas was born. In the first Clover Lecture delivered in this College in 1949 A D Marston quoted Buckston Browne's description of Clover 'as a creator, an inventor-with a quality of mechanical invention which deserves to be called genius'3. It is interesting to speculate on the anthropological implications of that sentence in Clover's family tree. His father was descended from sound yeomen stock, the family having lived and worked as manufacturers and tradespeople in Norfolk for three generations at least. Clover's father, John Wright Clover, owned a successful (Iraper's shop in Aylsham. Clover's paternal uncle, Joseph Clover, was a noted artist and is best remembered in this College for the delightful portrait of Joseph Thomas Clover that hangs in the Council Chamber (Fig. i). This was painted in 1844 when Clover was I9 years old. Clover's paternal great uncle, also called Joseph Clover, started life as a village blacksmith but later became a veterinary practitioner and made so many contributions to his chosen field that he became known as the 'father of veterinary art'. Clover's ancestry has been described on many occasions, but it is vorth reflecting that these family attainments of practical ability, intellectual talent, original thought, and considerable common sense ultimately blended themselves so well in our Clover that for the relatively short period of his working life he became ihe dominant influence in our specialty.
FIG. I Joseph Thomas Clover, aged I9. From the portrait by his uncle, Joseph Clover. When John Snow died in I858 Clover became, as Nunn has phrased it, 'the leader of the second generation of anaesthetists-an expert clinician who laid the solid foundations for the safe practice of anaesthesia'4. He did not write extensively, but his contributions to anaesthesia and to surgery were many. The most important to anaesthesia were the researches he carried out for various committees investigating anaesthetic problems, including death, the major changes he made in the concept of anaesthetic apparatus, and the popularization of the sequence nitrous oxide-ether anaesthesia. This last made ether more acceptable to the patient and lessened the need for chloroform, thus increasing the safety of anaesthesia. In the surgical field Buckston Browne5 described Clover's equipment for evacuating stones from the bladder after lithotrity as 'unquestionably the prototype of all modern evacuators and in it lay the germ of the whole of modem lithotrity'. Bryn Thomas" reckons that Clover was 13 years ahead of Bigelow in the invention of a bladder evacuator. Despite his researches Clover4 was essentially a
'There, but for the grace of God . . .'
173
clinical aniaesthetist with an important private prac- 8000 tice, a fact wvhich in those days no doubt contributed to his personal influence and perhaps indirectly did much to ensure that anaesthesia 7000 started in the United Kingdom as a branch of medicine worthy of a medical practitioner's interest. He died in I882 aged 57 years and is buried 6000 ini Brompton Cemetery, where his grave is kept ini perpetuity by the Association of Anaesthetists of Great Britain and Ireland. Alas, there are no loniger any living direct descendants, and the last 5000 occasion when we anaesthetists were able to honour a Clover in person was in 1959, when Clover's surviving son, Dr Martin Clover, and his grand- 4000 (laughter, Miss Nancy Clover, attended the Faculty Anniversary Dinner. Judged by the standards of IOO years ago, Clover's 3000 contributions were immense, and we today, with the advaintage of hindsight, can honour him as one of the few who established our specialty. The very 2000 rapid progress of modern medicine sometimes makes it difficuilt for young doctors of today to uniderstanid, let alone appreciate, the contributions 1000 made by their older colleagues even a decade or so ago unless they have a sense of historic persj)cctive. One of the advantages of keeping green 100 the mcmory of Joseph Clover is to draw attention 1846 '50 '60 '70 '80 '90 1900 '10 '20 '30 '40 '50 '60 '10 to this fact and to remind us that sound principles FIG. 2 Deaths recorded as associated with are rarely, if ever, outdated. In 1871 Clover was able to write that he had anaesthesia in England and Wales by decades. giveni chloroform more than 7000 times in addi- (From Sykes9 and Registrar General's Antion to other anaesthetics in another 4000 cases anid 'never lost a patient from any anaesthetic'7. nual Reports.) This is a remarkable record of safety by any stanlard as he had been at that time practising anaesthesia almost from its beginnings. But in 1874 he me for the Registrar General's figures, to illushad a chloroform death" and subsequently at least trate very broadly the number of deaths associated with anaesthesia by decades onie other. Perhaps there is a moral herc.
