Allegation
Plaintiff alleged the defendant anesthesiologist violated the standard of care by failing to properly intubate, causing an esophageal perforation and collapsed lung.
Case Details
A 53 YOM (5’10”, 200 lbs.) presented to the hospital for the repair of a complex facial laceration resulting from an on-the-job injury. Surgery was scheduled right away. The defendant anesthesiologist evaluated the patient as an ASA 2, and started anesthesia at 12:30. An unexpected difficult airway resulted in three intubation attempts.
The operative report reflected a laceration of the gingiva overlying the left canine with a marked amount of debris in the laceration. The area was systematically debrided. The wound across the lip included a laceration through the vermillion ridge that extended through the border to the level of the mucosa, but no full thickness penetration along the musculature. After irrigation, the wound was repaired with sutures. The patient tolerated the procedure with no apparent complications. The pre-and post-operative diagnosis was a complex 6 cm laceration of the right upper lip and face.
The patient was discharged with instructions to follow up with his primary care physician. He began complaining of severe pain en route to his automobile. The nurse advised the patient to return to the ED for further evaluation where he complained of severe pain and acute muscle spasm. The patient was in distress, agitated, and uncooperative. There were no signs of respiratory distress. He was given pain medication and discharged home in good condition.
The patient returned to the ED via EMS with continued complaints of recurrent muscle spasms in the back that were not relieved by pain medications. He was evaluated and no respiratory distress was noted. Thoracic and lumbar x-rays were ordered and revealed no abnormalities. The patient was given IV Valium, Dilaudid, Norflex, and Zofran. At 05:03, the patient was again discharged home in good condition with a diagnosis of back spasm.
The following day, the patient returned to the ED, was diagnosed with a collapsed lung, and transferred to surgery for a right tube thoracotomy with re-expansion of the right lung. A chest tube was placed and 2 liters of purulent, foul-smelling fluid drained from the patient’s chest. A post-op chest CT revealed a pneumomediastinum. This surgeon then discussed the findings with the defendant anesthesiologist and learned the patient had a difficult intubation during the original surgery. This team then considered esophageal perforation.
On post-op day 3, a Gastrografin esophagram revealed a small leak to the right with extraluminal Gastrografin spilling into the pleural space of the right medial hemithorax. The patient returned to surgery for a primary repair of an esophageal perforation, right parietal pleural flap, right total lung decortication, and right tube thoracotomy x 2. A 3 mm perforation was noted to be in the mid-esophagus just distal to the carina. Following the procedure, a chest x-ray was obtained that showed expansion of the right lung and resolution of the effusion. The patient tolerated the procedure well with no apparent complications. The patient was transferred to the ICU, intubated in serious condition.
On post-op day 4 the patient was extubated and kept NPO on IV antibiotics, then transferred to stepdown until post-op day 5 when an esophagram was performed, showing no evidence of a leak.
The patient remained at the facility for nine more days. At discharge, he was tolerating his diet, his WBC had returned to normal, and he made a full recovery.
Expert Testimony
At trial, the plaintiff’s medical expert testified that the defendant anesthesiologist breached the standard of care in several areas. He criticized the pre-op evaluation of the patient’s airway and documentation limited to normal dentition, while failing to note the Mallampati classification, neck mobility, and submental distance. He also criticized using a bougie and claims there was a failure to maintain visual of the bougie during intubation and/or advancement of the bougie through resistance. He also claimed the defendant anesthesiologist failed to perform a proper post-operative evaluation, which would have noted difficulty breathing and pain, prompting further care and an earlier diagnosis of the esophageal perforation.
The defense expert testified that he did not believe the anesthesiologist perforated the patient’s esophagus because, as an experienced anesthesiologist, he could not have possibly inserted the endotracheal tube down to the level of the carina where the perforation took place, noting that nothing but the nub of the tube would have been visible. A perforation of the esophagus is a known complication of intubation and does not constitute a breach of the standard of care. This expert did not know what caused the perforation, but he was confident the anesthesiologist’s care and treatment during the surgery in question did not cause the injury.
Resolution
At trial there was a significant dispute in the testimony regarding the anesthesiologist’s use of a bougie during intubation with the surgeons testifying that he did, and the defendant testifying that he did not. The jury deliberated for four hours and rendered a unanimous verdict in favor of the defendant anesthesiologist, finding that his actions did not amount to negligence.
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