February 06, 2013

17 Year Old Girl Dies After Tonsillectomy

Patients sometimes focus too much on the intricacies and risks of the surgery itself and not realize that subsequent care AFTER surgery may be just as important and risk-laden.

Media reported yesterday about the tragic death of a 17 year old girl after tonsillectomy.

Apparently in March 2012, the Pennsylvania teenager underwent a routine tonsillectomy without any problems. While in recovery after surgery (PACU), she was given fentanyl, a powerful narcotic to help with pain, but also has a known side effect of slowing the breathing down.
"Over the next 25 minutes, her respiratory condition rapidly worsened and went unnoticed by nurses, who failed to perform required assessments and were not warned by the equipment monitoring Mariah's vital signs because it was not set properly and was muted. Sadly, as a result of these oversights and others, Mariah sustained significant brain damage due to oxygen deprivation and died 15 days later." [link]
It is also implied that in order to give the patient privacy, curtains were drawn such that her distress was also not visually seen by nurses.

Clearly, multiple lapses occurred leading to this tragic death.

Those alarms are there for a reason!!! Why mute them? Patients (and even staff) do complain of the annoying beeps and noises such machines make and out of exasperation, they can be muted due to the many false-alarms, but as this case illustrates, those very alarms could have saved her life.

Once a patient is identified with respiratory distress, narcan could have been given that would have reversed fentanyl's sedating (as well as pain-killing) effects. At worst, the patient could have been re-intubated.

This case also highlights that in certain situations, patient safety trumps patient privacy.

In PACU (a common open room where patients go after surgery), there is absolutely no patient privacy. Everyone can see everything. That way, if there's any problems, nurses can immediately see if a patient is in distress. That's also one reason among others why family is not allowed in the PACU (due to lack of privacy for other patients).

Abington Surgical Center where the surgery was performed has imposed a series of policy changes to ensure another death like this may never happen again. According to media, these policy changes include:

• each patient who has received IV narcotics (which is pretty much all patients who have surgery) in the PACU must be assigned one-on-one nurse care
• patient monitoring equipment may no longer be muted
• curtains restricting the view of the patient can no longer be drawn
• there must be a dedicated charge nurse to oversee nurse staffing and patient flow in the unit.

Except for the first point, I agree with all these policy changes which really shouldn't be a policy change per se... It should have been always there.

However, the one-on-one nursing care certainly can't hurt, but is probably unnecessary and potentially a waste of nursing resources. I should point out that IV narcotics are given ALL THE TIME in the hospital whether in PACU, the hospital floor, ER, and ICU, but one-on-one nursing care is not usually present in any of these locations. Rather, the intensity of nursing care should depend on the acuity of the surgery as well as the medical needs of the patient. A blanket policy change that applies indiscriminately is needlessly wasteful.

Watch a video showing how a tonsillectomy is performed here!

17-Year-Old Girl's Tragic Death After Routine Tonsillectomy Leads to Post-Operative Care Changes. SacBee.com 2/5/13
Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

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