Commentary:
Despite a difference of opinion regarding the responsibility of patient placement during surgery, the jury returned a defense verdict.
Case Details
The 43 YOWF (5'7", 186 lbs.) presented for a planned laparoscopic total hysterectomy, lysis of pelvic adhesions, and right ovarian cystectomy. Her past medical history was significant for right upper arm pain, anemia, fatigue, weakness, blurred vision, chest pain, headaches, and connective tissue disease with joint pain to her wrists, elbows, ankles, and hip.
In preparation for surgery, the defendant anesthesiologist placed the patient in the dorsal lithotomy position. The anesthesiologist used the following positioning devices: Allen stirrups, bilateral arm boards, padded shoulder supports, and Velcro straps to secure the patient’s arms. There was a difference of opinion between the co-defendant surgeon and anesthesiologist regarding the use of the shoulder supports and the positioning of the patient’s arms on the arm boards. The surgeon claimed that the shoulder supports must have been placed after draping the patient, while the anesthesiologist claimed the surgeon insisted on the patient’s arms being abducted at 60-90° with the patient’s palms facing up.
The surgery lasted almost seven hours. The patient was in steep Trendelenburg position for more than six hours. The surgeon attributed the prolonged surgery time to the patient’s extensive pelvic adhesions and the right ovarian cyst. Upon awakening in the PACU, the patient complained of bilateral upper arm pain and weakness, decreased sensation in both upper arms and hands, and bilateral shoulder discomfort. The patient’s face, neck, and arms were edematous bilaterally.
On post-op day one, the patient’s complaints persisted and the defendant anesthesiologist ordered a neurology consult. The neurologist diagnosed the patient with bilateral brachial plexopathy involving the upper and lower cord, likely due to pressure compression palsy from the patient’s positioning during surgery. The neurologist expected a full recovery. The surgeon noted that the patient continued to show good signs of progress with respect to her brachial plexus compression, and she was discharged five days later.
Approximately a month after discharge, the patient sought a neurology exam. Upon evaluation of her shoulders and arms, the neurologist reported that the patient had slow but progressive improvement in her strength. The patient returned the following month to the same neurologist who noted continued arm strength, lessening pain, and a good prognosis for a full recovery. Seven months later, the patient reported an improvement in her condition; the physical exam by the neurologist revealed 5/5 strength in both upper and lower extremities and bilateral interossei. The patient continued to see the same neurologist for several years.
At some point the patient moved out of state. After not seeking care for 18 months, the patient began care with a new neurologist for complaints of pain. This neurologist testified on the plaintiff’s behalf that her brachial plexus injury was caused by “traction, stretching, or pulling” of the brachial plexus nerves. He further testified that the patient continued to complain of pain in her thumbs, forefingers, and middle fingers. Upon cross-examination, he admitted these complaints were consistent with carpal tunnel, for which the patient had undergone two surgeries—one pre-hysterectomy and one post-hysterectomy.
The patient’s attorneys alleged that the doctors inappropriately positioned her during surgery, and that her arms should have been adducted rather than abducted at an angle. The patient also alleged that the doctors improperly used the shoulder supports and arm boards to support the patient during the procedure.
Expert Testimony
One of the patient’s medical experts opined that the arm boards are the “main culprit” and the cause of the compression injury. The defendant anesthesiologist testified that, during the procedure, he consistently slid his fingers between the shoulders and the shoulder supports, suggesting that there was not adequate pressure to cause the type of injury alleged by the patient. An expert witness for the defense testified that use of the shoulder straps during surgery is reasonable and within the applicable standard of care. A board certified neurologist also testified as a defense expert that the patient’s injuries were solely the result of dependent edema, not the shoulder supports.
The plaintiff and defense experts disagreed regarding which physician had the ultimate responsibility for the use and monitoring of the shoulder straps and arm boards. A plaintiff expert testified that the use of the shoulder straps ultimately rests with the surgeon, while a defense expert believed the responsibility for positioning the patient is shared between the surgeon and the anesthesiologist.
Resolution
After a three-day trial, the jury returned a verdict in favor of the defendant anesthesiologist.
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