18 year old QB in Georgia dies following "routine" shoulder surgery

[BLADEMDA]

It’s so odd that I’m accused of anchoring when my first post started with “pretty wide differential” and the other side of the argument is focused on a single possible cause but I tried to explain as best I can. To suggest that Tylenol pre-op and then post-op is how you can explain the timing is definitely reaching. For all we know, he was a fulminant Wilson’s patient and it had nothing to do with his surgery.

Wilson's disease, an autosomal recessive disorder of copper metabolism, is the most common inherited hepatic disease in Hong Kong. Diagnosis is based on the presence of Kayser-Fleischer rings, typical neurological symptoms, and/or a low serum ceruloplasmin concentration (<0.20 g/L). Early detection and treatment protect patients and their presymptomatic siblings from devastating organ damage. The diagnosis of Wilson's disease may nonetheless be overlooked if only established clinical and laboratory tests are used as diagnostic criteria. We report diagnosis of the disorder using genetic analysis of ATP7B in a presymptomatic sibling who escaped diagnosis during family screening 18 years previously. The patient was 11 months old when family screening was performed following diagnosis of Wilson's disease in an elder sister. The boy was considered to be unaffected on the basis of laboratory results in the expected range: serum copper level, 4.6 micromol/L; serum ceruloplasmin level, 0.16 g/L; and 24-hour urinary copper excretion, 0.14 micromol/day. Molecular analysis of ATP7B was performed; it revealed that the two siblings shared the same compound heterozygous mutations (G943D and 2299delC). We recommend that molecular diagnosis is the only definitive means of diagnosing Wilson's disease in children younger than 1 year.

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[BLADEMDA]

It’s so odd that I’m accused of anchoring when my first post started with “pretty wide differential” and the other side of the argument is focused on a single possible cause but I tried to explain as best I can. To suggest that Tylenol pre-op and then post-op is how you can explain the timing is definitely reaching. For all we know, he was a fulminant Wilson’s patient and it had nothing to do with his surgery.

The family needs an answer: Why did he die? Is it genetic? rare reaction to Sevoflurane? If they have other children the answer can mean life or death.

 

[chessknt]

It’s so odd that I’m accused of anchoring when my first post started with “pretty wide differential” and the other side of the argument is focused on a single possible cause but I tried to explain as best I can. To suggest that Tylenol pre-op and then post-op is how you can explain the timing is definitely reaching. For all we know, he was a fulminant Wilson’s patient and it had nothing to do with his surgery.

Do you think the single exposure dili time course synchs up perfectly here? Isn’t the time course for cephalosporin dili usually on the order of weeks not days? That’s what’s happened when I’ve seen it in the icu at least.

The dismissal of Tylenol and fixation with dili was what I read. Obviously differential is wide open to start but I think Wilson’s disease is pretty much off the list along with hemochromatosis yes?

 

[Gastrapathy]

I don’t think I’ve seen ALF from a cephalosporin. There are only 2000 cases of ALF in the US per year. Unintentional APAP overdose and idiosyncratic DILI have similar frequencies for diagnosis but the APAP patients have a much better survival. The odds of idiosyncratic DILI are higher because he died. We don’t know what he got and antibiotics are only the putative drug in ~45% of idiosyncratic cases (still the largest category). DILI leading to liver failure is most often subacute as you say but it can happen in 48 hours and it’s not dose related. For Tylenol to do it in 48 hours and be too late to save with NAC really requires a huge handful on POD1. So it’s definitely possible. All I said was it was less likely.

Anyway the DDx is very broad. Acute viral ( including HSV), AIH, DILI, clot (Budd-Chiari), ischemic, acute Wilson’s, I’m sure I’m forgetting something but one of the fellows who just took boards can remind me.

And, of course, the possibility that it wasn’t liver at all and he was in DIC.

 

[WheezyBaby]

I don’t think I’ve seen ALF from a cephalosporin. There are only 2000 cases of ALF in the US per year. Unintentional APAP overdose and idiosyncratic DILI have similar frequencies for diagnosis but the APAP patients have a much better survival. The odds of idiosyncratic DILI are higher because he died. We don’t know what he got and antibiotics are only the putative drug in ~45% of idiosyncratic cases (still the largest category). DILI leading to liver failure is most often subacute as you say but it can happen in 48 hours and it’s not dose related. For Tylenol to do it in 48 hours and be too late to save with NAC really requires a huge handful on POD1. So it’s definitely possible. All I said was it was less likely.

