A 31-year-old male underwent a left elbow tendon repair to fix a work related injury.

Pre-operatively he received a supraclavicular nerve block.

Total sedation given was Versed 6mg and fentanyl 100mcg in divided doses.

The block was performed under both neurostimulation and ultrasound guidance.

20ml of 0.25% bupivacaine and 20ml of 0.5% ropivacaine were injected incrementally with frequent aspiration.

Per the chart there was no elicitation of sharp pain or paresthesia during the block.

Post operatively he suffered a claw hand deformity.

He received an EMG.

He sued the anesthesiologist, CRNA, anesthesia group, and hospital. The surgeon was not named.

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The case proceeded to a trial.

Only the anesthesiologist and anesthesia group remained on the lawsuit.

The anesthesiologist took the stand in a cross examination.

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Outcome

MedMalReviewer/Anesthesiologist Analysis

1. Direct examination is the first questioning for a witness. As a defendant you will be asked questions that will support your case. These will typically be open ended and allow a narrative to build. The goal is to establish credibility and build your story. Direct examination is followed by cross examination where the plaintiff’s attorney will ask questions. These are often yes/no questions, and are designed to steer the conversation in a specific way. This will be a nerve-wracking experience for any defendant. I did crop out some of the beginning of the cross for the sake of length. There were pages and pages spent talking about the time displayed on the ultrasound machine pictures and how it did not match other documentation. Overall this is a good example of what a cross-examination looks like should you find yourself on the stand at trial.

2. Using nerve stim the anesthesiologist elicited biceps/triceps twitch, but the injury was localized to the medial cord- even ulnar nerve specifically per EMG. Those two findings are at odds with one another. That said, a total of 40ml were injected so I am sure the needle moved around quite a bit to get all that volume in. The volume amount was not primarily criticized here though, but instead the depth of sedation was the focus.

    

   

3. This is not the first case I have seen where a larger sedation amount is required for a patient and there is an injury. Proceed with caution should you find yourself giving increasing doses. This previous case dealt with a femoral nerve block, and the argument surrounding the case was the level of consciousness at the time of the block.

4. The plaintiffs appealed the verdict arguing the law doctrine res ipsa loquitur.

Res ipsa loquitur meaning “the thing speaks for itself.” It has a lower burden of proof. Look at his claw hand, what else could it be? One element of this doctrine is there can be no contribution from the part of the plaintiff. The defendants argued that the patient both injured his elbow, and it was operated on, so there were multiple contributions from other parties…as is often the case in med mal. The appeal was denied and the original verdict upheld.