A checklist for post-operative care: 25 minutes was too long

A 17-year-old girl, Mariah Edwards, had a routine tonsillectomy, with Fentanyl as a pain killer.  However, right after the outpatient surgical procedure, she stopped breathing, but no one noticed this for 25 minutes.  The only automatic monitors of her vital signs had been muted.  And no one saw her because a curtain had been pulled around the post-op bay.  She died days later from the lack of oxygen.  This tragedy could have been prevented with proper post-op monitoring and care.

Her family’s lawyers at Ross Feller Casey have posted online a free checklist of questions that patients or their advocates can ask beforehand to assure themselves that doctors and nurses will safely care for their family member.  This is particularly important because the first few hours after surgery are often the most risky due to the use of anesthesia, the delivery of pain medication, and other complications that can arise in the recovery room.

Don’t be shy about questioning credentials or asking about post-op care. You are putting your trust, medical health, and quite possibly your life, in the hands of these people, so it is absolutely appropriate that you want to know about their experience and what to expect in the recovery room. You can, and should, ask to talk to whoever will be participating in the operation. It’s not unreasonable to request to talk with the anesthesiologist, surgeon, and other members of the surgical team before any surgery is performed.

Remember, it is just as important to ask about what will happen after the surgery as it is to ask about the procedure itself. You can ask about anything that you find relevant to the operation and time spent in recovery. It’s a good idea to make a list of questions prior to surgery so that you don’t forget any.  Sometimes asking the right questions about post-op care can make the difference between a positive medical outcome and a tragedy.

Read another checklist story.  Thanks to Mario Cattabiani, the Director of Communications at Ross Feller Casey in Philadelphia and David Bernard of OutpatientSurgery.net for this story. 

She kept the remaining ones: A fatal fentanyl patch drug error

After an accident several years ago, a woman got a prescription for fentanyl patches to treat her chronic pain. She didn't use all the patches, and kept the remaining ones.

Years later, her six-year-old daughter complained of neck pain late one evening. The foster mother gave her an appropriate dose of ibuprofen, and placed one of the left-over fentanyl patches on her neck to treat the pain. The next day, the girl was found unconscious in bed, and was pronounced dead by the time she arrived in the hospital’s Emergency Room.

Mike Cohen's advice to parents: Discard unused prescription medication after you're done with it. Ask your pharmacist about the safe use of fentanyl patches. Don't share fentanyl patches with anyone else.

Read another Fentanyl story.

Thanks to Michael Cohen for the source story in his ISMP Medication Error Report Analysis, published in Volume 43, Number 9 of Hospital Pharmacy.

Pres. Bush, conscious sedation, and decision-making

On one day last week Vice President Richard Cheney was temporarily in command of the United States, during Pres. Bush’s colonoscopy. The president, we were told, was having the minor outpatient procedure under conscious sedation, and would hand over command to V.P. Cheney for a few hours.

The procedure removed five polyps from the president’s colon before they could become dangerous.

The president resumed his duties a few hours later.

Does this news of a chief executive being in command just after conscious sedation scare you too? Before my own procedure under conscious sedation under Versed and Fentanyl, I was appropriately told not to make any important decisions later that day. I felt quite in control afterward, however—which was quite a deceptive feeling. I had no memory, for example, of writing a thank you note to the doctor, or of asking someone to pass my note to the doctor afterward.

Advice: Make sure a family member or friend prevents you from making decisions while under the after-effects of conscious sedation.

Read one of our anesthesia stories.

Warning on antidepressant and antipsychotic drugs: Drug-drug interaction

A 45-year old man from Boston had been taking four drugs for depression when he had ankle surgery in December. When the anesthetic wore off, he was given Fentanyl in the recovery room. He suddenly developed tremors and violent shaking, and started cracking his teeth, according to his wife. Moved to the Intensive Care Unit, he thrashed and flailed, oblivious to those around him, and had to be restrained physically. Two weeks later, he was still in intensive care, very confused, well after his drugs had been discontinued. The same “serotonin syndrome” had caused the death of Libby Zion in 1984.

At especially high risk of such serotonin poisoning are patients on combinations of antidepressant drugs and antipsychotic drugs that are sometimes prescribed to treat resistant depression. It can result from a combination of an SSRI (Selective Serotonin Reuptake Inhibitor, like Zoloft, Prozac, or Paxil) or an MAOI (Monoamine Oxidase Inhibitor, like Marplan, Nardil, and Eldepryl, and another serotonin-raising substance.

Advice to patients taking these drugs: Ask your pharmacist and doctor about possible drug-drug interactions.

Read another of
our stories of a drug-drug interaction, or the blog post of Dr. R. W. Donnell, Jane Brody’s story in today’s NY Times, “A Mix of Medicines that can be Lethal,” and the review article in the New England Journal of Medicine.