Medicine, residency

Dear Mrs. X, I’m sorry about what happened to your son under anesthesia.

It was a sunny morning in July and I was scheduled at the outpatient center with the oral and maxillofacial surgeons for teeth extractions. One of my patients was your son, an athletic teenager, whose only medical history was asthma. According to you and him, he had not experienced any recent asthma attacks, and had never been hospitalized or intubated for one. In terms of breathing, he said he felt ‘perfectly fine’ for many years. The last time he took his inhaler was yesterday prior to exercising. He had not experienced any upper respiratory infections recently and was not having any difficulty breathing today. I placed my stethoscope on his chest and heard clear breath sounds. Reassured, I proceeded to finish setting up the operating room.

Confession: there are many risks and side effects of anesthesia, and we don’t always mention all of them — especially to the young, healthy patients that come for same-day surgery. The most common risks are sore throat (from the endotracheal tube), nausea and vomiting (from the anesthetic medications and the nature of certain surgeries), and short-term memory loss (also from the anesthetic agents). The major ones are very rare and include bronchospasm (when your airways close), heart attack, stroke, severe allergic reactions leading to cardiovascular collapse, and subsequently, death. I spoke to you about the common risks and mentioned your son’s slightly higher risk of an asthma exacerbation under anesthesia. You and him expressed understanding.

As I was setting up the operating room for your son, I thought about giving him an albuterol treatment just in case. His history did not suggest that he would be at high risk for an asthma exacerbation, and he did not bring his own inhaler. I thought about all the patients similar to him who did just fine without taking their inhaler on the day of surgery. So I decided against charging him extra money for the inhaler and proceeded to the operating room.

We planned to place a nasal endotracheal tube because the oral surgeons needed access to the mouth. On induction of anesthesia, we made sure to keep him very deeply anesthetized to avoid the stimulation associated with airway instrumentation. I obtained a perfect view of the trachea and proceeded to place the nasal tube. His airways immediately closed and we were unable to ventilate him. At this time, his oxygen saturation dropped significantly. We called for help and opted to skip the nasal tube as oral intubation is easier, especially in an emergency setting. After the oral endotracheal tube was placed, we were hardly moving any air at all as his hyper-reactive airways had completely shut, preventing vital gas exchange in the lungs. His oxygen saturation continued to drop, and we saw (and heard) the particularly ominous sign of a decreasing heart rate. I internally panicked. After multiple interventions including a deeper level of anesthesia, inhaled albuterol through the endotracheal tube, and IV medications to open up his airways, we were finally able to ventilate, and his heart rate and oxygen saturation increased appropriately. After a few minutes, my own heart rate and breathing stabilized.

The practice of anesthesia is often compared to flying a plane. Anesthesiologists are compensated for our training when things go wrong — for plan B, C, and D when plan A fails. Adverse events are more likely to occur on takeoff (induction of anesthesia) and landing (emergence from anesthesia). Sometimes complications occur in the middle of surgery and include major blood loss, accidental extubation, and pulmonary embolism to name a few.  Although rare, when these major events do occur, they can be devastating and everyone in the operating room looks to you to rectify the situation. It is for this reason that anesthesiologists have become the pioneers in patient safety. As one graduates from timid intern to senior resident, the level of personal responsibility significantly increases. I experienced a similar case of bronchospasm early in my residency. I had practiced a simulation of the situation but other than that, I had no idea what I was doing and looked to my attending for help. It is interesting to note that early on, residents are mostly concerned about their own performance during a crisis. However as we go through residency, the internal thought process becomes less about personal performance and more about teamwork and the overall safety of the patient.

When I heard your son’s heart rate go down, I admit that I experienced a moment of mental paralysis. Our conversation from the pre-operative area flashed through my mind. I mentioned to you and him that he could have an asthma attack during the anesthetic, but I did not expect it to happen. I thought about what I would have to tell you if things did not improve — that God forbid we had to do chest compressions on your son because he had a rare complication during a surgery that could have potentially been done in a dentist’s office. I’m sorry that your son experienced a life-threatening complication when all he did was come to have his wisdom teeth removed. I am sorry that I did not listen to my instinct and give him albuterol before putting him under anesthesia. It may not have prevented the adverse event, but it would have cleared my conscience.

