An anesthesiologist and CRNA were covering in-house call for both the general OR and L&D at a community hospital.

A laboring 24-year-old woman at 37 weeks was having concerning fetal monitor tracings.

The OB let the anesthesiologist know his services may be needed at some point soon, but he had not yet decided whether she was ready for an epidural or if she would need a C-section.

At this time there was also an emergent cysto stent case booked for the OR.

The anesthesiologist would later claim that the OB told him it was fine to start this case if needed. The OB disputed this.

By all accounts the cysto patient was critically ill, obtunded, and had numerous comorbidities.

The anesthesiologist and CRNA induced the cysto case shortly after the conversation with the OB.

The anesthesiologist sent a courtesy message to his backup call who was home, letting her know there was a chance she would need to come in.

At the same time the anesthesiologist and CRNA were starting the cysto case, the OB decided it was time for an epidural.

Multiple pages were placed to the anesthesiologist.

It took the anesthesiologist about 15 minutes to start the cysto case and head back to L&D.

Meanwhile, back on L&D, there was trouble getting a fetal heart rate.

A few minutes after the anesthesiologist arrived back to L&D, the OB placed an FSE which revealed a FHR of 60bpm.

A stat C-section was called and the anesthesiologist officially called in his backup.

As the patient was wheeled back to the OR, the anesthesiologist refused to participate in her care until his backup arrived to the hospital.

He cited a “federal rule” that he must be immediately available to the CRNA (who was still with the cysto patient in an OR on a different floor of the hospital), and claimed his licensure was at risk should he participate in the section.

The anesthesiologist was standing in L&D, but felt that he could not start the OB case until he received confirmation that the backup had made it to the hospital and was headed to the cysto case.

There was further discussion between the anesthesiologist and OB.

With the anesthesiologist refusing to start the case, the OB asks for local anesthetic.

The patient, of course, refuses.

The team continues to wait for 2nd call to arrive as the patient attempts to push in the OR, with the anesthesiologist standing only a few feet away.

About 20 minutes later, the anesthesiologist receives notification that his backup had arrived to the hospital.

He immediately administers GA and the baby is delivered.

The Apgar scores are shown below.

The baby required intubation and was brought to the NICU.

He had suffered hypoxic ischemic encephalopathy.

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Four years later, a pediatric neurologist would write this note about his condition.

The mother had a placental abruption and subsequently developed DIC.

After her initial C-section she required re-exploration that night for continued vaginal bleeding which resulted in a hysterectomy.

She needed multiple transfusions, and went on to develop TRALI and ARDS.

This ultimately led to transfer for VV ECMO.

After a 2 month hospitalization she was discharged.

At his deposition, the anesthesiologist was asked more about his refusal to start the C-section.

The plaintiffs hired an expert anesthesiologist who gave the following opinion

There is an expert anesthesia opinion from the defense which is quite long, so I have attached it here for anyone who wants to read further details.

Outcome

The anesthesiologist was given an ultimatum by his group to resign or be terminated.

He resigned soon after this incident.

The hospital reported the anesthesiologist to the national practitioner database for delays in care. At the time of his deposition he was suing the hospital for this mark against him.

The case was settled before trial.

The total settlement value was $4,593,179.54. 

The anesthesiologist and his group were responsible for $1.3 million.

The OB was responsible for $1.3 million.

Additionally, the court mandated that their malpractice insurance purchase 3 separate annuities that would pay the child a total of ~$5300/month for life. If he dies before 25 years of payments have been made, the payments will continue for a total of 25 years.

The total cost of these annuities was $1,868,204.55.

The court also ruled that the anesthesiologist had to pay part of the plaintiff’s attorney fees, reimburse Medicaid for the expenses incurred for the child’s care, and give the mother additional funds in a checking account. This added another $124,974.98 to the total.

MedMal Reviewer Analysis

1. I’ve never liked this sort of practice in which one team is covering two locations, both with the potential for emergencies. This is in addition to any floor or ED airway needs. What ends up happening is that the rules in regards to “immediate availability” need to get bent sometimes to make it work. Unfortunately this anesthesiologist didn’t understand during emergencies there can be this unwritten expectation, and he instead stuck to his own rigid interpretation of supervising rules. There is a risk you may have to take if you work in this practice model. With the benefit of hindsight, the biggest liability in that moment was on OB, not the cysto stent already underway. It can be difficult to weigh the pros/cons in the heat of the moment, but in my opinion there is obviously a much higher risk of a catastrophic outcome from the emergency section than there is a cysto stent that is already being managed by a CRNA. This is especially true from a legal perspective when considering that bad outcomes involving young mothers and severely disabled neonates result in far bigger settlements/verdicts than elderly cysto patients who are already critically ill.

2. The plaintiff’s expert criticized the decision to even start the cysto stent at all. Perhaps the anesthesiologist could have waited a short while to start the case and see what developed on OB. However, a similar situation could also arise in a completely unexpected fashion, without any pre-warning as happened in this case. There’s no way to predict the future and definitively know if/when a crash section is going to be called. You can’t hold up the OR all night for a “maybe” situation. Are you going to call in backup to sit on OB for a possible section while you supervise a cysto stent? This is what the expert is suggesting should have happened.

3. This anesthesiologist was about 5 years out of training. I suspect he really thought he was doing the correct thing. It’s unfortunate he was so concerned with his license (due to his arguably incorrect understanding of supervision rules), only for this incident to occur, and him be reported to the NPDB for delays in care. Ideally none of us would ever be in a circumstance in which we have to bend rules, but there are instances in which you have to do right by the patient.

4. Looking at this from the OB perspective, it’s hard to know what the obstetrician should have done. He gave the anesthesiologist a warning about a section, then called the emergent section. It seems that there may have been some miscommunication between the OB and anesthesiologist as to the expected urgency. Miscommunication is a common theme in malpractice cases. The OB tried everything to get the case started. In the end he was still sued for (and settled) an adverse outcome that he desperately tried to prevent.

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