A 49 year old lady was scheduled for vaginoplasty. The patient suffered a cardiac arrest after being given a spiral anaesthetic. A thoractomy was quickly performed and cardiac massage performed for one hour without the resumption of spontaneous breathing. In the meantime she was given oxygen under pressure.

Present were the surgeon, the anaesthetist, two residents and part of the time, the hospital’s chief of anesthesia and another anaesthetist.

The woman’s life was saved, but she suffered disabling brain damage. The patient’s husband sued all six doctors and the hospital.

There was no indication on the record as to who had actually given the spinal. There was no indication of a discussion on a “surgical plan.” There was no explanation of the chart entry “mixture of tetracaine and epinephrine given at T-10!!”

The two residents and the staff anaesthetist were dropped from the case, and the hospital and the other three doctors had to pay.