9mo old with upper esophageal FB

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So much wrong with this case. From Doximity.


SPENSER HAYWARD, MD

Do You Think the Child’s Symptoms Were Caused by the Foreign Body or Untreated Asthma?​

By Spenser Hayward, MD
October 2, 2024
Free Access

Background

A 9-month-old with prior admissions for asthma presented with stridor. An X-ray showed a penny in the esophagus. A surgeon was consulted and recommended endoscopic removal of the coin.
The coin was removed under general anesthesia. After the removal of the endoscope, the child experienced bronchospasm and suffered cardiopulmonary arrest. Prolonged resuscitation attempts were unsuccessful.
The parents sued the hospital, surgeon, CRNA, and internist working in the ED. Their only witness was Dr. L, an oncologist, who testified that the child’s asthmatic condition, not the coin, caused his presenting symptoms. He asserted that the coin removal was nonemergent and that the asthmatic condition needed to be controlled before any attempt to remove the coin was made, as it placed the child at risk for desaturation.
Dr. L denied that the presence of the coin in the esophagus constituted an emergency condition and suggested that the coin could have dropped from the esophagus into the child’s stomach without intervention.

On behalf of the defense, a pediatrician, an intensivist, and a surgeon all testified that the bronchospasm was the result of a rare complication of endoscopy and that emergent removal of the coin was indicated.

After a two-day bench trial, the judge found in favor of the defendants.
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Question​

Do you think the child’s symptoms were caused by the foreign body or untreated asthma?

Case review and explanation​

Note: The explanation below is a summary of the case written by the appellate court, lightly edited for length and clarity. Case specifics, such as names, have been redacted to protect all parties.
As established both in the record and by the parties’ joint stipulation, LC was hospitalized on four occasions between his December 30, 2008 birth and his October 21, 2009 death. Each hospitalization was associated with pneumonia and/or asthma. The last such hospitalization, which occurred October 11, 2009 through October 13, 2009, was atRegional Medical Center where the young boy was discharged with a diagnosis of atypical viral pneumonia with instructions tohis parents to continue him on medications as prescribed.

The medical care at issue in this caseoccurred only slightly more than a week later, on October 21, 2009, when the Plaintiffs arrived at the Medical Center Emergency Department (Medical Center) at 11:37 AM with nine-month-old LC. Ms. Creported that LC could “hardly breath[e].”The “Pediatric Nursing Assessment” noted, “when patient coughs, kind of whistle type sound,” and “adventitious breath sounds.”

Dr. P evaluated LC at 11:50 AM, noting the child’s recent hospitalization due to pneumonia. Dr. P reported that LC showed shortness of breath, cough, congestion, and fussiness. Dr. P's physical exam revealed the presence of stridor (the record indicates that stridor is a “whistling” sound), but the child was not wheezing. A chest X-ray ordered by Dr. P revealed a “foreign body,” lodged in theesophagus in the “transverse lie” position (i.e., sideways). The object was determined to be a penny. Dr. P ordered a surgical consult on an emergency basis.

Dr. G performed the surgical consult ordered by Dr. P and recommended removing the coin by esophagoscopy. Dr. G described the procedure as used in this instance as the introduction of an endoscope into theesophagus with the intent to grab and remove the foreign object. He explained that if the object was difficult to remove, the object could be pushed into the stomach for capture and for removal.

Ms. C consented to the procedure. LC was taken into the operating room at 1:30 PM and “inhalation induction” began, with Nurse Anesthetist F administering the anesthesia. Nurse Anesthetist F noted that LC had respirations of 32 and “O2 sats” of 98%. Thenurse anesthetist also documented copious clear oral secretions and “breath sounds pos[sible] obstruction of airway due to the coin.”

Medications prior to anesthesia included an albuterol nebulizer and decadron. The record establishes that oral intubation was successful, as was the surgical procedure, which lasted only twelve minutes. The coinwas removed at 1:52 PM.

Dr. G's operative report indicates that after the coin was located, the forceps were not initially able to “grab” the coin, causing it to slip downwards to the stomach. Dr. Gexplained that he was able to grab it “right away,” and it was removed with “no problem." After the scope was removed, however, LC ’s O2 “sats” fell to 90, and Nurse Anesthetist Fbegan to “manually breath the patient by himself.” Nurse Anesthetist F explained that he attempted to improve the child’s ventilation through the intubated tube. Steroids and adrenaline were used to assist in the resuscitative process. Despite the attempt, the child’s lung function would not return.

