December 7, 1941 Pearl Harbor.... Lots of casualties. Patient safety routine efforts primarily consist of finger on the pulse, eyes on the chest, observation of skin color. The recently released drug, thiopental, is employed. Some of the soldiers die…of anesthesia (1-3). Anesthesia-related death rate reported at 1 in 450 (2).
September 1979 – September 1981 (WAK residency time). The operating surgeon calmly notes blood’s dark. WAK’s reaction: BLOOD'S DARK!!! Dr. Todres says the first 3 things to check for with any problem in the OR is, first airway, then the airway, and finally the airway. So he checks it and finds a disconnect which somehow was not able to be heard with the esophageal stethoscope over the orthopedists’ hammers and drills. No oxygen analyzer, no disconnect alarm, no pulse oximeter, no automated blood pressure monitor; by today’s standards, no nothing, although we did have manual blood pressure cuffs, EKG machines, and the beginnings of advanced hemodynamic monitoring. WAK’s attendings were fond of saying “when I was a resident…” followed by some parable of how he managed with no monitors other than his five senses. It seemed like at least once a year at M&M there was discussion about an intraoperative death by undetected disconnect. Anesthesia death rate said to be about 1 in 10,000.