Anyway the DDx is very broad. Acute viral ( including HSV), AIH, DILI, clot (Budd-Chiari), ischemic, acute Wilson’s, I’m sure I’m forgetting something but one of the fellows who just took boards can remind me.

And, of course, the possibility that it wasn’t liver at all and he was in DIC.

Have you seen a previously young / healthy liver present with true ALF due to subacute APAP OD? I've only seen it happen with a vulnerable liver, otherwise has been massive acute overdoses

 

[deleted875186]

I don’t think I’ve seen ALF from a cephalosporin. There are only 2000 cases of ALF in the US per year. Unintentional APAP overdose and idiosyncratic DILI have similar frequencies for diagnosis but the APAP patients have a much better survival. The odds of idiosyncratic DILI are higher because he died. We don’t know what he got and antibiotics are only the putative drug in ~45% of idiosyncratic cases (still the largest category). DILI leading to liver failure is most often subacute as you say but it can happen in 48 hours and it’s not dose related. For Tylenol to do it in 48 hours and be too late to save with NAC really requires a huge handful on POD1. So it’s definitely possible. All I said was it was less likely.

Anyway the DDx is very broad. Acute viral ( including HSV), AIH, DILI, clot (Budd-Chiari), ischemic, acute Wilson’s, I’m sure I’m forgetting something but one of the fellows who just took boards can remind me.

And, of course, the possibility that it wasn’t liver at all and he was in DIC.

I would also add herbal and nutritional supplements as a cause of liver failure, especially in an athlete. I actually think this may be more likely.

 

[DocMcCoy]

I would also add herbal and nutritional supplements as a cause of liver failure, especially in an athlete. I actually think this may be more likely.

Tylenol and PEDs are a nasty combo for the liver.

 

[lobelsteve]

Liver involvement in urea cycle disorders: a review of the literature - PubMed

Urea cycle disorders (UCDs) are inborn errors of metabolism of the nitrogen detoxification pathway and encompass six principal enzymatic deficiencies. The aging of UCD patients leads to a better knowledge of the long-term natural history of the condition and to the reporting of previously...

pubmed.ncbi.nlm.nih.gov

With no facts provided, nothing but hearsay:

You guys talk a lot of smack about a kid you do not know. It is an internal reflection of yourself and your experience dealing with lousy people who pollute your trauma bays. Try and see this if it was your son and then come up with an answer.

 

[Mman]

You guys talk a lot of smack about a kid you do not know. It is an internal reflection of yourself and your experience dealing with lousy people who pollute your trauma bays. Try and see this if it was your son and then come up with an answer.

are you being sarcastic? This thread is full of people guessing why a seemingly healthy kid died. Certainly no "smack" talked about him.

 

[pgg]

Liver involvement in urea cycle disorders: a review of the literature - PubMed

Urea cycle disorders (UCDs) are inborn errors of metabolism of the nitrogen detoxification pathway and encompass six principal enzymatic deficiencies. The aging of UCD patients leads to a better knowledge of the long-term natural history of the condition and to the reporting of previously...

pubmed.ncbi.nlm.nih.gov

With no facts provided, nothing but hearsay:

You guys talk a lot of smack about a kid you do not know. It is an internal reflection of yourself and your experience dealing with lousy people who pollute your trauma bays. Try and see this if it was your son and then come up with an answer.

If you could quote the post you're responding to that context would help.

 

[coffeebythelake]

Liver involvement in urea cycle disorders: a review of the literature - PubMed

Urea cycle disorders (UCDs) are inborn errors of metabolism of the nitrogen detoxification pathway and encompass six principal enzymatic deficiencies. The aging of UCD patients leads to a better knowledge of the long-term natural history of the condition and to the reporting of previously...

pubmed.ncbi.nlm.nih.gov

With no facts provided, nothing but hearsay:

You guys talk a lot of smack about a kid you do not know. It is an internal reflection of yourself and your experience dealing with lousy people who pollute your trauma bays. Try and see this if it was your son and then come up with an answer.

