Over the past three weeks, we have sadly heard of five perioperative mortalities. Although I have not been directly involved with any of these cases here, the thought of a patient not surviving surgery unnerves me. I think we all know that a perioperative death, while always a possibility, is not common at our home institutions; certainly not in the operating room. When one does happen under our watch, it takes a while to recover from the experience. One can’t just roll into the next case; some decompression time is needed. Yet the residents here have all for the most part been involved with at least one perioperative death. They understand that in this setting sometimes negative outcomes happen, and sometimes that negative outcome is perioperative demise. I still have a difficult time with the thought of one of my patients not surviving a surgery, as I’m sure most of my US counterparts also do with regards to their patients.
Sometimes there is nothing you can do. A 14-hour postpartum hemorrhage patient with a Hb of 3.5 and in likely DIC at presentation. An infant with massive sepsis who develops bradycardia unresponsive to atropine and epi. These types of cases are heart-wrenching. Then there are also the ones where things possibly could have gone differently. Maybe if the CT scanner were working; perhaps if a compartment syndrome had been recognized earlier at the rural health center; possibly if a different dose of a medication or a different, currently unavailable, medication could have been used upon arrival to the hospital.
At other times, some near-misses have been witnessed. Usually it is no specific person’s fault. Partly, it is a systems issue or a procurement/equipment problem. Lack of communication among departments, help, blood, supplies, etc. We all work with what we have. Unfortunately what we have in developing countries sometimes is not enough. But sometimes there is a distinct action or decision that could have been taken that could have changed outcome. Once the dust settles, these actions and decisions are there for us to analyze in hindsight so that we may learn from experience. It is our duty to learn from these types of experiences. In this regard, I think the correct steps are being taken here. First, education is paramount, and a strong emphasis exists on improving anesthetic training in Rwanda. I truly and humbly hope we are helping on that front. Second, the system is changing to facilitate patient care, albeit more slowly than one would hope. Third, possibly dangerous situations that should be avoided if at all possible are being increasingly recognized and proper action taken. Prevention is key. If life-threatening events do occur, they must be recognized quickly, and acted upon even faster. As anesthesiologists and residents we need to constantly be vigilant, both of the patient and of the perioperative environment. We need to know what to do in case X happens, how to do it, and have backup plans. I believe these points are applicable globally no matter what the operative setting.
We should always be learning; we should always be reading. We cannot afford to say “that’s good enough”, regarding either our knowledge base or patient care. No should ever be able to say that our job is boring, inactive, or intellectually non-stimulating.
The lessons are there for us, whether Rwandan or American, to learn.