Unexpected operative death from hemorrhage: a review of six cases and recommendations

All busy surgeons will eventually face a severe intraoperative hemorrhage and about one-third will have an intraoperative death. Situational awareness is the key to good operating room leadership and clinical performance. Technical, emotional, and professional skills are equally necessary. When hemorrhage occurs, some surgeons are affected by a “startle” response and freeze. An immediate surgical plan to stop the hemorrhage by pressure or direct vascular control is required. A stable patient presents other options such as waiting for additional surgical or interventional help; an unstable patient does not. The operating room team and family look to the surgeon as the threat-and-error manager. The surgeon must fill this role with a skilled, open, and compassionate approach rather than a hesitant, protective, or defensive approach. The urgent needs of the patient can require a surgeon to perform an unfamiliar or unpracticed exposure when there is no safe alternative. The emotional and professional cost of a fatal intraoperative hemorrhage is significant. With preparation, a better path for the surgeon, operating room staff and patient is possible. This review presents six actual scenarios of managing hemorrhage in orthopaedic surgery.