Anaesthetic mortality The mortality of anaesthesia has been much discussed. The late Stanley Sykes drew up a table to illustrate the incidence and total number of deaths associated with anaesthesia in England and Wales from I8469. The figures were culled from various sources, including the Annual Reports of the Registrar General when these became available in relation to anaesthesia in I 9 I I and onwards. I have used Sykes's original figures and brought them up to 1970, the last year available to
(Fig. 2). The rise in the number of deaths up to 1940 and with only a small fall through to 1950 is of course paralleled by a rise in the number of surgical operations and by their increasing complexity, but the peaks of the decades of 1940 and I950 also coincide with the early days of modem anaesthesia and of specialization as we now know them. Scurr, in his Hewitt Lecture here in I 97I10, also quoted the Registrar General's figures to show that the decline in the number of deaths associated with anaesthesia relative to the number of anaesthetics adnministered started in the
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middle 1930s, and he tentatively suggested that the subsequent fall could owe something to the institution of proper education and training in anaesthesia. Both Sykes and Scurr-and indeed all who have looked at the Registrar General's figures-are at pains to point out the danger of reading too much into them, as the problem of deciding what is an anaesthetic death for inclusion in the -figures is a difficult one. Nonetheless the figure illustrates two facts. First, the number of deaths can now be seen to have fallen dramatically, particularly during the last decade recorded; indeed the figures for each individual year since I 950 show a steady decline, and for each of the last 2 years of the decade I961-70 there were fewer than 100 deaths. Second, this decrease must be viewed in relation to the enormous increase during the past 2 decades in the actual number of anaesthetics administered. There are now probably more than 4 million given each year in England and Wales. No one can seriously doubt that nowadays death is an uncommon complication of anaesthesia and that the quantitative use of anaesthetic deaths as an indication of anaesthetic risk is of very limited value. Anaesthesia is very safe indeed. However, it is of interest to look at this side of the story from the point of view of a medical defence organization and then to consider the picture presented by an analysis of some of the few patients who die or develop complications short of death.
The Medical Defence Union My source is the Medical Defence Union (MDU), which was originally founded in I885. I have looked up the available records of those early years of the Union in an attempt to follow any reference to anaesthesia, whether it is non-specific or detailed. In fact right up to the I930S claims by patients of alleged negligence on the part of a doctor practising
60. 000
50, 000 40. 000
i954 55 '56 57 '58 '59 '60 '61 '62 '63 '64 '65 '66 '67 '68 '69 '70 '71 '72 '73
3 MDU, I954-73. (A) Number of members on register of the Union. (B) Reported complications associated with anaesthesia. FIG.
in any field of medicine were rare, most of the work of the Union being related to reporting laymen masquerading as qualified doctors, to libel, and to 'covering'. From I937 to 1952 each year a number of anaesthetic problems of some significance were reported to the Union, and from 1953 onward some details are available. I have charted (Fig. 3) figures for the past 20 years to show the small number of significant anaesthetic problems that are reported each year to the Union in relation to the increasing membership. These figures are not restricted to the United Kingdom, although the membership is predominantly in these islands, and for various reasons I cannot claim that the totals recorded each year for significant complications are completely accurate. The systems of recording used over the years by the MDU have been related to the needs of the individual doctor rather than to the production of med-
'There, hut for the grace of God . . .
ical data-in this case anaesthetic complications-for statistical purposes. However, I think that the total figures are sufficiently comparable from year to year to show the trend, and that the figures for cardiac arrest which are shown in Fig. 4 are accurate
TOTAL SURVIVAL TOTAL CARDIAC ARRESTS
20 t
10 0
601
0
30
[
nmmmmm n .
1954 '55 56 '57
'58 '59
11
ml
I
1 75
l-X
'60 '61 '62 '63 '64 '65 '66 '67 '68 '69 '70 '71 '72 '73
FIG. 5 MDU, I954-73. Reported cases of cardiac arrest and of survival with complications for a week or longer.
