A 23-year-old man was attempting to extinguish a grease fire in his home.
He suffered 2nd and 3rd degree burns to 50% of his body.
In the ED he was unable to speak secondary to pain. He had singed facial hair and soot in his oropharynx.
The patient was intubated for airway protection and brought to the burn unit.
One week into his hospital course the vent high pressure alarm went off in the ICU.
The RN heard the alarm and paged the ICU NP to come investigate.
Learn from malpractice cases.
Paying subscribers get a new case every week.
The NP came to investigate.
The patient then began to desat and the RN is ambubagging as anesthesia is called.
The CRNA arrives first and puts a Glidescope in the patient’s mouth to look at the ETT to confirm placement.
The anesthesiologist arrives soon after.
The patient lost pulses and CPR was started.
More code team arrives and chest tubes are placed without a change in condition.
The anesthesiologist also looked on the Glidescope with the trauma surgeon, but the airway was bloody and swollen and the tube position not entirely clear.
The trauma surgeon performed a cric.
However, during placement of the cric the ETT was visualized and had to be withdrawn.
The patient did not survive.
The family sued.
A defense expert was hired for anesthesiology.
Outcome
In a motion for summary judgment the anesthesiologist and surgeon were dismissed from the case.
Become a better anesthesiologist and improve your practice.
Join thousands of anesthesiologists on the email list.
The medical center settled with the family in an annuity structure.
The hospital wished to seal the settlement terms to maintain confidentiality.
The settlement figures are unknown.
MedMalReviewer/Anesthesiologist Opinion
The ETT was visualized in the trachea during the cric and had to be withdrawn for successful placement of the cric tube. There was positive ETCO2 after the cric was done, so why couldn’t this patent be ventilated with the ETT? I read this case thinking a fiberoptic scope may have had some utility to assess tube positioning, but it sounds like it was always endotracheal. The expert thinks this was acute bronchospasm caused by ETT suctioning in this obese and sick man. The defense expert also notes 2 previous episodes of mucous plugging leading to desaturations. It’s possible this was an obstructed tube completely saturated with mucous and secretions, but the condition of the tube was not commented on in the records or depositions.
The motion to seal the settlement documents was denied which is why I could access them at all, but the figures on them were still censored out. I assume this was a large sum based on the medical center’s desire to hide the values. It takes a large value to hit the media and make non-medical persons interested in the outcome. Those extreme figures are usually jury verdicts. The lawyers are protecting the reputation of the institution, and it is low stakes to attempt a motion to seal the documents.
This obese man with anasarca who is one week out from a 50% burn injury was not going to be an easy tube troubleshoot. At presentation the trauma surgeon gave him a 50% chance of predictive mortality based on his initial injuries. Burn patients are notoriously challenging and should be treated with respect.