What are you talking about? This was a tragic death, and just like you we are trying to make sense of what could have happened given limited information. Although some people were quick to blame it on an anesthetic, many of us think jt is less likely if he was discharged from the hospital in good condition and later got sick and succumbed. I do not see even one post where we " talked smack" about the kid, and it is damned offensive that you accuse any of us of this.

 

[deleted875186]

What are you talking about? This was a tragic death, and just like you we are trying to make sense of what could have happened given limited information. Although some people were quick to blame it on an anesthetic, many of us think jt is less likely if he was discharged from the hospital in good condition and later got sick and succumbed. I do not see even one post where we talked smack about the kid.

Yes, liver failure from modern volatile anesthetics is exceedingly uncommon, as in only case reports, and difficult to even determine causality. I agree that saying “death from anesthesia” with liver failure is a disservice, it’s not even attempting to figure out what happened.

To the defense of some of the posters above, statistically acetaminophen overdose as mentioned above is statistically still the most common.

 

[GassYous]

Liver involvement in urea cycle disorders: a review of the literature - PubMed

Urea cycle disorders (UCDs) are inborn errors of metabolism of the nitrogen detoxification pathway and encompass six principal enzymatic deficiencies. The aging of UCD patients leads to a better knowledge of the long-term natural history of the condition and to the reporting of previously...

pubmed.ncbi.nlm.nih.gov

With no facts provided, nothing but hearsay:

You guys talk a lot of smack about a kid you do not know. It is an internal reflection of yourself and your experience dealing with lousy people who pollute your trauma bays. Try and see this if it was your son and then come up with an answer.

I looked through the thread again and the only one talking smack is you. Out of nowhere. Who's the lousy person here?

 

[anaesthetic]

With no facts provided, nothing but hearsay:

You guys talk a lot of smack about a kid you do not know. It is an internal reflection of yourself and your experience dealing with lousy people who pollute your trauma bays. Try and see this if it was your son and then come up with an answer.

Whoa, buddy. The trauma patients who “pollute” our ORs are already intubated half the time and are on their way to being prop-sux-tube’d the other half. Who really needs the self-reflection?

If it was my son and I had no answers but there were suggestions about anesthesia being the root cause, I’d probably want some, idk, unbiased anesthesiologists who are not me to weigh in on the matter, but that’s just me doing some internal reflecting.

 

[IMGASMD]

I am not going to re-read the thread. If I had to guess, he probably meant the over limit Percocet and/or alcohol usage.

Like everyone else is saying. I don’t think there was any bad intentions in speculating.

Part of the differentials.

 

[lobelsteve]

I am not going to re-read the thread. If I had to guess, he probably meant the over limit Percocet and/or alcohol usage.

Like everyone else is saying. I don’t think there was any bad intentions in speculating.

Part of the differentials.

This. You know kids that drink and do drugs. Hopefully not your kid. He was with his family in Florida. Not hanging with a bunch of dudes at a beach house.

If patient makes it out of the PACU, it ain't anesthesia's fault.

 

[GassYous]

This. You know kids that drink and do drugs. Hopefully not your kid. He was with his family in Florida. Not hanging with a bunch of dudes at a beach house.

If patient makes it out of the PACU, it ain't anesthesia's fault.

???
So he can't be taking percocets or drinking alcohol? What?
And the implication that tylenol or etoh could have contributed to liver failure is offensive how?

"Yeah I won't consider ectopic pregnancy in this female patient with abdominal pain because she is 15 years old and when I consider my own daughter I wouldn't want her to be pregnant so..."

 

[nimbus]

What are you talking about? This was a tragic death, and just like you we are trying to make sense of what could have happened given limited information. Although some people were quick to blame it on an anesthetic, many of us think jt is less likely if he was discharged from the hospital in good condition and later got sick and succumbed. I do not see even one post where we " talked smack" about the kid, and it is damned offensive that you accuse any of us of this.

Anesthesia was implicated because the initial public statements from the family said it was anesthesia related.

 

[chessknt]

This. You know kids that drink and do drugs. Hopefully not your kid. He was with his family in Florida. Not hanging with a bunch of dudes at a beach house.