1954 55 5657 585960b6 6263 646566768697671 7273
FIG. 4 MDU, I954-73. Reported com plica-
tions associated with anaesthesia. enough to illustrate the smallness of the problem when judged quantitatively. Of course these figures represent only cases reported spontaneously to the Union, and presumably reported because the doctor concerned was worried that there might be repercussions. Even so the number of cardiac arrests is small-in the decade ending 1970 there was an average of approximately I8 a year, whereas the Registrar General reported for England and Wales alone an average of about I00 a year. The difference is large, but there are other defence organizations and the cases referred to the MDU are likely to have occurred in circumstances requiring investigation, while most cases reported by the Registrar General, though associated with anaesthesia, were not necessarily unexpected or avoidable. Fig. 5 shows the relationship between reported cases of cardiac arrest with death and reported cases with survival for
a week or longer. The influence of resuscitation begins to show itself in the early I96os. Now to preserve some relevance to presentday anaesthetic practice the number of cases of cardiac arrest reported to the Union during the past decade and the number of cases of survival for a week or longer are set out in Table I. It is not the total number that needs to be noted here but the small percentage of survivors with or without complications. The importance of this figure will become more obvious when a few of the factors associated with some of these cardiac arrests are considered. I have been able to study personally 66 of these cases and have set out some of the relevant details in Tables II and III. All these cardiac arrests occurred during or after the induction of anaesthesia or in the immediate postoperative period-the distribution being pretty equal between all those periodsand nominally at least when the patient was still in the care of the anaesthetist. In summary, there are three points that arise. First,
TABLE I Cardiac arrest associated with anaesthesia (MDU, I964-73). Total reported cases Patients surviving I week or loniger Patients surviving without complications
204 45 (22.0%) I
(0.4%)
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'TABLE
II Cardiac arrest associatecI with an- delay in recognizing cardiac arrest and hence in commencing resuscitation. But there is no aesthesia (MDU, personal series, iu single common pattern in their probable 66 Total number of cases 20 (30.3 %) causation, while the number of cases is too Paticits surviving I week or longer Paticents surviving small and far too selected to make detailed 0 without complications conclusions worth while. A number of cases Type of operation be grouped together to illustrate 49 (74.2 %) can, though, Elective some of the probable primary causes (Table 17 (25.8%) lI'mergceicy IV). The headings are based on my opinion Physical state of patient Fit 40 (6o.6%) Poor I7 (25.8%) TABLE IV Possible primary causes of cardiac Vcry ill 9 (13.6%) arrest (MDU, personal series, I964-73) Degrec of operation 10 Major 37 (56.i %) Postoperative airway problems
)64-73).
Minor Status of aniaesthetist Conisultant or scnior registrar Registrar Senior house officer Other
29 (43.9%)
27 (40.-9 ',) i6
(24.2 %)
'3 (19.7%) I0 (15.2 %)
TABLE III Cardiac arrest associated with an(lesthesia (MDU, personal series of 66 cases, i964-73) Physical state of patient Fit Poor Very ill Degree of operation Major Minor Status of anacsthetist Consultant or scenior registrar Registrar Scnior house officer Other
22 i8
I0 7
20
4
3
6 7 7
6 5 2
4 I I
5 4
a large number of cardiac arrests occurred in fit patients, a high proportion of whom were undergoing minor elective procedures. Second, a relatively small number of patients survived, even with permanent complications. Third, most of the anaesthetists concerned were trained and experienced. There are some factors in this series that occtur relatively frecluently, such as the apparent
Errors of technique Hypotension Unexpected Deliberatc Technical failure Difficulties at induction Oxygen failure Others Total
I0
9 4 8 7 5
13 66
of the primary cause of cardiac arrest, but they reflect Sir Robert Macintosh's oft-quoted view that the causes of anaesthetic death are all too often mundane and obvious and rarely require much, if any, scientific investigation to establish them, provided a truthful account of the facts can be obtained. 'Others' in Table IV includes some patients who were seriously ill and had cardiac arrest despite everything being carried out correctly and some who died for no apparent reason and were seemingly perfectly fit. The facts suggest that approximately 50% of the cardiac arrests might have been prevented had a proper preoperative assessment been made by an anaesthetist or had the anaesthetist concerned maintained direct responsibility in the immediate postoperative period.
