A 46-year-old woman was booked for a robotic assisted laparoscopic hysterectomy for a fibroid uterus.

She had a history of HTN, HLD, and anemia (hct 34.6%).

She was brought to the OR at 10:02AM and was extubated at 3:41PM, drowsy with a nasal airway in place.

The anesthesiologist (Dr. P) discussed with surgery that she was more somnolent than expected and should plan to stay overnight.

Dr. P then left and let the anesthesia resident and surgery resident bring her to PACU.

Dr. P also asked the PACU resident to check on her.

Unknown to him the residents unfortunately brought her to the wrong PACU site and arrived at outpatient recovery at 4:08PM.

Head CT showed a left ICA and left M1 occlusion, now almost 8 hours from last known normal.

The following morning there was concern for brain swelling and the patient underwent a hemicraniectomy.

A full stroke workup found a focal thrombus within the aortic arch.

Some family history was discovered that was not previously known.

The patient’s mother died of a stroke at age 50 and her sister died of a stroke at age 30.

The patient went to rehab where she suffered another stroke.

She died soon after, leaving behind her 15-year-old son.

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The anesthesiology and surgery teams were sued.

The hospital was sued, and the maker of the surgical robot was sued.

An anesthesiology expert opinion was written for the plaintiff:

Here is an excerpt from the plaintiff’s OB/Gyn expert:

The plaintiff’s heme/onc expert wrote the following:

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The plaintiff’s neurology expert wrote this:

The judge denied motions for summary judgment from the ob/gyn, anesthesiologist, and hospital.

Outcome

All residents and fellows were dismissed from the case.

The hospital and robot surgical system settled. This dismissed the anesthesiologist as well.

The ob/gyn was alone on the caption now.

Time went by and the case settled only days before the trial was set to start.

After settlements, the law firm wrote to the judge saying they worked on this case for 12 years and they deserve even more money.

They wanted to increase their legal fee, and argued they are entitled to another $250,000+

The judge agreed.

MedMalReviewer/Anesthesiologist Opinion

1. It was really unfortunate this patient was brought to the wrong PACU site by the residents. This delayed care by 45 minutes and could have been longer were it not for the vigilant PACU resident. That said the patient was well out of the tPA window for thrombolysis whether they were brought to the wrong PACU or not. They would also miss the early window for mechanical thrombectomy of 6 hours no matter which PACU they were brought to, but remain in an extended window time. It was still sloppy, a bad look, and provided low hanging fruit for the expert to criticize the physicians and make it appear they don’t know what they were doing. I do have doubts it would have significantly changed the outcome, but it certainly weakened the defense’s case.

2. I’m surprised nothing of the family history was brought up prior to this operation. Two close family members with strokes at ages 30 and 50 is significant. That family history would certainly give me some pause. The plaintiff’s heme/onc expert wants to blame it on thrombocytosis with a platelet count of 470. This family clearly has something genetic that predisposes to strokes that is beyond a mild thrombocytosis. Ideally this could have been picked up at preadmissions testing or a primary visit.

3. The robot surgical system had been around before this case but was really starting to ramp up around this time. I had not previously seen them as part of a settlement although their contribution was small ($10,000). It’s no news to any of us that for many surgeries the robot adds delays and frustration. As the claims against the Ob/gyn point toward prolonged Trendelenburg and prolonged case time I can see how this ‘newish’ technology could be implicated in contributing to those claims. It’s a small settlement for them to pay to make this go away.

4. I can’t even be mad at the lawyers for arguing for more money for themselves. Honestly good for them trying to get paid what they think they are worth, although it seems a bit perverse when you realize they are taking it away from the dead patient’s children. They argued they took the case on contingency, but that is their business model and they knew the risks going into it. We physicians could learn a thing or two about advocating for ourselves and making sure the paycheck matches the work. I do wonder what that conversation was like with their client when they told him they wanted a higher legal fee from him and how he went along with it. He must have been happy with the work. After all, they did secure him $3million+ in settlements.