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When the one hand doesn't know what the other is doing in the OR, disaster can strike. In this month's case, an 87-year-old woman recovering from successful knee replacement surgery was plunged into a drug-induced vegetative state because her anesthesiologist didn't bother telling the surgeon or the nursing staff that he changed from epidural to spinal anesthesia and that he left the unmarked spinal catheter in place in case additional pain medication would be needed later. He noted these facts in the patient's chart, but didn't communicate them to the people in the room.
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