1. Death on the table Tariq Alzahrani Demonstrator College of Medicine King Saud University

2. Introduction It is a rare occurrence. But one that can have considerable psychological & professional consequences for all members of the theatre team. Prof. Aitkenhead has noted Avoidance of disasters rather than the management of their aftermath.

3. Incidene Peri-operative deaths solely due to anaesthesia or anaesthetic error are extremely uncommon (0,5-0,8:100,000) The intra-operative death of anaesthetised patients is a more common occurrence ( 1-30:100,000 )

4. In the U.K ( excepting Scotland ) : - 5000,000/Y (GA & Reg. ). - 20,000/Y death in 30D of surgery. - 2000 of it in 24H of surgery. - about 100 (5%) of these deaths occur intra-operatively.

5. Causes Anaesthetic factors: - human error - equipment failure - organisational factors - interprofessional relationships Patient factors: - age - pre-operative condition - nature of surgery - doctor-patient relationship

6. Effect of death on the anaesthetists. Anaesthetists are not automatons. Human error is a factor in anaesthetic practice & its consequences, more so than in other medical specialties, tend to be immediate, adverse & conspicuous.

7. Examples : 1. 10Y --- RTA. --- elective surgery by medical error.

8. Gautam, notes a number of factors that may increase the risk of depression & anxiety amongst doctors : Biological factors: - gender. - age. - family history. - lack of sleep. - poor eating habits. - poor level of fitness. Psychological factors: - perfectionism. - sense of responsibility. - need for control. - self-doubt.

9. Environmental factors: - patient demands. - professional. - occupational hazards. - personal life. - work-life balance.

10. The juxtaposition of these factors in routine practice may in turn have 2 consequences: 1. The stressed anaesthetist may be prone to making more fatal errors. 2. They may subject to greater psychological stress if an intra-operative death occurs.

11. AAGBI (Association of Anaesthetists of Great Britain & Ireland) have previously noted that as many as 30% of anaesthetists feel stressed a lot of the time & that stress- related behaviour, including alcoholism, drug abuse & suicide, is particularly prevalent amongst anaesthetists, compared with other medical specialities.

12. Survey don, only 53% of the surgeons questioned had witnessed an intra- operative death, but 81% of these had performed further operation within 24H without subjective detriment to their operating skill. 77% of anaesthetists who felt perfectly competent to deliver another anaesthetic within 24H.

13. CISD (critical incident stress debriefing): - is a formal process of intervention that employs cognitive group psychotherapy, has been previously advocated to limit stress occurring after exposure to emotional trauma.

14. - this group used to reduce immediate distress & identify individuals at risk of developing chronic psychological problems ( who require referral for further treatment ). - used: fire service, police personnel, intensive care nurses, bank employees subjected to armed robbery & military personnel.

15. Conclusion Avoidance of disasters rather than the management of their aftermath. Death on the table is a rare. Whether death are expected or unexpected, any anaesthetist may be emotional affected by any intra- operative death at any times.

16. Death on the table does note mean that every death will trigger psychological distress in the anaesthetists, or affect his/her professional ability to continue delivering safe anaesthesia.

17. Consultants feeling greater responsibility than juniors. There is no professional guidance concerning the management of intra- operative death. (rare)

18. If the death occurred, the departmental director should act to relieve affected individuals from their duties, whilst arranging for the incident to be discussed in more formal detail & help them if they have signs of stress, depression or other psychological sequelae.

19. Recommendation The anaesthetists should have one month real vacation every 6 months ( no locum is allowed ).