A 1d old male infant was found to have a systolic ejection murmur at the left lower sternal base.

An echocardiogram and MR angiogram were performed. The baby had dysplasia of the aortic valve with aortic stenosis, pulmonary artery stenosis, a moderate PDA, and a PFO.

At 6mo of age he underwent a cardiac cath and was then scheduled for surgery.

For that cath he was given remi, but could only tolerate a small amount of sevo, needing a phenylephrine drip.

The patient came for open surgery.

IV access was attempted but not successful.

IM ketamine/atropine were given followed by an inhalational induction, IV access, and intubation.

At this time ST elevations were noted in lead I with a drop in ETCO2 and no discernible blood pressure.

Compressions were started and the surgeon summoned to the room.

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The surgeon placed a femoral A-line.

He rapidly opened the chest and put the patient on bypass.

The op note described massage of the pericardium while bypass was being started.

The operation continued:

However, after establishing a rhythm they could not come off CPB due to poor ventricular function.

The patient was put on ECMO, but the venous side was collapsing and the circuit could not flow.

He was put back on CPB and a second attempt was made on ECMO, but still without adequate flow.

It was determined the baby would not survive. He was decannulated and pronounced dead.

His parents sued the hospital, surgeon, anesthesiologist, and anesthesiology resident.

Here is an excerpt from the plaintiff’s anesthesiology expert:

The following is an excerpt from the defense:

Outcome

The judge had this to say about the plaintiff’s expert opinion

Due to these inconsistencies the case was dismissed.

The judge also commented on the anesthesia resident, specifically that there was no evidence he departed from following orders.

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MedMalReviewer/Anesthesiologist Analysis

1. The plaintiff’s anesthesiology expert was an attending who was a few years out of residency. He had not completed a pediatric cardiac anesthesia fellowship, and he had not even completed a pediatric fellowship. If this case were to have progressed further his credentials would certainly be called into question and risk the viability of this case. I could not imagine writing that opinion criticizing someone with so much more specialized training in a very niche field I had limited exposure to. Unfortunately the monetary incentives in the medicolegal field can promote this type of brazenness.

2. I do think it can be challenging for lawyers to find experts in highly specialized and niche fields. There are only a few hundred pediatric cardiac surgeons in the US. Who among these is going to write an opinion bashing a colleague for his decisions? A colleague seen at annual meetings, someone whose papers you have read, or called to ask about a candidate. While anyone can be sued, when the work is highly specialized- there may be some degree of medicolegal protection.

3. I’ve yet to see a resident not be dismissed or be responsible for a settlement or verdict. However, this may not occur for several years after the lawsuit is filed which can cause undue stress to a trainee. When they are eventually dismissed the language used is often that they followed orders and were under someone else’s license and decision making. I do have an upcoming case where the anesthesiologist was dismissed but the CRNA was not and we will explore how that occurred.