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Difficult airway management and the risk of vicarious liability

Greenland and Irwin state that training in difficult airway management remains ‘word of mouth’ [1]. This applies also to the communication of airway difficulties, despite advice from the Difficult Airway Society that both a warning and an ‘airway alert’ should be issued for patients whose airways are difficult to manage [2, 3]. Using multiple communication pathways reduces the risk of failing to pass on a message, and although some may consider this a redundant task, we support this approach as an example of a legal ‘defence in depth’ [4]. Pre-operative clinic assessment of a patient presenting for elective shoulder surgery recorded an unremarkable airway, with a modified Mallampati grade 3. On the day of surgery, however, she was noted to have a prominent dental overbite with a short (5 cm) thyromental distance, and to have had a failed tracheal intubation during previous anaesthesia, with resort to a ProSeal laryngeal mask airway. An ‘airway alert’ had been issued after this operation, but the patient was unsure of the nature of the problem. This case illustrates that difficult airway communication can be problematic, but is enhanced by multiple communication paths. The ‘Airway Alert’ scheme identifies four such paths: an alert document for both patient and general practitioner; a case record; and a recording in the department archive. Additional safety methods include prompts to complete the anaesthetic record, inscribe the front of the patient’s casenotes and discuss with the patient a referral to the MedicAlert Foundation (see www.medic alert.co.uk) [5]. Airway management involves managing risk; occasionally the risk can be life-threatening. Benumof tells us “. . .the patient’s responsible doctor must guarantee communication of this difficult airway experience to future care takers so that the near death experience does not become a future death” [5]. When harm ensues following airway management for a patient with known but under-reported airway difficulty, the second anaesthetist may resort to a defence of vicarious liability, citing the first anaesthetist as contributory to the harm by failing to ensure adequate reporting of the difficulty encountered. Although we are not aware of such a defence, we predict that with trends in legal Figure 4 A Hunsaker Mon-Jet catheter inserted through a 6-mm tracheal tube that has been slit along its convex curve length to within 4 cm of the tip.