Dr. G remarked in his operative report that it seemed like the child “went into severe bronchospasm.” The medical team, including Dr. P, attempted resuscitative efforts for one hour and six minutes. When attempts proved unsuccessful, LC was pronounced dead at 2:56 PM.

A resulting autopsy listed the cause of death, as a “[r]are complication of removal of a lodged esophageal foreign body (a penny).” Alleging medical malpractice, Plaintiffs initially requested a Medical Review Panel be formed to consider their malpractice claim against Medical Center and Dr. G. Plaintiffs also filed a February 2013 medical malpractice suit against Dr. P.

The Medical Review Panel rendered a unanimous opinion in February 2014 finding that, “[t]he evidence does not support the conclusion that the defendant, G , M.D. and Medical Center, failed to meet the applicable standard of care as charged in the complaint.”

The medical review panel rendered “Written Reasons for Conclusion,” stating,

"As to Medical Center: As to the failure to supervise, we find that there is no evidence in the records provided to us that the hospital deviated from the standard of care.

As to Dr. G : The panel finds that there was no evidence that Dr. G acted below the standard of care. The child was apparently in respiratory distress. The child was appropriately evaluated and Dr. G responded promptly. He urgently took the patient to the operating room to remove the coin and try to relieve the respiratory distress. He was successful in removing the coin.


Unfortunately, the patient sustained arare complication from esophagoscopyresulting in bradycardia, bronchospasm, cardiac dysrhythmia resulting in a fatal cardio-pulmonary event. The use of a CRNA was appropriate under the circumstances. There is no evidence that Desflurane was used in this operation. We find there was no deviation from the standard of care."

Plaintiffs thereafter amended the initial petition, adding Dr. G and Medical Center as defendants in the malpractice suit initially filed against Dr. P alone. The matter proceeded to a two-day bench trial in February 2021 against all defendants.Plaintiffs argued that Defendants breached the applicable standard of care as they failed to treat what Plaintiffs contended was LC ’s underlying asthma condition prior to or concurrent with the surgical procedure. Plaintiffs maintained that their breach of the standard of care put the child at risk for bronchospasm, leading to his death.

Plaintiffs relied on the deposition testimony of Dr. L , their sole expert witness, in seeking to meet their burden of proving the elements of medical malpractice, including the applicable standard of care. Dr. L focused on LC ’s history of asthma and asserted, generally, that Defendants failed to properlytreat his presenting symptoms. Dr. Lmaintained that it was LC’s asthmatic condition, not the coin in the child’sesophagus, causing the symptoms of shortness of breath and whistling soundwhen he breathed. He testified that the asthmatic condition needed to be controlled before any attempt was made to remove the coin as it placed the child at a risk for desaturation (i.e., a drop in blood oxygen concentration). Dr. L denied that the presence of the coin in the esophagus presented an emergency condition and suggested that the coin could have possibly dropped from the esophagus to the child’s stomach without intervention. With regard to Medical Center, Dr. L suggested that the hospital breached its standard of care in failing to have a physician anesthesiologist in place to supervise Nurse Anesthetist F.

Dr. M, a board-certified physician in both internal medicine and emergency medicine,discounted Dr. L ’s expertise in the emergency room setting as well as Dr. L ’sopinion that the presence of the coin did not present an emergency. Dr. M instead testified that the coin, although in theesophagus, had to be immediately removed as it was compressing the trachea, the air passageway. He denied that the child’s asthma could have been further treated before the removal of the coin and testified that Dr. P acted appropriately both in his evaluation of the child and in his immediate pursuit of a surgical consult. Further, Dr. X, aboard-certified surgeon, was presented as an expert in the fields of general surgery,surgical critical care, and critical care. Dr. X also served as a member of the MedicalReview Panel reviewing the case.

