On 14th January, 1989, the 55 year-old owner of a popular Hong Kong night-spot was administered general anaesthesia for open reduction of a tarsometatarsal fracture She was also the wife of a University Professor and popular part-time correspondent for the major English language newspaper in Hong Kong.

After seven minutes of uneventful anaesthesia, a noninvasive blood pressure recorder signaled an unsuccessful reading, and the ECG revealed a bradycardia. Simultaneously, the patient was observed to be “gray” and cardiac arrest was diagnosed.

Cardiopulmonary resuscitation began immediately, and a cardiac output was produced, and the patient’s color changed, in that she became blue, rather than gray. Despite vigorous CPR, appropriate pharmacology, and effective ventilation via an endotracheal tube which was proven to be correctly placed, no further improvement occurred in her condition.

The NIBP recorder incorporated the hospital’s only oxygen analyzer (it has five O.R.’s), but this function was not in use since it was not routine practice at the time. An oximeter at first showed desaturafion, but during the course of resuscitation gave a number of readings which were at variance with the patient’s clinical appearance.

Arterial blood gasses taken approximately ten minutes into the resuscitation showed the following: PaO2 = 2.7 mm HS, PCO2 = 38.7 mm HS, pH = 7.5333, Base excess 9.0, Sat 02 = 0.2%.

Continued efforts at resuscitation were unavailing. About 40 minutes after cardiac arrest was first diagnosed, a patient in an adjoining O.R. was induced and intubated, and immediately became cyanosed. Disconnection of the apparatus and inflation of the patient via the E.T. tube with expired air produced a return to normal color.

A defect in the gas supply was then suspected and the anesthetic apparatus in both O.R.’S converted to reserve (cylinder) supply. The first patient’s color now improved, whilst the second maintained normal oxygenation and her operation was completed uneventful.

The first victim, however, did not recover neurological function and died 48 hours later.

Analysis of the contents of a 100 litre vacuum insulated liquid oxygen container, which had been delivered to the hospital and connected to the gas pipeline about one hour before the fatal anesthetic was commenced, revealed that its contents were almost pure nitrogen.

The hospital called the police, and the media took a keen interest in the ensuing events. The subsequent inquest took more than six weeks to hear medical and technical evidence as well as many expert witnesses.

Monitors Not Standard

It was established that standard practice in Hong Kong at the time of the accident did not include the routine use of oxygen analyzers or oximeters, and in fact there were no minimal monitoring standards applying in Hong Kong at all. Many anaesthetists apparently relied entirely on clinical judgement, and the anaesthetist for the surviving patient described above actually spoke strongly against the routine use of any monitoring devices.

The cause of the misfiring of the container was never established, the company maintaining that it was “sabotaged”. A feature of the inquiry was a vigorous attack on the anesthetist’s clinical management by the counsel assisting the coroner, and the gas company’s attorney. Professor James Payne, formerly British Oxygen Professor of Anaesthesia at the Royal College of Surgeons was also critical of the anesthetist’s failure to diagnose the cause of the problem.

The court also heard evidence from Ross Holland, APSF member and Professor of Anesthesiology. That previous wrong-gas accidents had almost always been fatal for the first victim to be exposed, and that whatever might be happening elsewhere in the world, right or wrong, the standard of care in Hong Kong at the time of this accident did not include the use of inspired oxygen concentration monitors.

The jury found that there was no medical negligence, and that the sole cause of death was the faulty gas container. A number of recommendations were made, including the routine use of inspired oxygen analyzers during general anaesthesia.

Enormous Costs

The bottom line is that before any liability claim has been heard, much less settled, the cost to the community and various parties involved has already exceeded (U.S.) $1 million, and it all could have been averted by the expenditure of less than (U.S.) $2000 on oxygen analyzers routinely fitted to all five anesthesia machines of that hospital, provided of course, that they were routinely used. Even the cost of providing analyzers for all anaesthesia machines in Hong Kong would have cost less than half of the legal expense for this case so far.

Ever since the accident, the Government health authority has been testing every oxygen container arriving at its hospitals, at the cost of countless man-hours.

The Society of Anesthetists of Hong Kong is now engaged in a program of drafting standards similar to those issued by the Australian Faculty of Anaesthetists, and so far has promulgated two on minimal monitoring standards and minimal facilities for sale anaesthesia in operating suites.

Had these documents been in force before January 1989, not only this accident, but others (such as flowmeter mix-ups) might also not have occurred.

Dr. Holland is Professor and He-ad, Department of Anesthesiology, University of Hong Kong.