Litigation It has been said by Ilarman1' that patients' traditional attittude to a surgeon's mistake is tolerant because they believe that he is fight-
'There, ing for life and accelt that solnetiiries lie will be defeated. Death and other complications associated with anaesthesia are uncommon and therefore, to the patient or the relatives, totally unexpected. This perhaps accounts for the fact that anaesthetic complications are often followed by litigation. Many of the 66 cases I have briefly described have in fact been the subject of litigation, but I do not intend to imply that all the anaesthetists concerned were necessarily negligent. There was clear evidence of negligence in 12 of the cases. It is possible to make the wrong clinical decision for the best of reasons and have a patient die, and it is equally possible to carry out all the correct procedures and yet have an ill or difficult patient die-without in either instance being negligent. These are examples of misadventure. A young doctor in training mav have problems where a more experienced colleague would have none. This may be misadventuire too, yet it may also b2 negligence on the part of the consultant who delegates the case and is personally and vicariously responsible. I doubt whether there are a handful of hospitals in the United Kingdom in which all the very junior anaesthetistTI refer to the house officers-are continuouslv responsible to a consultant anaesthetist who knows what they are doina and who is free, if required urgently, to assist them. I also doubt whether all consultant anaesthetists appreciate just how vulnerable they are in legal terms for the mistakes of their most junior trainees. This is a problem in some ways peculiar to a service specialty which is often overstretched in its clinical commitments and in which practical, and potentially dangerous, things are done to patients. It is my experience that the defence organ-izations look with increasing frequency to the responsible consultant when something goes wrong in the hands of a junior doctor.
buit for the grace of God .
177
.'
TABLE V Some approximate costs of cardiac arrest (MDU, personal series, i964-73) £ 6750 Deceased 1965 Female adult £I5 000 Alive I966 Male child I 967
Male adult
1968 Female adult
1i969 1971
Male adult Female child Male youth Female youth Male adult Female adult
Female adlult
1972 Male adult
Deceased Deceased Deceased Alive Alive Alive
Deceased Deceased Deceased Alive
£ 6oo £ 7500 £ 1300 £ 7300
£69000 £39 000 £13 000 £ II00 £
700
£12 000
Trhe couirts in Britain expect a very high standard of care from medical practitioners, yet traditionally thev demand strong proof of negligence by a plaintiff before condemning a doctor. In recent years the pendulum has tended to swing against the doctor. When a defence against an allegation of negligence is difficult or impracticable, or wvhen negligence is clear, damages are paid. The financial cost of a cardiac arrest may be very high indeed, but the costs to the relatives of those patients who die, or of those patients who survive with permanent and terrible complications, can never be matched bv a sum of nmonev. Nonetheless the cost to the defence organization is considerable and is increasing. Table V shows the round figures for damages paid for 12 cases, all of which are amongst the 66 cases I have discussed. Responsibility During the past decade there has been and continues to be a steady erosion of the personal responsibility of medical practitioners for their patients, a trend that is particularly anparent within the National Health Service. Shared responsibility under the name of team work, delegated responsibility to junior doctors (and by them to more junior doctors), responsibility for somne traditional medical
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duties entrusted to nurses, clinical factcollecting by social workers and others, and recently, within the hospital complex, the delegation of some nursing duties to technicians and other ancillary staff-all these delegations of responsibility have weakened the direct personal relationship between patient and doctor to the extent that in some instances once a policy of management for a patient has been agreed the doctor's direct responsibility becomes nominal. Many factors contribtute to this state of affairs, but those which predominate are specialization, nmedical and other staff shortages coupled with an increasing work load, and a desire by those at the top of each level to do that which interests them most and consequently to do less of that which does not. As there are always more of the less interesting cases it does not take long before some of this less favoured work is delegated to the upper echelons of a lower grade. Mluch of this pattern of change is rational-increasing knowledge and technological advances have made many erstwhile testing or difficult procedures relatively simple and within the capacities of personnel who are not trained to a very sophisticated level. But it may be a dangerous philosophy. The problem is to know how far the process of fragmentation of the direct care and responsibility for an individual patient can go before the advantages are outweighed by the inherent risks. Now let me consider anaesthesia. Amongst a variety of factors that attract some doctors to our specialty is a desire, not necessarily fuilly developed or consciously formulated at an early stage in a postgraduate career, to limit personal responsibility for patients. The consultant physician or surgeon who looks aftel 30 or 40 patients in hospital beds is continuously responsible for these patients so long as they remain in hospital, even though he may delegate as a matter of routine
