disaster concluded

so for those of you who have been following these disasterous events, you'll remember i reinserted an et tube into the man's tracheostomy, thereby allowing him to breathe and then went home in full confidence he'd be wonderfully looked after in icu.

so i arrived at work the next morning, almost expecting adulation because i'd saved the guys life (we surgeons tend to have ego problems). imagine my shock when i heard he was dead!!! what had happened??why wasn't i called if he'd collapsed or if he lost his airway again??? what had happened is the following:-

although there was an icu bed as i'd been informed, there were no available nurses to man the bed (they have similar overtime pay problems in this province to what the doctors experience) so the patient was not given the bed. this had not been conveyed to me. what then happened is a total calamity. in the ward, where the patient ended up, he developed a mucus plug in his tracheostomy tube, couldn't breathe and died. no one even realised until it was all over. this is a simple thing to prevent. all that needed to happen was that his trachi pipe needed to be suctioned intermittently through the night. not exactly high intellect stuff. anyone can do it. but if it doesn't happen when it's needed the results can be dire.

when i wrote the post disaster on disaster, one of the things i wanted to comment on is the feeling this sort of thing causes in us, (or me) the surgeons. firstly i felt the total tragedy of the unnecessary loss of the life of someone who died who didn't need to. it's sort of like hearing that the guy you met at the pub last week was hit by a bus just after saying goodbye to you. you don't really know him but you feel the intensity and finality of the situation. it's terrible!!!

then there are another two feelings. the one is a feeling of guilt. shouldn't i have done more? should i not have stayed to make sure my medical officer did in fact get the guy to icu? should i not have gone to suction the trachi myself? how could i have foreseen this??? etc. etc. etc.

lastly, there is a feeling that all the work we did was futile. this is where the normal person on the street may miss what i'm talking about and even consider us a bit heartless. but remember that this is my job and just like the advertising executive who spends nights preparing a presentation and in the end doesn't get the deal will feel a sense of disappointment, i felt sabotaged. after all i'd done, someone dumps him in the ward and everyone including the nurses on duty get a good night's sleep. it's more than just frustrating!!! i suppose the problem is when we have a work associated disaster, usually someone ends up dead. somewhat like the mafia i suppose.

i feel i have so much more to say to fully express how i feel but words seem to fail now