An 81 year old obese male presented to the hospital with abdominal pain found to be gallbladder related.

He was to undergo an ERCP followed by an immediate lap chole.

He had ankylosing spondylitis.

He was brought to the OR and intubated with the Glidescope.

Next the anesthesiologist had a conversation with the GI doc.

The anesthesiologist called the general surgeon to discuss alternative positioning.

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They proceeded with the turn.

After the audible crack the patient was flipped back supine and a cervical collar was placed.

He was woken up and brought to PACU.

There were no neuro deficits or complaints, but a CT of the cervical spine revealed a C6 fracture.

Neurosurgery brought him to the OR.

The GI physician was questioned about ERCP positioning.

The patient’s wife answered some questions about that day.

After C-spine surgery the patient suffered chronic neck pain, difficulty swallowing with weight loss, and an inability to perform ADLs.

He was put in a nursing home and continued to decline, dying 5 months after sustaining the fracture.

The anesthesiologist wrote an affidavit

A tech in the OR wrote an affidavit after she was named in depositions as being involved in turning the patient.

Outcome

The general surgeon was dropped from the case. Although he was not helpful in finding a solution in the OR, the ERCP was not his case, and he was not responsible for the positioning for it.

Motions to dismiss the GI and anesthesiologist were denied.

There was a settlement conference conducted as the case headed toward trial.

Court documents end after this conference schedule with the last document being dismissal of all parties.

This implies a settlement, but the terms were not public.

We dedicate ourselves to providing cutting edge medical care in tense situations, but often times the malpractice lawsuits we face are related to simple concepts like positioning.

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MedMalReviewer/Anesthesiologist Analysis

1. The anesthesiologist was very careful and made a genuine effort to find a solution. He was not blindsided by this neck fracture. He recognized the dangers, used the Glidescope, discussed with GI and surgery, but proceeded forward. Was there anything he could have done differently to avoid getting sued? MRCP could not be tolerated due to patient’s spinal issues (in fact, there have been lawsuits about patients suffering severe spinal cord injuries from positioning during an MRI). This GI cannot do ERCPs supine. It is unfortunate when we as anesthesiologists get forced into a corner to do a case, and we know there is liability on the line. A spine surgery consult may have offered additional medicolegal protection here, but would be an atypical consult that may have been met with disdain. Might be worth sharing this case with the specialists you work with.

2. Affidavits like the one written by the OR tech are not uncommon. I included it as a reminder that positioning is your liability and not theirs (partially due to their role and partially due to the fact that you have malpractice insurance and they don’t). When there are questions about assigning liability, suddenly they are just a tech or just a nurse, no matter how opinionated and stubborn they may actually be in real life. If you ever receive pushback about proper positioning you can be reminded of this. I hope you all work at places where your opinion is highly regarded and is the final rule. Of note, there is no evidence here the tech did anything other than turn the feet, and it is true she was not making medical decisions.

3. After the fracture the anesthesiologist spent some time with the patient explaining things, and was able to develop good rapport. He even requested the anesthesiologist do his spinal surgery. Unfortunately, this rapport doesn’t matter as much when the patient dies, because the patient is not suing, his widow is. It also doesn’t help because the plaintiff’s lawyer is the one deciding who to name as defendants, not the patient himself. Developing a good rapport probably does have some degree of protective nature, but it doesn’t make the risk zero.