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< Case 6 of 6 >

It was a day like any other. I was preparing for a routine breast uplift on a 41-year-old private patient. What happened next was about as far from routine as you can get.

I performed anaesthesia using propofol and fentanyl, and inserted a laryngeal mask airway. I also administered a muscle relaxant. I maintained anaesthesia with a propofol infusion, and used a remifentanil infusion.

Just after my patient was transferred from the anaesthetic room to theatre, her heart rate and blood pressure increased significantly. Surmising that this indicated a light level of anaesthesia, I increased the rate of infusion of both propofol and remifentanil, and also gave midazolam.

After that the surgery proceeded uneventfully. Until the patient came out of anaesthesia, and I heard the words you never want to hear as an anaesthetist: “I woke up.” During the operation she had heard me talking, and felt tugging and pushing. She had tried to scream and pull away, but had been unable to move.

It was a nightmare for the patient. As one of the key people responsible for her physical and psychological safety, it was also a nightmare for me. I felt terrible about the ordeal she’d had to endure, and the damaging effects it could have.

It was not long before I heard from the patient’s solicitors. She was bringing a claim against me for intraoperative accidental awareness resulting in psychiatric injury.

Although it didn’t really come as a surprise, I experienced the letter like a physical blow. I called Medical Protection, who assigned me a medicolegal consultant. After reviewing the medical records, he instructed a consultant anaesthetist to provide an expert report.

That report came as an even heavier blow – or more accurately, a series of heavy blows. The expert pointed out that I’d not used a target-controlled infusion (TCI) pump, which uses mathematical modelling to calculate infusion rates based on the required drug concentration at the target site, and the patient’s height, age, and weight. I’d also failed to perform any calculation, or refer to an infusion regime, regarding the rate of propofol infusion that would be required to keep the patient adequately anaesthetised.

On the day of the procedure the TCI pumps were in use in another theatre. Rather than changing my usual anaesthetic technique, or changing the order of the list so that they would be available, I opted to use the pumps without TCI. As I was less experienced at using these manual infusion pumps, I miscalculated the infusion rates. I realise now that this was the unwise decision that led to terrible consequences for the patient.

The expert calculated that the rate per hour at which the propofol was administered was around half that which would be recommended based on the patient’s weight, as was the infusion rate of the remifentanil. She also concluded that there was no surgical or anaesthetic requirement for muscle relaxation to be used in this case, and that the use of a muscle relaxant contributed to the patient’s awareness, as did my failure to monitor the depth of anaesthesia. Although such monitoring wasn’t mandatory at the time, it has been since 2021.

On a less damning note the expert felt I’d been right to administer midazolam, and to increase the rate of infusion of propofol and remifentanil, when I suspected anaesthesia to be light after noting the patient’s increased heart rate and blood pressure. But I was rightly criticised for not clearly documenting this on the anaesthetic chart.

Based on the report and the medical records, Medical Protection considered the claim could not be defended, and paid out a compensatory sum on my behalf.

It was a hard lesson on more than one front. My professionalism had been called into question and I needed to address that. For example, in cases where a TCI pump isn’t used, careful consideration and calculation of the rate to be infused must be performed.

I now always think very carefully about whether a muscle relaxant is necessary. And when a muscle relaxant is used, I use a depth of anaesthesia monitor. I won’t use equipment or a technique I’m unfamiliar with.

I have also learnt a lot about awareness during anaesthesia – how to reduce the risk, how to detect it and, sadly, the terrible consequences for the patient. I now meticulously record every procedure and patient interaction. I hope that this never happens again to any patient I anaesthetise.

The whole event made me question my abilities as a professional and an anaesthetist. My medicolegal consultant gave me unwavering support and although I couldn’t escape from the facts of the case, his input made the process much easier to deal with. He helped me appreciate that I could use this experience to learn and improve my practice. On a positive note, I am now a more reflective doctor and have shared this learning with my colleagues.

In hindsight, I wish I had made more of my Medical Protection membership. Yes, they provided world-class legal expertise when I really needed it, and of course my indemnity was a lifesaver in terms of the payout. But they are there for you in many other ways too, for example with extensive professional development resources around minimising risk.

I’m not saying that the situation wouldn’t have happened – the main issue was one of medical process – but if I’d taken advantage of these resources, at the very least it would not have been exacerbated by poor record-keeping.

Having come through the darkest episode of my career, I have to focus on the positive, and one of the things I’m most thankful for is the ongoing support I get from Medical Protection.

Get protection you can depend on from just £549*

This case is based on a real scenario, with some facts altered to preserve confidentiality.

*Cost shown is the annual membership price for a UK Medical Consultant working exclusively in the NHS. Subject to protection requirements and underwriting approval.

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