If patient makes it out of the PACU, it ain't anesthesia's fault.

Taking Percocet prescribed after surgery isn’t ‘doing drugs’ and a teenager not following medication directions is basically what is expected not throwing shade. Lay people don’t think Tylenol is that dangerous and people don’t even know that Percocet contains it if they aren’t using opiates regularly.

 

[coffeebythelake]

Anesthesia was implicated because the initial public statements from the family said it was anesthesia related.

Probably what the surgeon told the family...

 

[nimbus]

Probably what the surgeon told the family...

Well it’s unlikely the shoulder repair killed him unless he stuck a trochar through the subclavian or something.

 

[coffeebythelake]

Well it’s unlikely the shoulder repair killed him unless he stuck a trochar through the subclavian or something.

Not saying it was a surgical complication, unless the surgeon gave him incorrect instructions for acetaminophen use leading to massive overdose.
Most bad things relating to anesthesia would have presented itself pretty quickly, not a couple days later.
For a surgeon to equate a non-surgical complication as meaning it must be an anesthetic complication is dubious, at best.
(hopefully that wasn't what actually happened here)

 

[DocMcCoy]

Georgia HS quarterback did not die from complications after surgery, dad says

The father of the standout high school quarterback in Georgia who died earlier this month said at his son's funeral Tuesday that early reports linking his son's death to complications after a routine surgery were not true.

www.foxnews.com

So dad said not anesthesia. And no autopsy?

 

[WheezyBaby]

Georgia HS quarterback did not die from complications after surgery, dad says

The father of the standout high school quarterback in Georgia who died earlier this month said at his son's funeral Tuesday that early reports linking his son's death to complications after a routine surgery were not true.

www.foxnews.com

So dad said not anesthesia. And no autopsy?

Nothing unusual about the lack of autopsy imo. Some families just want to move on

 

[nimbus]

Nothing unusual about the lack of autopsy imo. Some families just want to move on

Yep….autopsy won’t bring him back😥

 

[Ronin786]

In my experience autopsies rarely show the cause of death when it was so ambiguous in the first place. Particularly when you consider the amount of damage being in the ICU does to the human body.

 

[Blockit]

Depending on state laws involved I would speculate that he definitely was a medical examiner case. And in many states, the only way that a medical examiner would decline to investigate further is if the cause and manner of death is not in question.

 

[chessknt]

Depending on state laws involved I would speculate that he definitely was a medical examiner case. And in many states, the only way that a medical examiner would decline to investigate further is if the cause and manner of death is not in question.

ME cases are typically only for admits <24 hours or if there was violent trauma. Unknown failure of organs does not ever trigger ME unless the police are involved (ie suspected poisoning).

 

[jwk]

Anesthesia was implicated because the initial public statements from the family said it was anesthesia related.

The family did NOT ever say it was anesthesia related AFAIK. That was all media speculation.

 

[Blockit]

ME cases are typically only for admits <24 hours or if there was violent trauma. Unknown failure of organs does not ever trigger ME unless the police are involved (ie suspected poisoning).

In the state of Florida, these are the criteria for a patient being a “medical examiner case“. Note that being a medical examiner case does not mean that they have to autopsy. Just means they are mandated to be notified and potentially investigate.


(a) When any person dies in the state:
1. Of criminal violence.
2. By accident.
3. By suicide.
4. Suddenly, when in apparent good health.
5. Unattended by a practicing physician or other recognized practitioner.
6. In any prison or penal institution.
7. In police custody.
8. In any suspicious or unusual circumstance.
9. By criminal abortion.
10. By poison.
11. By disease constituting a threat to public health.
12. By disease, injury, or toxic agent resulting from employment.
(b) When a dead body is brought into the state without proper medical certification.
(c) When a body is to be cremated, dissected, or buried at sea.

 

[chessknt]

In the state of Florida, these are the criteria for a patient being a “medical examiner case“. Note that being a medical examiner case does not mean that they have to autopsy. Just means they are mandated to be notified and potentially investigate.


