Risk Management

Co-Defendant CRNA Denies Responsibility for Failed Resuscitation

OMIC ARTICLES ON ANESTHESIA LIABILITY

• This article appeared in an issue of our Digest devoted to wrongful death claims. The policy article in that issue addresses supervision of CRNAs and liability questions: https://docs.google.com/viewerng/viewer?url=http://www.omic.com/wp-content/uploads/2012/12/Digest-Summer-2012.pdf
• Another issue of the Digest analyzed ophthalmic anesthesia claims: https://docs.google.com/viewerng/viewer?url=http://www.omic.com/wp-content/uploads/2012/12/Digest-Winter-2006.pdf.
• Here are detailed risk management recommendations on ophthalmic anesthesia: http://www.omic.com/wp-content/uploads/2012/04/Anesthesia-Liability.pdf.

Ryan Bucsi, OMIC Senior Litigation Analyst 

Digest, Summer 2012

Allegation

Negligent resuscitation resulting in death of 45-year-old father of three.

Disposition

Case settled for $1,775,000 of which CRNA contributed $975,000 and OMIC insured contributed $800,000.

Case Summary

Anon-OMIC-insured ophthalmologist performed cataract surgery on a patient who subsequently developed a hemorrhage OD. The patient was then seen by the insured, who had previously treated his proliferative diabetic retinopathy and bilateral retinal detachments. The insured recommended a vitrectomy under local anesthesia at a surgery center knowing that the patient had tolerated the cataract surgery under local anesthesia. During the vitrectomy, a CRNA administered local anesthesia with IV sedation, and the insured performed a retrobulbar block OD. When the patient became agitated and complained of pain, the CRNA provided more sedation after which the patient turned pale and stopped breathing. The CRNA administered oxygen through an Ambubag but O2 saturation did not increase. The insured instructed the CRNA to intubate and 911 was called. Despite intubation, the patient’s O2 saturation did not improve. The CRNA confirmed that the tube was in the trachea but asked the surgeon to listen for breath sounds with him; both the surgeon and CRNA heard breath sounds. When the paramedics arrived, they determined that the CO2 monitor had not changed color indicating the tube was in the esophagus rather than the trachea. This prompted the CRNA to get into a shoving match with one of the paramedics. The paramedic re-intubated the patient and O2 saturations began to go up. The patient was transferred to the hospital where he died eight days later.

Analysis

The plaintiff’s anesthesiology expert had many criticisms of the insured ophthalmologist. He testified that surgery should not have been performed since the plaintiff had low blood sugar and high blood pressure on the morning of surgery. It was this expert’s opinion that, given the patient’s medical condition, general anesthesia should have been used, but if local anesthesia was used, the surgery should have been performed in a hospital or facility where an MD anesthesiologist was available. Since this surgery center did not have an MD anesthesiologist, the expert pointed to the ophthalmologist as the “captain of the ship.” The expert testified that the CRNA did not intubate the patient properly and the insured did not diagnose improper esophageal intubation.

The defense expert disagreed with these opinions and the role of a surgeon in anesthesia care. He insisted that the anesthesia provider is responsible for monitoring the patient during surgery. He testified that the CRNA failed to monitor and communicate a low oxygen level to the insured prior to the patient’s arrest, thus leading to a delay in resuscitation. Unfortunately, the defense expert was not comfortable rendering an opinion on the standard of care related to the decision to perform surgery. The co-defendant CRNA testified at his deposition that he was responsible for providing anesthesia to the patient, but that the insured was the “captain of the ship.” The CRNA admitted that he had not performed an intubation in the five years preceding this case and that he never discussed the risks and complications of anesthesia with the patient because he did not want to scare him. However, he maintained that the intubation was properly done and that the paramedic dislodged the tube. It was defense counsel’s opinion that a jury would award the plaintiff $2.8 to $4 million and hold the OMIC insured 25% to 50% liable. The CRNA settled first for $975,000, and the OMIC insured settled later at mediation for $800,000.

Risk Management Principles

For the OMIC insured, this could be viewed as a case of being in the wrong place at the wrong time. The procedure was performed in a surgery center with a CRNA who allegedly did not properly intubate the patient leading to a prolonged period without oxygen and eventual death. There are several steps insureds can take to minimize the risk of an improper resuscitation in a surgery center. First, find out if there is a peer review process in place to review the competency of CRNAs and anesthesiologists. Inquire about the emergency response measures in place and whether there is anyone else available within the surgery center to assist with resuscitations. Lastly, call 911 immediately when a potentially life-threatening situation arises.