much of the immediate care to others. For many anaesthetists, once the patient has left the recovery area responsibility ceases unless there are complications attributable to anaesthesia. Now the paradox of this situation is that for most of the past 2 decades there has been a gradual widening of the potential areas of the anaesthetist's responsibilities, not only to certain aspects of the pre- and postoperative care of the patient but to fields unassociated with surgical problems. Many anaesthetists, but not all, have taken this opportunity to increase their personal contact with individual patients. Not all anaesthetists appreciate that the attainment of a consultant position positively endows them with responsibilities which-at least in the ultimate legal sense-they cannot avoid. It is not sufficient to be satisfied with the minimum of practical care of the patient in the operating theatre, for a consultant anaesthetist's responsibility for matters pertaining to anaesthesia is considerably wider than that. There are two broad areas of responsibility; that which is clearly a doctor's but in which there is often overlap between the anaesthetist and the surgeon (or other doctor concerned) and that which is frequently, but not always, delegated to someone other than a medical practitioner. An obvious example of the former is the preoperative assessment of a patient for anaesthesia-to which I have already referred. My medicolegal experience stuggests that on occasion a patient is anaesthetized without adequate assessment by an anaesthetist, and with catastrophic results. Fitness for surgery and fitness for anaesthesia are still two separate entities, though most commonly in concert together. On the rare occasions when they are not, the anaesthetist's view of the patient's likely response to the anaesthetic may be of considerable importance. The current discussion about
hepatic damage following anaesthesia and
'There, but for the grace of God . . .'
surgery, particularly after multiple exposure to both over a brief period of time, illustrates the importance of the anaesthetist's personal responsibility. Some anaesthetists may not realize that they are responsible, at least in part, for complications not normally associated with the anaesthetic but occurring during it. I quote the example of the effects on the whole patient of the injection of carbon dioxide during surgical and gynaecological procedures or of air embolism during others. Anticipation, even of rare complications, may lead to a successful outcome provided treatment is speedy. Late recognition or failure to match the anaesthetic to reduce the risk could be considered negligent. An example of the second or commonly delegated type of responsibility is in the immediate postoperative and postanaesthetic period when a nurse is left to care for the patient. Recovery areas in operating theatre suites have saved many lives that might otherwise have been lost in open wards, yet the delegation of responsibility to a nurse in a recovery area does not absolve the anaesthetist from a continuing interest in his patient. Again my medicolegal experience suggests that the creation of a facility of undoubted merit is abused by some doctors who assume that, having transferred the patient to an area of special care, their responsibility ends. If responsibility is shared by too many people it ceases to exist"t. The traditional field of direct responsibility by the anaesthetist lies in the anaesthetic care of the patient in the operating theatre. There is already a system of delegation to theatre personnel for the provision and preparation of equipment and drugs used in anaesthesia. This is sensible provided the ultimate responsibility of the anaesthetist who finally administers the drugs and uses the equipment is fully appreciated, yet there is some evidence from recent enquiries that this
179
TABLE VI Death or permanent complications associated with problems with the gases supplied to or from anaesthetic apparatus or with the apparatus itself, including connections (MDU, I964-73) 17 No oxygen-various causes Apparatus disconnected Equipment incorrectly used Carbon dioxide excess Contaminiated initrous oxide Total no. of cases
5 3 2 2
29
