Nearly everything we do in veterinary medicine, let alone life, has a routine or pattern in the way we do it. Let’s take dental cleanings for example. In vet school, we’re trained the “right” way to do them. Examine the patient, run blood work, administer pre-meds, place an IV catheter, induce anesthesia, intubate, yada, yada, yada. Each of these steps has an important purpose. And even sometimes, no… a lot of times, we think to ourselves, “This step is such a waste of time.” But when we forget our training, or cut corners, or get too complacent, really bad things can happen.
On a normal Wednesday morning at a small animal general practice at which I was externing, a middle-aged healthy dog, let’s call her Peaches, came in for a routine dental cleaning. As I stood in the shadow of the doctor I watched them examine her and administer her dose of pre-anesthetic meds. In Peaches’ case, her owners elected to decline blood work. About an hour later Peaches was ready to be induced. An IV catheter was placed and checked for patency. General anesthesia was induced. She was intubated and placed on gas anesthetic. The doctor pulled up a stool and began to examine Peaches’ mouth and scale her teeth. No more than 60 seconds later the doctor lifted her head and said, “It looks like she’s taking agonal breaths!” She turned her head towards the anesthesia machine to find a fully distended reservoir bag. The needle on the machine’s pressure gauge was nearing 40-50 centimeters of water. Seconds after it was discovered the pop-off valve was closed. Peaches was not breathing, had no heartbeat, and her mucous membranes were turning blue. The team immediately began performing CPR.
But in that quick minute, the damage had been done. After about 5 minutes of CPR, Peaches was gone. She sustained a fatal pneumothorax.
The point of this story is to remind everyone to follow your steps. No matter how many times you do it, for how many years you’re in practice, don’t forget the basics. In this tragic story, the anesthesia machine was not checked prior to Peaches’ procedure. Had the proper check happened, the pop-off valve would have been left in the correct open position and this avoidable mistake mitigated.
Sometimes it takes a tragic experience like this to really make a point stick. Hopefully, this story made an impact on you. But it’s not just about anesthesia machines. Cross your t’s, dot your i’s. Don’t cut corners. It’s easy to get lazy, complacent, forgetful. Call it what you will.
Mistakes happen. We’re only human. But we can always do our best to deliver the best care possible.