We almost expect adverse events to happen in the sick, elderly patients, especially the ones with significant cardiopulmonary disease. What we don’t expect — the severe bronchospasm in your teenage son, or the cardiovascular collapse of a healthy, pregnant woman from an embolism — is what leaves the deepest scars on our conscience and simultaneously makes us more competent physicians. I’m sorry about what happened to your son under anesthesia. You may never know this, but because of him I am a better doctor — and for that I would like to tell him, thank you.

37 thoughts on “Dear Mrs. X, I’m sorry about what happened to your son under anesthesia.”

    1. Yes. But in patients with cardiovascular or cardiovalvular disease, Epi can truly be a double-edged sword.
      Imagine a 70 yr old with moderate/severe AS (and/or severe CAD ) who bronchospasms and quickly desats to <50 with subsequent bradycardia and a now very ischemic heart. The board answer IS correct — you have got to give the Epi. But damn!! You may relieve the bronchospasm just in time to see an unrecoverable V-fib due to Epi induced tachycardia in an AS patient whose O2 sats will recover too slowly.
      This is the reason that this particular scenario is the stuff of nightmares. It’s likely “damned if you do — and damned if you don’t.”

      Liked by 1 person

  1. Good teaching lesson! All anesthesia residents should read. Couldn’t have been written better. Been there done that. Keep a clear head and keeping moving to plan B, C, D. Involve another anesthesiologist, if one is available. But, use your training, knowledge and experience to guide you. If you panic, all is lost! 10% of people solve life threatening situations, 30% follow and 60% are paralyzed with panic and DIE. Hope the numbers are better for anesthesiologists on the job, using their training, knowledge and experience. As anesthesiologists, we expect 100% success. Anything less is unacceptable, but the law of averages can catch up with you. Lightning strikes even the BEST of us. Good SAVE.

    Liked by 1 person

  2. Right or wrong, I’ve setyled on albuterol nebs on all asthmatics who have used albuterol within the last 3 months, as well as heavy smokers who admit to “morning/smoker’s cough”. Nope, not evidence based medicine, but early in my career I witnessed a severe bronchospasm during a MAC (yeah, I know) podiatry case. Pt almost died, and only after multiple doses of albuterol and epinephrine did the bronchospasm resolve. Way easier to prevent this crisis then treat it.

    Liked by 1 person

  3. This is the very real side of physicians that we never hear are see. You poignantly expressed what many anesthesiologist wish they could say to their patients when unexpected events happen in the operating room that are not related to negligence or blatant errors. Maybe one day society will move towards transparency. A society, where physicians can openly discuss and express their feelings with their patients about important events like this one without the fear of blame and potential litigation. To the author, I would like to say thank you. I am truely appreciative for your words.

    Liked by 1 person

  4. I’m curious. So I really can not tell. Is this what you told the patient’s mother or just imagining in your own mind what you would like to tell her? Because if you just imagined this in your own mind – and it is a nice piece of creative writing; don’t get me wrong – you really should have explained to her (and probably the patient as well) what happened. More specifically, IMO, you should have given the patient as well as his mother (if he is a minor) a hard copy “progress note” stating: “During induction and attempted placement of an endotracheal tube for oral surgery, the patient experienced life threatening bronchospasm with near cardiac arrest. We we’re able to break the spasm before he actually did arrest and patient subsequently did well. I would suggest preinduction albuterol inhalation next time if he requires GA.” Or something to that effect. Hopefully you did just that. Tell them to show this note to his future anesthesiologist of anesthesia care giver if he ever has surgery again.