While Dr. P did not appear as a defendant before the panel, Dr. M explained that he reviewed Dr. P ’s care and found that the emergency room physician acted appropriately in his evaluation and in his seeking of an X-ray of the child’s chest. Like Dr. M, Dr. X found the presence of the coin in the esophagus presented an emergent situation. He explained that it was the cointhat was causing LC’s difficulty breathing. On this point, Dr. X observed that Plaintiffs had administered some of LC’s respiratorymedicines before arrival at the emergency room, yet the child’s breathing difficulties continued. Given those circumstances, Dr. X found no merit in Dr. L ’s suggestion that the placement of the coin posed no emergency, and Dr. X found no fault in Dr. G’s decision to address the removal of the coin. Dr. X further rejected Dr. L ’s position that Nurse Anesthetist F breached the standard of care in his purported use of Desflurane as the general anesthetic. Pointedly, Dr. X reviewed the medical record and found that Sevoflurane was used, not Desflurane. Dr. X noted that while Desflurane would potentially cause anirritation, Sevoflurane, an alternative anesthetic agent, is more generally used and would be potentially therapeutic, although he did not elaborate as to why. Nurse Anesthetist F confirmed in his own testimony that he used Sevoflurane and stated that he would never give Desfluraneto a nine-month old infant.

Finally, Defendants presented the testimony of Dr. E in the fields of pediatric, pediatric emergency medicine, and pediatric pulmonology. Like Drs. M and Dr. X, Dr. Eexplained that the presence of the coin presented an emergency. He went further, however, testifying that the failure to remove the coin would have been “malpractice” as its presence in the airway would have caused complete constriction of the airway and closed or partially closed the trachea. In this regard, Dr. E explained that the size of the coin almost completely occluded the esophagus, causing it to bulge and impede on the adjacent trachea.


Dr. E denied that LC’s upper respiratory distress was due to asthma, given his respiratory rate. Likewise, the presence ofstridor, the whistling sound commemorated on the ER notes, is indicative of an upper airway obstruction according to Dr. E .Pointedly, Dr. E stated that leaving the coin in place “wasn’t an option … the coin had to come out.” Dr. E explained that the passage of the coin, as suggested by Dr. L , was unlikely, stating that “it’s possible to win Powerball too, but you’re probably not going to.”

Dr. E referenced the autopsy report’sindication of an esophageal tear and explained that, in his opinion, the coin was embedded and had already begun to erode the esophagus. He stated that had LCcoughed due to the presence of the coin, it could have entered the airway and posed a suffocation risk.

Dr. E explained that he had performed as many as 7,000 bronchoscopies in his career and that LC’s death resulted from an extremely rare complication of that surgery. He testified that, given the child’s respiratory history, LC was prone to a series of the “cascade of events” that caused his death.When asked whether Dr. L was qualified to comment on this case, Dr. E reported, "Dr. Lmay be a very capable oncologist. His understanding of the pediatric airway and some of his statements that he brought up and some—many of his conclusions—I’m just speechless. I just don’t even know how to comment. They’re just–it’s–they were just–just not grounded in physiology in a pediatric airway."
 
My daughter is 9 months old.

The parent in me wish I didn't know the anesthesia facts.

No parent deserves this. There is a lot of information missing. But this isn't an endoscopy issue or an asthma issue.
 
What? Yes, you do. Cases of severe bronchospasm happen, and it’s scary when it does. I’ve seen it myself.
Not denying it happens. But when it's bad enough to lead to cardiac arrest despite adequate treatment it's often masking another underlying process. Autopsy had an esophageal tear as well and this all happened when the scope was removed.
 
I've seen it too. Regardless, it's anesthesia dropping the ball. This isn't a surgeon screw up.
If I’m misunderstanding you, apologies, but didn’t the surgeon almost certainly tear the esophagus?

Granted, this may well have been an unavoidable outcome of the case with the tools and proceduralist available, and I don’t even want to get in to the very germane difference that may have happened if it was an anesthesiologist rather than CRNA caring for the child, but taking this all on anesthesia is the self dick punching that our speciality can’t seem to get enough of.
 
If I'm reading this correctly, the patient was intubated when the bronchospasm occurred. Can a broncjospam oclude an ETT?
 
If I’m misunderstanding you, apologies, but didn’t the surgeon almost certainly tear the esophagus?

Granted, this may well have been an unavoidable outcome of the case with the tools and proceduralist available, and I don’t even want to get in to the very germane difference that may have happened if it was an anesthesiologist rather than CRNA caring for the child, but taking this all on anesthesia is the self dick punching that our speciality can’t seem to get enough of.

