Legal Case from Russia

[yoga]

I thought some of you would find the following case enlightening. It is hard to read in between the lines, but it looks like a muscle relaxant was given without knowing if child could be ventilated. Be happy you don't live in Russia.
Yoga



Russian anesthesiologist sent to jail after 3-year-old girl dies
*

MOSCOW, August 25* - A Russian anesthesiologist was sentenced Friday to two years in a penal colony for a mistake that led to the death of a three-year-old girl.
Alexander Rekunov from Ulyanovsk in central Russia was found guilty of causing death by negligence and banned from working on the medical professions for three years.
The court said the girl, Yekaterina Gulko, had died because the doctor had failed to collect information about her medical history, including her sensitivity to hypoxia, or oxygen deprivation, before performing lung surgery.
Prosecutor in the trial Mikhail Balakshov said, "The court ruling is appropriate and agrees with the position of the prosecutors."
He added that it was the first case in the Ulyanovsk Region, whose eponymous capital is about 550 miles east of Moscow, when a doctor had been punished in practice for a mistake.
Prosecutors established that parents of the girl had brought her to a local clinical hospital for children on May 26, 2005 because she was suffocating and they suspected she had a cashew nut in her lungs.
An X-ray confirmed their suspicions, and the girl was sent for surgery.
Prosecutors said Rekunov, who was on duty, had failed to ask the girl's parents about her medical history, although the parents knew that the girl was hypoxic.
Prosecutors also said Rekunov had chosen the wrong type of anesthesia and extended the period of oxygen deprivation, which stopped blood circulation in the brain.
The girl was in a coma for a few days and died on June 4.
Prosecutors said the doctor should have used a different type of anesthesia that would not have led to a halt in breathing. Even though he had used artificial lung ventilation, prosecutors said Rekunov should have prevented hypoxia by monitoring the girl's pulse, skin color and other indicators.
They also said the hospital had insisted that the parents sign an autopsy waiver for fear of prosecution, which had hampered the investigation. But after a criminal case was opened, the body was exhumed and an independent examination took place in Kazan in central Russia on the Volga River.


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[NursePink]

Sounds like you're right, yoga. What a tragedy. :(

[MmacFN]

scary stuff for sure.

[TranMan]

Even though we don't know the specifics of this case, it would seem like I hear of many cases like this all the time.

Anesthesia Providers (CRNAs and MDAs) making lethal mistakes b/c of negligence or just plain bad luck.

Here's an example. A colleague shared this story with me.

A CRNA doing a labor epidural and gets a "wet tap" (goes into the spinal canal w/ the big epidural needle and gets CSF leakage). Removes the Epidural needle and repeats the process placing the catheter in the appropriate place this time. Gives a test dose to verify catheter placement and tapes up the Epidural. Does not initate the initial bolus. It is now 7am and patient is scheduled for a C-section at 7:30. During shift change, CRNA 1 gives report to CRNA 2 and fails to mention the "wet tape". CRNA 2 goes to bolus 20cc of a local aneshetic in preparation for the C-section, leaves the room to set up the OR. Returns to a dead patient.

So what happened? how could this have been avoided? Should you proceed with placing an epidural after a "wet tap" ?

Remember, crap happens in anesthesia all the time whether it's your fault or not. There are many and many pitfalls in anesthesia. Through experience, maintaining strict practice guidelines, vigilance, and sharing of stories can we hope to avoid these pitfalls.