Dr Christine Cheng

Sandwell Hospital at the West Midlands has reported an incident regarding the tampering of some of its portable oxygen cylinders. The general consensus is that a disgruntled member of staff is involved.

The incident was first discovered when doctors attempted to give a sick patient additional oxygen through a face mask. No oxygen was flowing. Fortunately, this was recognised and a new cylinder was brought in, so the patient received the oxygen he needed.

The hospital discovered that the outlet of the cylinder was blocked by a mysterious substance. Two other oxygen cylinders were similarly obstructed too.

This has led to the conclusion of malicious intent.

Why are there so many disgruntled hospital workers worldwide? It seems such a shame that the systems set out to help people treat their own members, the core support workers, so poorly.

I certainly was glad to leave the NHS in 1999. Morale was so very low at that stage. I’m not sure it’s any better now. But things were probably worse in Singapore at SGH. I really hated the inhumane working conditions there.

I love private practice. I have to work very hard at times. I can go for weeks without a single day off, but it’s much more gratifying. And I usually have some semblance of control over my workload.

Source: Daily Mail

The Times reported the conviction of Spanish Consultant Anaesthetist Juan Maeso with 275 counts of causing injuries and 4 counts of manslaughter.

Dr Maeso was a morphine addict who injected himself with morphine that was meant for patient use. The sharing of contaminated needles led to his own infection with the deadly hepatitis C virus. This was diagnosed in the 1990s. He continued to share needles with his patients, leading to 275 infections, 4 of whom died.

Hepatitis C can cause chronic hepatits, cirrhosis and liver cancer.

He was sentenced to 20 years jail for each infected patient, and ordered to pay 500,000 Euros compensation to each patient/family.

To be honest, I’m surprised he would do something so stupid! All doctors know that needle-stick injuries put us at risk of blood-borne diseases such as Hepatitis B, C and HIV. Why would he knowingly put himself at risk?

Most anaesthetists also use cannulae with injection hubs for the administration of drugs. No needles are involved at the point of patient injection. We rarely use direct injection into the vein for the sheer number of drugs involved and the number of injections that have to be done through an operation. It’s all rather strange.

But yes, Anaesthetists do seem to be a high risk group for drug abuse.

I have had a colleague who was addicted to fentanyl. We weren’t any the wiser until he decided to play with remifentanil one day. He forgot his pharmacology. Remifentanil acts very fast and causes dramatic respiratory depression, so he basically stopped breathing and collapsed.

He was found by an Eye Surgeon who saw his leg stuck out of the toilet cubicle door.

We later discovered that he was behind all the missing vials of fentanyl in theatre, and he wore long sleeves all the time to cover the needle puncture marks (not because he was cold like the rest of us!).

Obesity is a huge problem for doctors, not just in terms of the health implications. Diagnosis is also more difficult. Physical examination is hampered by the think layer of fatty tissue. Now even radiological diagnosis is said to be less accurate.

I had a few “memorable” encounters with morbidly obese patients when I was an Anaesthetic Senior House Officer in Wales.

 The first was a lady who suffered from severe depression and ate herself to the point where she could not get out of bed. She ended up breaking her leg (can’t remember how) and needed surgical fixation.

She was too large to fit onto the standard operating table. Fortunately the obstetric delivery bed was able to take her weight. She was admitted to the intensive care unit after the operation so as to ensure she didn’t stop breathing when she was asleep.

The other lady needed an epidural for labour. When I saw how huge she was, I freaked and ran for a consultant’s help. I was in Swansea’s Singleton Hospital then, and I had only just started doing labour epidurals.

My consultant struggled to get an epidural in, and eventually succeeded. The midwives spent ages after that trying to find the foetal heart again. They eventually got worried and decided to call the obstetricians in to do a caesarean section.

The baby was stillborn.

No one knew when the baby had died. Monitoring was just so difficult because of her weight.

Morbid obesity is just such a disaster. Find the help. Lose the weight. Regain health. Your life depends on it.

A 20 month old girl presented with cracked upper front incisors after being dropped by her elder brother. The elective operation to repair the broken teeth was set for the morning following a public holiday. She fell ill the night before the holiday, and had rhinorrhoea on the day of the operation. She was otherwise well and afebrile, so the operation went ahead as planned.

A gas induction was performed. A size 2 disposable laryngeal mask was inserted. IV access was obtained subsequently. The laryngeal mask was secured with the tube anchored to one side to improve surgical access. Cardiovascular parameters were stable at this stage, with good tidal volumes and normal saturation as measured by pulse oximetery.

Upon start of surgery, the child was noticed to be “moving”. There was loss of capnograph trace and it was clear the observed movement was from the child struggling to breath against an obstructed airway. 100% oxygen was administered, with positive pressure ventilation. The larynx relaxed fairly rapidly, with return of normal saturation. The airway was suctioned and large amounts of mucoid secretions were removed. The layungeal was was removed and re-positioned to entire an optimal position. Once secured in place, the capnograph trace disappeared again. The decision was made to proceed to relaxation and insertion of an oral endotracheal tube. A size 4.5 RAE (S) was inserted after the administration of 5mg of Atracurium.

The gas flows were altered to 35% oxygen in nitrous oxide with sevoflurane for maintenance of anaesthesia. Surgery continued. Within a few minutes, she started to desaturate again. The FiO2 was increased once again to 100%. The was eventually reduced to 70%, with maintenance of oxygen saturation at 96%.

The rest of the operation and extubation was uneventful. The child was well, but fretful in recovery. She was coughing a lot, with some stridorous sounds on deep inspiration. She was unco-operative with monitoring attempts.

Comments:

1) URTI is common and usually has little negative sequelae in elective surgery, especially if the atient is feeling well & afebrile, with no respiratory compromise.
2) An armoured laryngeal mask would have provided better positioning, but this was not available at this centre
3) Crying, a common scenario in paediatric anaesthesia, increases airways secretions
4) Dry anaesthetic gases with endotracheal tube irritation of the laryngeal area can increase coughing/produce stridor after general anaesthesia

Conclusion:

Anaesthetists should be at increased vigilance when giving anaesthesia to people with URTI in view of increased airway sensitivity during this time. Most cases proceed uneventfully, but they must be ready to respond should an airway event occur. Ideally, elective procedures should be postponed. However, most children start a new infection soon after they recover from one. The advised 6 weeks after recovery from URTI rule may not be practical.