(a) When any person dies in the state:
1. Of criminal violence.
2. By accident.
3. By suicide.
4. Suddenly, when in apparent good health.
5. Unattended by a practicing physician or other recognized practitioner.
6. In any prison or penal institution.
7. In police custody.
8. In any suspicious or unusual circumstance.
9. By criminal abortion.
10. By poison.
11. By disease constituting a threat to public health.
12. By disease, injury, or toxic agent resulting from employment.
(b) When a dead body is brought into the state without proper medical certification.
(c) When a body is to be cremated, dissected, or buried at sea.

I assume you are thinking #4 would trigger it but I am not sure that means how you understand it. I think that means if someone drops dead outside of a hospital for no apparent reason (IE HOCM or SAH or aortic rupture etc), not someone who is fine, goes in to cryptogenic liver failure, then dies because the cause of death is clearly liver failure even if the etiology of the liver failure is unknown.

 

[Blockit]

I assume you are thinking #4 would trigger it but I am not sure that means how you understand it. I think that means if someone drops dead outside of a hospital for no apparent reason (IE HOCM or SAH or aortic rupture etc), not someone who is fine, goes in to cryptogenic liver failure, then dies because the cause of death is clearly liver failure even if the etiology of the liver failure is unknow

You could absolutely be right, not disputing that. I’m certainly not a medical examiner.

 

[jwk]

I assume you are thinking #4 would trigger it but I am not sure that means how you understand it. I think that means if someone drops dead outside of a hospital for no apparent reason (IE HOCM or SAH or aortic rupture etc), not someone who is fine, goes in to cryptogenic liver failure, then dies because the cause of death is clearly liver failure even if the etiology of the liver failure is unknown.

He died in the hospital so #5 deals with #4.

 

[nimbus]

Our ME declines most in hospital deaths.

 

[patriot6]

This young man died from urea cycle disorder with toxic blood ammonia levels arising postoperatively.

 

[deleted875186]

This young man died from urea cycle disorder with toxic blood ammonia levels arising postoperatively.

Interesting, do you have a link?

 

[DirtDocMD]

Father of High School Quarterback Robbie Roper Speaks Out About the Real Cause of Player's Death

It was initially reported that the talented player died due to complications from routine shoulder surgery but his family is now speaking out about what led to his tragic passing

www.yahoo.com

 

[Beeftenderloin]

I wonder if they declined to mention he had a known urea cycle disorder to the members of his medical team who initially evaluated him when he took a turn for the worse post-op, or if that “provider” was just incompetent and in over their head?

Often patients/family don’t mention details they don’t view as important or relevant and if he’s been stable his whole life, never had any major issues related to it, they might not have thought it wasn’t important to bring up. “Any medical issues?” “No doc, he’s healthier than you or me, big time college football recruit.”

If I they had the urea cycle disorder info, the response likely wouldn’t be “yea yea whatever, just tell me what drugs the kid took”. Having that one data point should immediately change the calculus and put some kind of metabolic derangement high on the differential. Sure, also send a UDS, but you can’t anchor on that if you know this piece of his history. Hind sights 20/20, but I’d hope most competent medical providers would think like this.

NOT trying to victim blame here. Just trying to figure how it could have been missed.

 

[chocomorsel]

I wonder if they declined to mention he had a known urea cycle disorder to the members of his medical team who initially evaluated him when he took a turn for the worse post-op, or if that “provider” was just incompetent and in over their head?

Often patients/family don’t mention details they don’t view as important or relevant and if he’s been stable his whole life, never had any major issues related to it, they might not have thought it wasn’t important to bring up. “Any medical issues?” “No doc, he’s healthier than you or me, big time college football recruit.”

If I they had the urea cycle disorder info, the response likely wouldn’t be “yea yea whatever, just tell me what drugs the kid took”. Having that one data point should immediately change the calculus and put some kind of metabolic derangement high on the differential. Sure, also send a UDS, but you can’t anchor on that if you know this piece of his history. Hind sights 20/20, but I’d hope most competent medical providers would think like this.

NOT trying to victim blame here. Just trying to figure how it could have been missed.

I am trying to figure out why they kept mum for six months only to now reveal it. It’s obvious they roped in a lawyer very early on.
But you are right, I wonder if they mentioned it. You would think that they would be so well versed in this that they would immediately say it could be the cause and state that he needs dialysis. Parents of kids like this are usually very on top of these things.
Something doesn’t add up.