degree of delegation is believed by some anaesthetists to absolve them from any responsibility for equipment failure or incorrect drug usage that results in harm to a patient whom they anaesthetize. Some hazards of equipment failure are illustrated in Table VI. Contamination of the nitrous oxide can be fairly eliminated as being out of the control of the anaesthetist, but the remainder are less easily disposed of. Three of the 17 cases in which there was no oxygen arose because of failure or mistakes in piped oxygen supplies to the operating theatre, but the remaining I 4, though arising in a variety of ways, were under the immediate control of the anaesthetist concerned. In some cases simply disconnecting the patient from the anaesthetic apparatus and substituting air might well have prevented cardiac arrest. There are many anaesthetists who advocate the delegation of anaesthesia for routine straightforward procedures on fit patients to specially trained assistants, provided a medically qualified anaesthetist is available in case of need, and there are others who advocate the delegation of continuing care in the operating theatre but short of the actual administration of the anaesthetic. Delegation in some degree would give more time to the anaesthetist for other consultant duties, and some of the routine of protracted operating
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lists, particularly when the work load is heavy in relation to the number of anaesthetists available, would be avoided. Indeed such a dilution of the personal responsibility of an anaesthetist for a patient may be dictated on economic and logistic grounds. But this is hardly an ideal way in which to decide about the quality of patient care, and the factors that make a few anaesthetists less safe than their colleagues are not necessarily going to be solved by someone with a less comprehensive training and a far narrower knowledge of the problems involved when something unexpectedly goes wrong and experienced help is not immediately available. There is little dotubt that non-medically-qualified workers can be trained to carry out medical procedures, certainly at a technical level, though sooner or later some want to think for themselves and then their limited background has disadvantages. Whether thev should do thesc things is another matter. I have made no attempt to marshal all the arguments for or against a system of delegation of the administration of anaesthetics; certainly I have no objective evidence from my medicolegal experience that convincingly supports either view. But subjectively I fear for the personal relationship between an individual patient and an individual doctor. That patient whom Lytton Strachey described as 'the quintessential pivot around whom the whole magnificent machine revolves'. It is becoming increasingly easy to treat disease but increasingly difficult to treat patients, to safeguard their interests, and to maintain that degree of personal relationship with them which affords mutual satisfaction and reassurance'2. This personal relationship is often the best buttress against an action for negligence. We mtust consider the value and the disadvantages of delegated responsibilitv in ouir partictular field of active medicine. If it can- paradoxically perhaps-assist anaes-
thetists to increase their personal relationship with patients, then we must not be frightened of it. Whatever we do we must not be complacent about these matters nor let them evolve-as seems to be the case-without proper control. I believe that Joseph Clover would have favoured this approach, for in i882 a colleague wrote of him that 'he showed always a critical and careful spirit in examining and applying all new knowledge'. I am grateful to the following who have made this lecture possible: Miss F J Allatt, Mr J Banfield, Mr T W Brandon, Dr Charles Briscoe, Miss Jean Davenport, Miss Margaret Matthews, Mr Nevillc Ripley, Miss Gail Thomas, Mr F A Tubbs, and all those whose experience and knowledge have contributed over the years to my own understandinig of medicolegal matters.
References I
2
3 4 5 6 7 8
Solly, S (I849) Londont Medical Gazette, 9, 757. Tubbs, F A (1946) St. Thomas' Hospital Gazette, 44, '47Marston, A D (I1949) Annals of the Royal College of Surgeons of England, 4, 267. Nunn, J F (I968) Annals of the Royal College of Surgeons of England, 43, 200. Browne, G B (190I) Twenty-five years' experience of urinary surgery in England. Harveian Society Lectures. Thomas, K B (I972) Anaesthesia, 27, 436. Clover, J T (187I) British Medical Journal, 2, 33. Clover, J T (1874) British Medical Journal, i, 817.
Sykes, W S (1961) Essays on the first hundred years of anaesthesia, Vol. II, Chart I, p. 32. Edinburgh and London, Livingstone. io Scurr, C F (I97I) Annals of the Royal College of Surgeons of England, 48, 274. ii Harman, J B (I973) Therapeutic Accidents. Joint Meeting of the Medical Defence Union and Le Sou Medical. Private printing. I2 Thompson, A (I968) Practitioner, 201, 73.
9