An esophageal tear could lead to severe infection but shouldn't cause immediate cardiovascular collapse. Could it be a vasovagal response?
 
If I'm reading this correctly, the patient was intubated when the bronchospasm occurred. Can a broncjospam oclude an ETT?
Not really but severe bronchospasm can completely prevent ventilation.

But you can break with albuter, inhaled agent, epi etc

This sounds like maybe a lost airway/laryngospasm situation combined with a marginal infant.
 
Not really but severe bronchospasm can completely prevent ventilation.

But you can break with albuter, inhaled agent, epi etc

This sounds like maybe a lost airway/laryngospasm situation combined with a marginal infant.


No evidence to back it up but I also feel like this was more likely airway than bronchospasm. Maybe the tube was dislodged or malpositioned during the procedure.
 
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If I'm reading this correctly, the patient was intubated when the bronchospasm occurred. Can a broncjospam oclude an ETT?
I didn’t peruse the file but a coin cannot be removed through an ET tube, certainly not in a 9 month old. The procedure is to remove the foreign body and remove the ET tube simultaneously. Sounds like the airway was lost afterwards.
 
I didn’t peruse the file but a coin cannot be removed through an ET tube, certainly not in a 9 month old. The procedure is to remove the foreign body and remove the ET tube simultaneously. Sounds like the airway was lost afterwards.


Report says it was an esophageal FB but I agree it sounds like a lost airway.
 
My daughter is 9 months old.

The parent in me wish I didn't know the anesthesia facts.

No parent deserves this. There is a lot of information missing. But this isn't an endoscopy issue or an asthma issue.


Keep her away from coins and button batteries. Also guns. Just had a 17yo who shot himself in the knee with his 9mm Christmas gift. It never ends.
 
If I'm reading this correctly, the patient was intubated when the bronchospasm occurred. Can a broncjospam oclude an ETT?
Bronchospasm. This is all airway constriction/occlusion that is happening distal to to ETT. Epi and Beta2 agonist are the answer and quick frankly since the patient was intubated already....muscle relaxant.

Edit: Sorry. Just realized someone already answered above
 
I didn’t peruse the file but a coin cannot be removed through an ET tube, certainly not in a 9 month old. The procedure is to remove the foreign body and remove the ET tube simultaneously. Sounds like the airway was lost afterwards.

The coin was in the esophagus, so why would it be removed through the ETT? Did you think it was in the trachea?
 
Bronchospasm. This is all airway constriction/occlusion that is happening distal to to ETT. Epi and Beta2 agonist are the answer and quick frankly since the patient was intubated already....muscle relaxant.

Edit: Sorry. Just realized someone already answered above

From reading this forum the answer always seems to be sux first. Is it order different in an infant?

This obviously isn't a pediatric center. I'm surprised the CRNA felt comfortable intubating an infant. How much training do they actually receive where they anesthetize infants? Why didn't the surgeon inspect the esophagus after the coin was removed? Why couldn't the plaintiffs find a better expert witness?

Lots of questions here.
 
If I’m misunderstanding you, apologies, but didn’t the surgeon almost certainly tear the esophagus?

Granted, this may well have been an unavoidable outcome of the case with the tools and proceduralist available, and I don’t even want to get in to the very germane difference that may have happened if it was an anesthesiologist rather than CRNA caring for the child, but taking this all on anesthesia is the self dick punching that our speciality can’t seem to get enough of.
I'm gonna try to understand you before I comment:

You think an esophageal tear killed the patient?
 
Not really but severe bronchospasm can completely prevent ventilation.

But you can break with albuter, inhaled agent, epi etc

Albuterol and volatile anesthetics can't get to the lungs if the brochospasm is so bad ventilation is next to impossible.

IV epi is the answer.

I mean, you'll try to get albuterol and 8% sevo in, and it'll help eventually once the epi has started to work.

I guess you could add some ketamine too.

All that is assuming the tube wasn't dislodged or kinked by the endoscopist, and that bronchospasm is the actual problem.

From reading this forum the answer always seems to be sux first.

Succinylcholine is for laryngospasm, not bronchospasm. It's to relax the muscles to open the airway, to allow ventilation of (presumably) not-bronchospasmed lungs.

Succ won't help with bronchospasm. In theory it could make it worse via histamine release.
 