    Liked by 1 person

    1. Thank you for your comment. The boy and his mother were both informed of the potentially catastrophic bronchospasm and what it meant for future anesthetics. I don’t recall a progress note going home with them, however I plan to incorporate that into my practice for future anesthetic complications.


  5. The episode was well described and the sequence of events well explained and thoughtfully presented to the parent. All of us who have practiced Pediatric Anesthesia, especially outpatient dental procedures, have a healthy respect for asthma. The availability of immediate resources and expertise to manage the acute airway emergencies are mandatory. The favorable outcome is a tribute to these precautions and your action to implement them.
    Clyde W. Jones, M.D., F.A.C.A.

    Liked by 1 person

    1. Yes, the nasal tube was attempted to allow the oral surgeons access to the airway, however, due to his acute bronchospasm and ensuing hypoxia, we aborted the nasal tube and went with an oral tube as it is easier to intubate orally.


  6. 12 years of supervising 4-5 CRNAs. Intervened in over half a dozen of similar reactions. Have to react swift and maintain calmness. 10-15mcg of epinephrine and drip at 2 mcg/min, then other Rx.
    Good job saving kids life.

    Liked by 1 person

  7. Dear Mrs. X,
    I’m sorry my idiocy almost killed your son. My attemp to save you money almost caused me to lose him. I was stupid enough to not see that he had exercise induced asthma for which he used in haler yesterday. You did ignore that you were told to bring his inhaler with him, so you do share some of the blame. Fortunately, my attending saved me and your som.

    That’s a more accurate translation. The resident is trying to get sued with his “apology”.


    1. Thanks for your comment, but I disagree. Residency is a time of learning through experience, and this one definitely added to my skill set. Mistakes happen in medicine and you do what you can to minimize risk, but sometimes all those preventative tactics do not work. Then you rely on experience to manage the complications and mitigate harm. So no, I am not trying to get anyone sued, and like I stated above — I am thankful to this patient for making me a more confident, vigilant physician.


  8. Discussion of all risks with patients and families is extremely important, same as being prepared to deal with complications. Training, knowledge, and expertise make the difference between life and death. And we must understand that every anesthetic we provide comes with a real possibility of serious complications, therefore we must be always ready to diagnose and treat anesthesia and surgery related complications.

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  9. This is a super common occurrence in pediatric anesthesia, not a rare complication, and it occurs during dental procedures often too. Albuterol can help, it rarely helps through the ETT. Epi usually fixes it. You did nothing wrong, other than get used to it and don’t let it fluster you. It’ll happen many times again. In my 6000+ patients as an attending, I’ve never had one I couldn’t fix fortunately, but that can happen too. Be kind to yourself.

    Liked by 1 person

    1. Thanks for your comment. In intubated patients we typically use short acting beta agonists (inhaled bronchodilators) depending on the severity of the bronchospasm. If ventilation is impossible, 5-10mcg of epinephrine IV is usually effective at opening up the airways.


  10. I think that you are being too hard on your self. I am a pediatric anesthesiologist and know how you feel. A pre-op bronchodilator may or may not have helped. You’ll never know. In situations like this, ask yourself, ‘would someone else have done a better job?’. I don’t know how long you’ve been doing this, but new attendings tend to blame them selves too quickly. This is the nature of what we do. You reacted well and saved the day. You had plans B, C and D. Pat yourself on the back because this will not be the last time that the unexpected will happen.

    Liked by 1 person

    1. Thank you for your kind words. I am in my final year of residency and will go on to pursue an Obstetric Anesthesiology fellowship. And yes, I notice I am more hard on myself the more “senior” I become, as the responsibility of being the ‘attending of record’ looms in the near future…


  11. Can you clarify this part

    “I obtained a perfect view of the trachea and proceeded to place the nasal tube. His airways immediately closed and we were unable to ventilate him. At this time, his oxygen saturation dropped significantly. We called for help and opted to skip the nasal tube as oral intubation is easier, especially in an emergency setting. “

    Was the nasal tube advanced into the trachea or not?

    Liked by 1 person

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