Legal Review & Commentary: Improper intubation: $1.5 million FL verdict
News: After being burned on the job, a teen-ager was immediately transported to a small nearby hospital. The patient was to have been transferred to a specialized burn unit but, prior to being air transported, he was improperly intubated by the rural hospital’s nurse anesthetist and died before transfer.
A jury awarded $1.5 million in favor of the plaintiffs, including $750,000 for the decedent’s son and $370,000 for each of his surviving parents. The case is on appeal to the Florida Supreme Court on the issue of whether the employee and employer should have been named on the verdict form.
Background: The 18-year-old had just started a new job and was eager to succeed because his fiancée was pregnant. One of his work duties was cleaning up an elevator company’s grounds. One day, he was cutting the top off an empty barrel for use as a trash can. He had previously cut off the tops of hydraulic barrels with no problems. He selected an empty lacquer thinner barrel that still contained flammable liquid. When he started to cut into the barrel, the fumes ignited and blew the top off of the base. Co-workers described a fireball that set his clothes on fire. His skin and hair continued to burn until they put the fire out with fire extinguishers. The young man sustained serious burns over more than 80% of his body, including his face. The hospital record indicated the presence of 62% second-degree burns and 20% third-degree burns.
An ambulance was called and quickly responded. The burn victim was immediately transported to the nearest medical facility, a small rural hospital. In the emergency department, he complained of pervasive pain, but he was alert and oriented. His blood gases reflected some hypoxia. However, the nature and extent of hypoxic brain injury was later disputed at trial. A specialized burn unit was contacted, and the burn victim was being prepared to be transported by helicopter to the other facility. The decision was made to intubate the patient before the helicopter arrived, and a nurse anesthetist was called in to perform the procedure. The nurse anesthetist successfully paralyzed the patient so he could no longer breathe on his own. Second, an endotracheal tube was to have been placed in his trachea to deliver oxygen to his lungs. Autopsy results later showed the endotracheal tube in the esophagus, not the trachea.
The patient was then placed on a device to constantly monitor his oxygen saturations and vital signs. A chest X-ray showed air in the patient’s stomach, possibly a sign that the intubation had gone wrong. The patient’s condition deteriorated, and 23 minutes later, he had no pulse. The young man died prior to being transported to a facility that would likely have been able to save his life.
The plaintiffs’ contention that the decedent was intubated in error was consistent with the endotracheal tube location on autopsy, oxygen saturation levels, and the chest X-ray showing air in the stomach, and that this failure caused his death. Further, the plaintiffs maintained that the hospital’s failure to monitor the patient fell below the standard of care, that oxygen saturation and vital signs should have been read every minute as opposed to eight-to-nine-minute intervals. The plaintiffs noted that the monitoring device was capable of more frequent readings and that the least the hospital could have done was monitor the critical patient more closely given the severity of injuries and the fact that the patient had undergone a procedure that precluded him from breathing on his own.
Further, the facility’s medical records were such that the oxygen monitoring device’s read-out tapes had been eviscerated by the adhesive tape used to secure them to the medical record. This could have been avoided by photocopying the read-out tapes prior to securing them to the patient’s record.
The defendants countered that the intubation was proper and that the tube had been repo-sitioned at some point after the initial placement. The defense also questioned whether the decedent’s burns were survivable, which the plaintiff’s countered by questioning whether the hospital and associated physicians recognized just how survivable burns can be. After the plaintiffs dismissed all claims for economic damages, the trial proceeded only upon claims for the survivors’ pain and suffering. The decedent was survived by a son and his parents. The jury returned a verdict in favor of the plaintiffs of $1.5 million and awarded $750,000 to his son and $375,000 to each of his parents. The hospital was assigned 60% of the fault and the anesthesiology group the remaining 40%.
Even though the plaintiffs did not include economic damages, the case has been appealed on the basis that the employer and employee should have named so that the jury would have the opportunity to assign some percentage of the fault to them. However, the plaintiffs have maintained that the damages awarded were for the post-accident treatment of a burn victim who should have survived — not those associated with someone who may have been able to go back to work, but someone who should have survived from the injuries had he not been fatally harmed prior to transport to the burn facility. If the appeal is unsuccessful — in order to collect from the hospital in this jurisdiction — the plaintiffs would need to have a claims bill filed and passed by the state Legislature to overcome the jurisdiction’s limits on claims paid by entities such as the hospital, which enjoy sovereign immunity.
What this means to you: "While the facts in this case do not tell us why the decision to intubate was made, other than that the blood gases reflected hypoxia, it appears that the patient was alert and oriented when he arrived in the emergency department," observes Lynda Nemeth, RN, MS, JD, risk manager of Norwalk (CT) Hospital. "Once the decision was made to intubate and to use a paralytic agent, [perhaps the thought was that it could be more easily accomplished on the ground rather that on an emergency basis in the air], there are many safety issues that must be addressed. Upon intubation, there should be measurement of the tube. Endo-tracheal tubes are marked in centimeters to show where they should be in relation to the trachea. After intubation and after checking the tube’s position, the tube should be taped in place to prevent dislodgment. The next step is to obtain a chest X-ray to ascertain that the tube is in the trachea and not in the esophagus.
"Further, while awaiting the chest X-ray and prior to taping, the patient’s lungs should be auscultated to check for bilateral breath sounds and if unsure, the stethoscope should be placed over the belly to listen for air entering the belly. Once all safety parameters have been met, the patient should be placed on a ventilator and the ventilator should be set for volume in, with return volume set at the same parameter, along with the setting of the alarms. If the ventilator settings are correct, and the intubation tube is not in the trachea, the alarms would have sounded and the patient’s abdomen would have gotten larger and larger with the influx of forced air from the ventilator," adds Nemeth.
"From the outcome of this case, it appears that all of the indications of a failed intubation were there — air in patient’s stomach and oxygen saturation levels below acceptable — but they were not acted upon. Machinery inside a young person with 80% burns in an emergency department awaiting medical air transport should have been provided with at least one-to-one assignment with either a nurse or a nurse and respiratory therapist," she continues.
"While we rely on technology, such as ventilator alarms, to alert us to changes in a patient’s clinical condition, there is always the obligation to physically assess the patient using nursing judgment and other clinical assessment skills. It appears that the standard of care was not met, in that this critically ill patient should have been monitored closely and protocols related to intubation, ventilator setups and documentation of vital signs followed. Had this been done, the outcome might have been different," concludes Nemeth.
Reference
- The Estate of William E. Roddenberry Jr. v. Jackson County Hospital Corp. and Bay Anesthesia Inc., Jackson County (FL) Circuit Court Case No. 98-246CA.
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