›› Thank you for highlighting the important case of a nerve injury following a femoral nerve block (“Stumbling block”, Casebook 21 (3)). However I would dispute your statement that use of ultrasound has revolutionised the safety and efficacy of regional anaesthesia.
Surely the key factors in this case were the use of an unsafe nerve block technique, as well as severe deficiencies in consent and communication
Published works show a rate of nerve injury whilst using ultrasound to be similar to traditional techniques.1 Surely the key factors in this case were the use of an unsafe nerve block technique, as well as severe deficiencies in consent and communication. From the details published the decision to use a regional block at all might seem questionable, regardless of technique. The presence of an ultrasound machine would not have made any difference to these factors.
Dr Ben Chandler, Consultant Anaesthetist, Scarborough Hospital, UK
- Fredickson MJ, Kilfoyle DH, Neurological complication analysis of 1,000 ultrasound guided peripheral nerve blocks for elective orthopaedic surgery: a prospective study, Anaesthesia 64:836- 44 (2009)
You correctly identify the issues of unsafe technique, consent and communication as being the factors which made this claim indefensible; the comment about ultrasound, whilst making no difference to the outcome of this case, was a comment made by one of the experts in passing.
An unavoidable amputation
›› Re: “An unavoidable amputation”, Casebook 21 (3). Thank you for your interesting case reports, which I always read.
I was trying to gain a better understanding as to why the patient, Mrs N, did not make a claim against Dr B, the initial clinician, or at least claim against both doctors. It seemed her focus was on one doctor rather than the other. This is relevant to my locum GP work.
Dr Vishal Naidoo, Portfolio GP, UK
One can only presume that the claimant was either herself satisfied with the consultations with Dr B, or that she was advised by her solicitors or their GP expert when examining the record, that Dr B had exercised a reasonable standard of care. Given that the care provided later by Dr G was also considered to be reasonable, it would seem to have been the right decision.
Hospital managers: support needed
›› Dr Rob Hendry makes a very valid point in his article (“Under the influence”) in the latest edition (Vol 21 No 3, September 2013) of Casebook about failing teams being at the root of much of the problems in failing hospitals.
He is not precise about which teams he has in mind but the point is valid in all contexts; perhaps in failing hospitals it is the management team that needs most help. There can be considerable antipathy, as well as inability to understand the other’s point of view when managers and doctors meet. This may not be all that surprising when each have very different goals. People who just cannot get on need outside help.
Changing our own approach might encourage change in “the opposition” and avoid the need for involving a third party
Dr Hendry might like to follow up his comments with a note about where one should turn. I felt this was a lack in the article. His concluding comment was too vague. One needs to be aware of which of one’s actions one needs to “take responsibility for”, and how to do that.
Behaviours that impact negatively are compounded by communication failures, and some may find it helpful to read something on the subject. I would recommend a book by three American authors, which of the hundreds available and several I have read is really outstanding. Though I have not read the latest edition of 2012 there is every reason to believe it will be as good as earlier ones. Changing our own approach might encourage change in “the opposition” and avoid the need for involving a third party.
Dr Howard Bluett (retired consultant paediatrician), Tewkesbury, UK
The book recommended by Dr Bluett is Interplay: The Process of Interpersonal Communication, by Adler et al, published by Oxford University Press, USA; 12 edition (13 Jan 2012) ISBN-10: 0199827427; 1SBN-13: 978-0199827428 It will be reviewed in a future edition of Casebook.