Comment – Seems to be rather lot of disasters so far in this blog. Things will change.

He lay there, in front of me, motionless and not breathing. This was not supposed to be happening. A second or so earlier he had been talking to me about his hobby which was model aeroplanes. This was all I knew about Pat Farmer’s personal life besides him being a lawyer I was about to give him one of the worst experiences of his life.

The day after I terrified him, I read a story in the Morning Gazette. It was about how various states were using the same technique I’d accidentally used on Pat Farmer.

Pat was admitted as an emergency after he’d woken, early in the morning, with belly pain. We were about to chop out his appendix.

“Pat, I am going to give you an injection of Pentothal, This is powerful stuff. You will be asleep within a few seconds. I’ll put an IV in first. Once you are asleep, I will give you a drug to relax (paralyse) your muscles, so I can place a tube into your windpipe and then attach you to a ventilator. This is all quite routine”

“Don’t bother giving me all the details doc. Just get on with it. This whole scene terrifies me and the faster I am out of it the better.”

I turned round to fill up my syringes; a 2cc one with a short acting paralysing drug, a 2cc one with atropine, a 10cc one with Pentothal and a 5cc one with a curare like drug (long acting muscle paralyser). I laid them out in the tray in my usual order. I turned to Pat to place an in-dwelling catheter in his right arm and connected it to a bottle of normal saline. I was ready.

“Hold on a minute”. It was the theatre sister. “We have to change theatres. There is some thing wrong with the lighting in number one. We are going to theatre three”.

“Okay”, I said, “Let’s go”.

I turned to pick up my syringes to find someone had taken them already. I wheeled Pat along the corridor.

“This is all I need for my nerves. Things never go right for me”, Pat moaned.

Little did I know, just then, how right he was. I made some casual comment to him along the lines that everything was fine and there was no need to worry, as every thing was under control. He did not look convinced. Could he read the future? We arrived in theatre three and my syringes were in the tray and everything appeared to be in order.

“Okay Pat, Here we go. This first drug is atropine and you won’t notice too much with this, “I pushed it into his vein and as I turned round to pick up the Pentothal, I heard this strange and unfamiliar noise come out of Pat’s mouth. I whipped round to find him sitting bolt up right and staring into a horizon that wasn’t there. I placed my head in front of him to see if I could attract his attention. He was vacant. In the next moment, he fell back on the table as if he’d been pole-axed. He wasn’t breathing and his pulse was very fast. He was motionless, like a guard at Buckingham Palace.

‘Jesus Christ, what the hell is going on’? I thought to myself. He was still not breathing. Time had stopped and I could not understand what had happened. My brain had seized up with shock. I gave it a hard shake and then realised. I’d given him the wrong drug first.

In the move the syringes had been swopped around. I’d paralysed him before putting him to sleep. This drug makes the muscles of the body go into a sudden spasm before it paralyses them.

“What’s going on”? The theatre sister enquired casually. As she was asking this question, I was pumping Pentothal into Pat as quick as I could. The poor bastard was probably terrified. I knew that he was fully conscious and couldn’t move a muscle, not even an eyelid. The drug I had given him had paralysed all the voluntary muscles in his body.

Within seconds I had him asleep with a tube in his lungs and was giving him a hundred percent oxygen. The next day, I went to the ward to find out how he was and to explain to him what had happened. I gave him the article in the Gazette.

“It was awful. I wanted to breathe and I couldn’t. I felt like I was bursting and nothing would move. I am going to report you for negligence”. I aplogised and wandered off dejectedly and waited for prosecution. It never happened.

COMMENT

I should have labelled the syringes and I didn’t. It was a busy night and that is no excuse, I shouldn’t have assumed the syringes were in their original order. If he’d taken me to court, I wouldn’t have had a leg to stand on. I was guilty. If you are the person I did this to and you are reading this, I am sorry and thank you for not taking proceedings against me.

We doctors carry some powerful drugs in our kit bag and even when used correctly can cause problems. I attended an old lady in her home. She was in the middle of a heart attack. I gave her half the recommended adult dose of Morphine slowly, not slowly enough. She stopped breathing. I gave her mouth to mouth with her husband watching. It took twenty minutes before she started to breathe. This shouldn’t have happened but it did. I was sure I’d been careful. She must have been hypersensitive to morphine.

I was a witness in a coroners court as I was on-call when an eight year old boy had died. I didn’t know him, had not seen him before. He’d had a routine appendicectomy. He had been returned to the ward. He was found dead in his bed half an hour later. The lawyer for the family didn’t ask any of the right or best questions. He had no idea. I could have told him what to ask. There is no question this boy should not have died. I don’t know what the coroner’s findings were.

This blog so far gives the impression that disasters are common when they are not. But these stories suggest doctors are human beings, fallible, and we need to be alert, watch what’s going on, ask questions, have friends or a family member with us, get as informed as we can and not subject ourselves to treatments and procedures lightly. There is potential for harm even with taking Aspirin or Voltaren. I won’t have a general anaesthetic unless there is no other option.

I haven’t seen a medic for advice since I was 18 when I had a strangulated hernia – they saved my life. I will be staying away from the clutches of my profession for as long as I can.

In a book called “Aging Well,” Vaillant wrote that six factors predicted healthy aging for the Harvard men: physical activity, absence of alcohol abuse and smoking, having mature mechanisms to cope with life’s ups and downs, and enjoying both a healthy weight and a stable marriage. For the inner-city men, education was an additional factor. “The more education the inner city men obtained,” wrote Vaillant, “the more likely they were to stop smoking, eat sensibly, and use alcohol in moderation.”

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Sent from my Samsung Galaxy smartphone.

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