 

[gudog]

I am trying to figure out why they kept mum for six months only to now reveal it. It’s obvious they roped in a lawyer very early on.
But you are right, I wonder if they mentioned it. You would think that they would be so well versed in this that they would immediately say it could the cause and state that he needs dialysis. Parents of kids like this are usually very on top of these things.
Something doesn’t add up.

Article in Atlanta paper today said disorder was only discovered after the fact and that family did not disclose earlier so as to not besmirch the kid's legacy by implying he was unhealthy/disabled in any way

 

[IMGASMD]

From the father.

"I just wanted him remembered as a perfect kid. I just didn't want anybody thinking that he had some abnormality when they thought about him,"

Sinister side of me is thinking that they intentionally left that out in the beginning to try the case in the court of public opinion. If he was “prefect”, someone must have fuked up. As we saw in the first 80 messages.

 

[WheezyBaby]

Was it clearly said anywhere that it was a known diagnosis prior to anesthesia? It's rare but can have late presentation of UCD's

 

[PTPoeny]

Was it clearly said anywhere that it was a known diagnosis prior to anesthesia? It's rare but can have late presentation of UCD's

I am wondering the same thing. Especially with the family comment in the story about not rushing to the hospital when a kid first starts throwing up. Going to the hospital immediately, especially for vomiting, is the first thing these families learn...

 

[chocomorsel]

Article in Atlanta paper today said disorder was only discovered after the fact and that family did not disclose earlier so as to not besmirch the kid's legacy by implying he was unhealthy/disabled in any way

So they take no culpability at all in this? They just want to blame the system and make some money out of it.
They cannot accept the fact that their not disclosing affected the outcome. And some lawyer has actually taken the case.
I love America.

EDIT: Apparently it was discovered after the admission to hospital. It’s amazing that as a footballer, with the amount of stress he was under on the field and gym, with the amount of proteins he was probably taking that he’d never had any problems till the stress of shoulder surgery.

 

[gudog]

Was it clearly said anywhere that it was a known diagnosis prior to anesthesia? It's rare but can have late presentation of UCD's

Apparently diagnosis was unknown to anybody until after the operation

 

[CHARLESTONMMM]

Do you think the lawyer contacted the family before or after he was buried?

 

[lobelsteve]

Liver involvement in urea cycle disorders: a review of the literature - PubMed

Urea cycle disorders (UCDs) are inborn errors of metabolism of the nitrogen detoxification pathway and encompass six principal enzymatic deficiencies. The aging of UCD patients leads to a better knowledge of the long-term natural history of the condition and to the reporting of previously...

pubmed.ncbi.nlm.nih.gov

With no facts provided, nothing but hearsay:

You guys talk a lot of smack about a kid you do not know. It is an internal reflection of yourself and your experience dealing with lousy people who pollute your trauma bays. Try and see this if it was your son and then come up with an answer.

Man, looking back it: this guy is a genius. Well technically, his sister is.
If only I was one degree closer connected....

My son goes to his high school and had shared friends. My sister is a rare disease specialist (Mito-Peds Neuro).
Context bias.

 

[chocomorsel]

Man, looking back it: this guy is a genius. Well technically, his sister is.
If only I was one degree closer connected....

My son goes to his high school and had shared friends. My sister is a rare disease specialist (Mito-Peds Neuro).
Context bias.

Could you ask your genius sister why this would not present itself until simple shoulder surgery. This is football player, he’s used to being bruised and beaten up. As in stress on his body is nothing new. I am sure he loads up on tons of protein.
Why now?

 

[lobelsteve]

Could you ask your genius sister why this would not present itself until simple shoulder surgery. This is football player, he’s used to being bruised and beaten up. As in stress on his body is nothing new. I am sure he loads up on tons of protein.
Why now?

That's anesthesias fault.

Metabolic Disorders and Anesthesia

Metabolic disorders encompass a group of inherited inborn errors of metabolism that are uncommonly encountered but can pose challenges when encountered during the perioperative period. Hence, it is paramount that anesthesiologists are experienced and ...

www.ncbi.nlm.nih.gov

And I can ask her, I just poke people for a living.

 

[epidural man]

If the disease had been known - what decisions would have been made differently (from an anesthesia standpoint)?