$17.5 million awarded to family of teenager for hospital’s improper administration of anesthesia
Incident happened during routine jaw-wiring surgery
News: A DeKalb County jury awarded the family of a gunshot victim $17 million after finding a major Atlanta hospital to be liable for causing the victim’s brain injuries. The victim, a then 19-year-old male who was struck in the face by a stray bullet, presented to the emergency department for injuries resulting from the shooting. However, when the hospital performed a jaw-wiring surgery to stabilize his injuries, the patient was deprived of adequate oxygen for an extended time, which resulted in a coma and severe detrimental brain injuries. A jury found the hospital, anesthesiologist, and physician’s assistant liable for failing to follow the proper anesthesia procedures when the patient was coming out of surgery.
Background: On April 9, 2008, a 19-year-old male was rushed to the emergency department of a major Atlanta hospital after he was struck in the face with a stray bullet in a local Wal-Mart parking lot. By all accounts the patient was an innocent bystander, and he was not involved in the drive-by shooting that led to his bullet injuries. At the emergency department, the male patient was responsive and "very much like his normal self" according to his mother, also a plaintiff to the lawsuit. Despite the alarming nature of a bullet to the face, the patient’s mother was assured that her son’s perforated cheek was not life-threatening.
After two days at the hospital, physicians decided to wire the patient’s jaw shut in an extremely routine surgery, which usually comes with few to no expected adverse reactions. Jaw wiring, also known as maxillomandibular fixation, is a surgical procedure in which metal pins and wires are anchored into the jaw bones and surrounding tissues to keep the jaw from moving. It is used in situations in which the jaw might be fractured to keep the bones aligned and stable while the jaw heals. The hospital physicians decided to proceed with the surgery despite knowing that the patient’s airway remained partially obstructed and swollen. The fact that the surgery was elective, and not medically necessary, later fueled plaintiffs’ arguments that it should have been delayed until the patient’s airways were sufficiently healed.
Physicians planned for the patient to be discharged the day after his surgery. However, when the plaintiffs arrived at the hospital the next day, they found their son as non-responsive, in a coma. Hospital staff informed the plaintiffs that the patient had been deprived of oxygen for seven to eight minutes during the procedure, resulting in massive brain injuries which continue to inhibit the now 24-year-old’s ability to walk and communicate.
At trial, defense counsel presented evidence that the patient was partly responsible for his lack of oxygen during the procedure as he "emerged violently from anesthesia and began fighting with physicians and other medical providers, and ultimately pulled out his own breathing tube." In addition, attorneys for the hospital argued that hospital personnel acted swiftly to save the patient’s life.
However, the plaintiffs’ attorney claimed that the hospital had departed from the standard of care by failing to follow its own policies and procedures regarding the administration of anesthesia. Specifically, the attorney argued that the anesthesia team brought the patient "out of unconsciousness too quickly," which resulted in the patient becoming "combative and agitated." Furthermore, plaintiffs’ attorney further claimed that the hospital failed to keep sufficient staff on its floors during the patient’s surgery. Plaintiffs also argued that the hospital was aware of the tendency to become agitated when extubating a patient with swollen airways, as evidenced by their plan to have four extra people in the room to restrain the patient as he came out of anesthesia. Yet when the patient was being moved to recovery after the surgery, there were only two people present to restrain him. He was therefore able to remove his endotracheal rube and flip over his bed, leading to the delay in re-intubation that ultimately caused the brain injuries at issue in this case.
In terms of damages, plaintiffs’ counsel contended that the patient now has "the mind of an infant" as he is unable to walk and write, and he can barely talk, although he is making slow improvement with speech as a result of speech and physical therapy. In addition, the patient’s mother claimed that she took off nine months from work to provide her son with 24-hour care, seven days a week.
A jury found the hospital, anesthesiologist, and physician’s assistant liable for $17.5 million in damages. The hospital has shared that it plans to appeal the verdict.
What this means to you: This case pivots around the lack of monitoring of a patient who is emerging from anesthesia; the inability to recognize the stages of anesthesia recovery and a patient’s response to that recovery; and most importantly, the lack of bedside safety precautions when caring for a postoperative patient who has just undergone maxillomandibular fixation, i.e.: wire clippers.
There are four stages of anesthesia recovery. The second of these stages is called the stage of emergence delirium. The signs and symptoms of emergence delirium or agitation after anesthesia include excitement and alternating periods of lethargy followed by excitement and disorientation. Inappropriate behavior such as screaming, kicking, and use of profanities might occur. Also, patients generally do not respond appropriately to commands. This appears to be the scenario described in the case summary. The notion, presented by defense counsel, that the patient was partially responsible for his lack of oxygen because he emerged from anesthesia in this violent manner is ridiculous. Clearly the defense attorney was making a futile attempt to depend on something that was useless. This state of mind and behavior is completely involuntary, and the onus is on the hospital staff to ensure the patient’s safety.
Every post-anesthesia care unit (PACU) nurse, certified registered nurse anesthetist (CRNA), and anesthesiologist must be aware of these signs and symptoms. As such, precautions to avoid self-extubation or the ramifications of other harmful, jerky movements must be anticipated and always must call for a quick staff response.
Once this patient exhibited these symptoms, it was incumbent upon the postoperative staff to ensure the patient’s safety. One safety precaution could include soft wrist restraints or mittens to avoid self extubation. Of utmost importance is the presence of wire clippers. These small devices always must be readily available at the beside, whether in the immediate postoperative area or on the nursing units, should the patient’s airway become compromised. The mandibular wires can be cut to release the mandible/jaw and allow for suctioning to clear the airway of any secretions or even allow for the ability to intubate the patient should it be deemed necessary.
According to the case summary, the plaintiffs’ attorney further claimed that the hospital failed to keep sufficient staff on its floors during the patient’s surgery. What this claim suggests is that the staffing was such that no one was present to notice and respond to the signs and symptoms of respiratory distress for 7-8 minutes. In fact, it appears that the hypoxia did not occur during the actual surgery but immediately postoperatively when the patient emerged violently from anesthesia. He self-extubated, with a wired jaw, and there was not a quick staff response to remedy the event, thus this situation allowed the patient to be deprived of oxygen.
This is a sad case that appears, from the facts presented, to have been both predictable and preventable.
Reference
Parents of Sheriod Merritt v. Emory University. Dekalb County Court (Ga. 2013) Unpublished citation.
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