Commentary
Despite a poor outcome, treatment based on the practitioner’s clinical judgment provided a strong defense.
Case Details
A 56 YOM (5'11", 257 lbs.) was seen in the ED by an advanced registered nurse practitioner (ARNP) with complaints of severe abdominal pain, nausea, and vomiting. Elevated labs included WBC 34.5 (4.3-1.9), glucose 171 (70-110), creatinine 1.8 (0.6-1.0), and total bilirubin of 1.6 (0.0-1.0). The patient’s medical history was significant for obesity, HTN, GERD, dyslipidemia, renal insufficiency, and appendectomy. He had also been smoking a half a pack of cigarettes per day for 20 years.
A CT of the abdomen showed an enlarged and inflamed gallbladder consistent with acute cholecystitis. The ARNP recommended transfer of the patient to another facility for a cholecystectomy due to possible septicemia, and the high probability of needing intensive post-op care due to renal insufficiency. At the time of the transfer, the patient was on O2 at 2L per nasal cannula, with a sat of 95%.
The next day, the co-defendant general surgeon performed a laparoscopic cholecystectomy and removed a gallbladder that was gangrenous all the way down to the cystic duct. Since the patient’s gallbladder was falling apart, the surgeon placed clips on the base of what appeared to be the bottom of the cystic duct. There was a layer of purulent material between the gallbladder wall and the liver bed. A drain was placed and the liver bed was irrigated.
The defendant anesthesiologist noted the patient’s smoking history, and that the patient had no family history of anesthesia complications. He also documented an airway assessment Mallampati score of 3 and he had no concerns. After the procedure, the anesthesiologist documented that the patient was slow to wake up and had poor respiratory effort. Narcan 0.04 mg was given five times. According to the testimony of the CRNA, each Narcan dose she administered was one-tenth of what is considered a normal dose. The patient became more responsive and was extubated without difficulty. While in the PACU, the patient had one episode of O2 desaturation to 88%. The patient had no further documented apneic events while in the PACU.
Before the patient was transferred to the surgical floor, nursing documented that the patient was on 5L of O2 via NC with a sat of 94%. While in the PACU, a nurse noted the patient's statement that "my dad died of sleep apnea." There is no documentation indicating the nurse advised the defendant anesthesiologist of the patient’s statement.
After transfer to the surgical floor, the patient continued to receive supplemental oxygen via NC with O2 sats ranging from 92-94%. His Aldrete score was 9/10. There was inconsistency among the nursing staff as to whether they knew that the patient was difficult to arouse post-op and that he had a history of sleep apnea. Information about the patient’s difficulty post-op as well as his history of sleep apnea was not relayed to the co-defendant surgeon who was with the patient on the surgical unit. During the first post-op night, the patient required an increase in O2 from 4L to 6L in order to maintain saturations at 92%. The patient also received two doses of Dilaudid for pain.
Several hours later, a phlebotomist found the patient unresponsive, ashen, and without pulse or respirations. A Code Blue was activated. The patient was intubated and a pulse was restored. The patient was transferred to the ICU where he remained comatose and unresponsive to stimuli. After several days with little improvement, the family elected to withdraw life support and the patient died. Multiple physicians caring for the patient in the ICU stated that the cause of death could have been due to either cardiac asystole, sepsis, stroke, pneumonia, or a pulmonary embolus. Anoxic encephalopathy was noted on the death certificate as the immediate cause of death. No autopsy was performed.
Expert Testimony
At trial, the plaintiff’s attorneys alleged the patient had obstructive sleep apnea (OSA) which the defendant anesthesiologist failed to diagnose and treat. Plaintiff’s experts testified the plaintiff was extremely sensitive to opioids, had periods of obstruction and desaturations, had impaired lung function, and was at risk for post-op complications. They also alleged the defendant was responsible for writing an order to continue pulse oximetry monitoring when the patient was transferred to the surgical floor.
The defense countered that the only way to make a definitive diagnosis of OSA is with an overnight sleep study. The patient never had this test and did not have an OSA diagnosis. The defense stated that an anesthesiologist’s orders end when the patient is discharged from the PACU. Upon admission to the surgical floor, the attending surgeon is responsible for patient orders. The defendant anesthesiologist testified that he determined the patient was at risk for moderate to severe sleep apnea and he followed the standard of care. He also testified that if the patient was going to obstruct, it most likely would occur immediately after removal of the endotracheal tube; he stated that did not happen.
Resolution
After a nine-day trial, the jury returned a verdict in favor of the defense.
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