Legal Review & Commentary: Death from negligent intubation during tonsillectomy: $440,000 in settlements reached
By Jan J. Gorrie, Esq., and Mark K. Delegal, Esq.
Pennington, Moore, Wilkinson, Bell & Dunbar, PA
Tallahassee, FL
News: To alleviate her chronic sore throats and difficulties with breathing and sleeping, a 44-year-old patient was admitted for a tonsillectomy and adenoidectomy. The attending physician’s failure to communicate with the other health care providers and surgical scheduling changes contributed to the patient’s death. Settlements with the treating physicians and the hospital totaled $440,000.
Background: The 44-year-old divorced mother of two adult daughters suffered from recurrent sore throats, making breathing and sleeping difficult. She sought the help of an otolaryngologist, who had multiple X-rays and MRIs of the neck performed. The tests revealed hypertrophied tonsils encroaching upon her oropharyngeal airway. The physician scheduled her for a bronchoscopy, tonsillectomy, and adenoidectomy.
Due to changes in the surgery schedule made by the hospital, an anesthesiologist was brought in at the last moment. The otolaryngologist did not tell the anesthesiologist that the hypertrophied tonsils compromised the patient’s airway, and the anesthesiologist did not have the time or opportunity to assess to the patient’s X-rays or MRIs prior to initiating the anesthesia. The anesthesiologist used a muscle relaxant, atracurium, so that the otolaryngologist could first perform the bronchoscope to explore the soft-tissue neck mass and tonsillar enlargement before removing the tonsils and adenoids.
The otolaryngologist did not use a fiber-optic bronchoscope to perform the procedure and, given the patient’s pre-existing conditions, was unable pass the tube down her throat. The anesthesiologist failed several times to intubate the patient before calling in three other anesthesiologists. The patient had symptoms of negative pulmonary edema and was secreting sanguineous bloody material by the time the fourth anesthesiologist successfully intubated her.
Approximately 2½ hours after the procedure began, the patient died on the operating table.
The patient’s two daughters filed medical malpractice claims against the otolaryngologist, all four anesthesiologists, and the hospital. Claims against the otolaryngologist included failure to communicate the patient’s condition with the first treating anesthesiologist and failure to abort the procedure once the patient could not be intubated. The plaintiffs also claimed that the otolaryngologist should have first performed the bronchoscope on an outpatient basis if his concern — as stated in pre-suit discovery — was to rule out cancer.
After dropping their case against the three anesthesiologists who had been called in to assist with the intubation, the plaintiffs contended that the treating anesthesiologist failed to perform an adequate pre-anesthetic evaluation and failed to properly consult the hospital record prior to initiating anesthesia. The plaintiffs contended that review of the records and tests would have revealed the pre-existing conditions, which merited an entirely different standard of care, and that the patient should have been handled as a difficult airway management case. Further, the plaintiffs claimed that under the protocols recommended by the American Soci-ety of Anesthesiologists — in this instance, awake intubation — would have been appropriate rather than the long-acting altracurium. Had the awake intubation approach been employed, the plaintiffs maintained that it would have been easier to arouse the patient and abandon the procedure once difficulties were encountered.
In the claim against the hospital, the plaintiffs said the scheduling was chaotic and resulted in the last-minute change in anesthesiologists. The plaintiffs also claimed that the hospital did not make the results of the pre-surgical diagnostic tests readily available in the hospital medical record and that despite the schedule change this would have made the patient’s pre-existing condition information more readily available to all physicians involved.
The defendants countered that the degree of difficulty in intubating the patient was unforeseeable and that early into the surgery, she began to emit sanguineous bloody secretions, making intubation absolutely necessary to save her life. The defendants also contended that her overall life expectancy was significantly compromised given her other pre-existing conditions, which included interstitial lymphocytic pneumonitis, myocarditis, and chronic hepatitis.
Prior to trial, each of the remaining defendants settled with the plaintiffs for $440,000 — $220,000 from the anesthesiologist, $145,000 from the otolaryngologist, and $75,000 from the hospital.
What this means to you: As seen in the breakdown of the total settlement amounts, this case illustrates the consequences of medical treatment that fell below the standard as well as a poor surgery scheduling system.
"For the otolaryngologist not to communicate all relevant medical facts concerning the patient’s condition to the anesthesiologist is not only substandard medical practice but also borders on reckless disregard for the patient’s safety," says Ellen Barton, JD, a risk management consultant in Phoenix, MD. "One simply wonders why the relevant medical facts were not shared with the health care team. As for the anesthesiologist, for one to commence intubation without obtaining all relevant medical facts is also substandard practice and also borders on reckless disregard for the patient’s safety. This raises several questions: Why didn’t she inquire as to those issues that she needed to be aware of? Why weren’t the medical records available? Clearly, there was a need for a pre-anesthesia evaluation, which brings up the whole issue of whether it is necessary and/or appropriate to have a separate consent form for anesthesia. In this case, if the hospital had such a requirement, this case would have turned out very differently."
The physicians’ malpractice aside, "this case points out how critically important systems’ can be to providing quality patient care. For a hospital to bring in an anesthesiologist at the last moment’ because of changes in the surgery schedule’ is setting the stage for trouble. It is the hospital’s responsibility to maintain an environment where appropriate medical and nursing personnel can safely treat patients. Since it is inevitable that there will be modifications in the surgery schedule, the scheduling system must take such changes into account and provide for whatever equipment, supplies, and personnel may be necessary to adjust accordingly," notes Barton.
"In addition to maintaining such an operating room scheduling system, the hospital still has the responsibility to assure that all protocols are followed even when there are schedule changes. This includes being certain that all necessary medical records are available to all involved medical and nursing personnel and to be certain that necessary communication takes place to minimize placing the patients at risk," adds Barton.
Reference
- Anonymous v. Anonymous, Santa Ana County (CA) Superior Court. Case settled. The attorney for the plaintiff was Rodney E. Moss, Whittier, CA.
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