A male infant at 39w gestation was born via Cesarean and admitted to the NICU with transient tachypnea of the newborn.

He was discharged home after 7 days.

At 24d of age he came to the ED with fevers and increased work of breathing.

He was admitted for workup and tested positive for RSV, diagnosed with bronchiolitis.

He required CPAP on the floor, but with further respiratory distress he was put on BiPAP and transferred to the PICU for closer monitoring.

The nurse attempted to insert an ND tube for feeds.

3 hours later he had worsening tachypnea and hypercapnia.

The ICU team decided to intubate.

The PICU attending had the fellow attempt first.

The pediatric anesthesia fellow Dr. W arrived to assist.

Dr. W performed DLx1 with a grade I view and passed a 4.0 without difficulty.

No ETCO2 seen.

Epi was given peripherally for presumed bronchospasm.

No improvement seen.

There was continued difficulty oxygenating and ventilating the patient.

The child began to brady and a pulse was lost, compressions were started.

Needle decompressions were done bilaterally.

There was some success on the right and ETCO2 was seen.

Surgery arrived and noted subcutaneous emphysema.

They placed bilateral chest tubes and the child stabilized.

The peds anesthesia fellow Dr. W wrote the following documentation.

The code had lasted around 30 minutes and oxygenation was poor throughout.

The child suffered a permanent hypoxic injury and requires lifelong care.

Become a better anesthesiologist and learn to defend yourself.

Paying subscribers get a new case every week!

The parents initiated a lawsuit.

Here are some excerpts from the plaintiff’s pediatric ICU expert:

The defense hired a pediatric ICU physician to write an expert opinion as well.

It is attached below for anyone interested in further reading.

Outcome

The defense submitted a motion for summary judgment.

They succeeded in dismissing only a small portion of the claims.

The hospital paid a settlement. The total value was for $10,772,727.27.

However, around half this value went to a state program called the medical indemnity fund.

The lawyers then collect their fee, liens need to be paid, and the infant’s mother gets some cash.

In the end the child has a trust worth $4,352,545.32 and is admitted into this medical indemnity fund which will help pay for future health care costs.

Join thousands of anesthesiologists on the email list.

CME plans are also available for those who want to receive credit.

MedMalReviewer/Anesthesiologist Opinion

1. Diagnosing a pneumothorax can theoretically be straightforward, but cannot always be an immediate diagnosis. It is challenging to walk into a situation with little knowledge of the patient and quickly arrive at the answer. I will agree with the plaintiff’s expert though that the differential for this kind of situation is not vast. It sounds like there was some tunnel vision here. The patient was intubated 6 times likely all in the trachea. The code was documented as lasting 33 minutes. I’ll keep this case as a reminder to avoid that tunnel vision and continue to explore differentials.

2. I’ll cut the team some slack, as there wasn’t an obvious cause of tension pneumothorax. Do you think the ND tube was responsible? Was it inserted into the trachea and down into the lungs? Based on the placement note from the RN citing spasmodic coughing, tachycardia, distress, it sounds quite possible. So did the ND tube perforate this baby’s young and inflamed lungs? Did the positive pressure from bipap turn this into a tension pneumo? The first intubation was successful with ETCO2 that then vanished as direct positive pressure likely worsened the developing pneumothorax. It would be challenging to put all those pieces together during a code even if you were aware of the ND tube history.

3. This case happened at a fancy teaching hospital. I’ve heard comments before that suggest ivory tower hospitals have medicolegal protection because of their name. Anyone can be sued for anything. There is no protection from a fancy name. The protection here for the physicians comes down to the hospital employing them, as we have discussed before. This is not a guaranteed shield, but a layer of potential protection. All 3 docs who were the PICU attending, PICU fellow, and peds anesthesia fellow were dismissed. They have no marks against them and were not responsible for any of the settlement. The hospital pays. As we have also seen before if this was a private anesthesia or peds group, the hospital would be attempting to separate themselves as much as possible. We have seen other hospitals claim they are not responsible for the actions of private physicians.

4. The medical indemnity fund will come up again in future cases, but briefly it is a state fund that exists to help with healthcare costs from those who have suffered birth-related neurological injuries, specifically as a result of medical malpractice. Seven states have this fund or an equivalent (patient compensation fund) with some differences between them. In New York, this fund is specifically for birth-related neurological injuries. Individuals must be plaintiffs to qualify. I was actually surprised this baby qualified as this medical malpractice action was not birth related. Health care costs can be submitted as they come up in the child’s life and this fund will help pay for them.