I’ve had kids with both bad URIs and foreign bodies and it sucks. One I had to leave intubated but that was more from croup that the foreign body in around the same place likely caused additional swelling with manipulation. If bronchospasm or other obstructive lung disease is the issue and meds aren’t working then it’s ECMO or heliox time

My defense for this case would be, what was the alternative, leaving the penny sitting in the glottis? They found a foreign body, even if the kid is sick it had to come out. There are kids that could tolerate it sitting there for a few days until their lungs are clear but if he coughs and bounces over to his airway then there’ll be a big lawsuit to follow.
 
Albuterol and volatile anesthetics can't get to the lungs if the brochospasm is so bad ventilation is next to impossible.

IV epi is the answer.

I mean, you'll try to get albuterol and 8% sevo in, and it'll help eventually once the epi has started to work.

I guess you could add some ketamine too.

All that is assuming the tube wasn't dislodged or kinked by the endoscopist, and that bronchospasm is the actual problem.



Succinylcholine is for laryngospasm, not bronchospasm. It's to relax the muscles to open the airway, to allow ventilation of (presumably) not-bronchospasmed lungs.

Succ won't help with bronchospasm. In theory it could make it worse via histamine release.

How do you know the difference in an emergency?
 
Would anyone mask induce a peds patient with FB ingestion without an IV?
Seems high risk to me. If the kid came in through the ER, then he should get an IV.

No atropine in a kid with increased secretions from a FB?

Complete bronchospasm without any oxygenation? If patient goes into cardiac arrest, epi is the first treatment, so I would think it would break the bronchospasm.

My assumption is that the crna wasn't prepared for these scenarios, was late to recognize it, probably lost airway, etc
 
Would anyone mask induce a peds patient with FB ingestion without an IV?
No. I've had this scenario in training. 3yo with foreign body (lego steering wheel) in upper airway vs esophagus, to OR without IV. Not NPO. Masked with a little nitrous only while getting the IV, then induced and ENT did a very fast rigid scope expecting airway foreign body. Wasn't there. They placed a tube then scoped the esophagus.

The culprit:
Screenshot_20250105-235624.jpg
 
Just overall seems like a tragedy. Should have been an anesthesiologist (if one was available). Crnas simply don't see enough cases in training to be prepared for this.

But there was enough plausible deniability that it was difficult to get a guilty verdict.
 
Anyone care to comment on the plaintiff’s sole expert? 😂

What is wrong with people?
Since I do expert witness work, this stuck out immediately. An oncologist is in no way a qualified expert witness for this case. One has to wonder what the plaintiff's attorney was thinking. I'm surprised this "expert" was even allowed to offer testimony - he has no expertise in GI, pediatrics, anesthesia, or pulmonology.
 
Since I do expert witness work, this stuck out immediately. An oncologist is in no way a qualified expert witness for this case. One has to wonder what the plaintiff's attorney was thinking. I'm surprised this "expert" was even allowed to offer testimony - he has no expertise in GI, pediatrics, anesthesia, or pulmonology.
Maybe he wasn't their first choice. Maybe he was the only guy who'd take their money to say what they wanted him to say?
 
Since I do expert witness work, this stuck out immediately. An oncologist is in no way a qualified expert witness for this case. One has to wonder what the plaintiff's attorney was thinking. I'm surprised this "expert" was even allowed to offer testimony - he has no expertise in GI, pediatrics, anesthesia, or pulmonology.
this is not uncommon.
lot’s of “expert” witnesses trying to make a buck.
 
As a Laryngologist who does a lot of bronchoesophagology, this is the stuff that scares the hell outta me.

Stridor almost certainly due to deviation of the party wall from the coin. Wouldn’t do that in an adult or larger child, but easily in an infant.

Esophagus tear sounds mucosal at most and quite common. That party wall is pretty thick and well vascularized and when coming via the goose, very flexible. I’ve popped through accidentally one time in my practice - it was when replacing a t-tube through a tough trach stoma using a big tonsil clamp - but from that angle the party wall was between my instrument and the spine. Going from the goose just pulling a coin out, there’s too much flexibility and nothing to push against that would allow you to punch into the trachea. And it would be an instant bloody mess too - it wouldn’t be subtle.

The timing definitely sounds like dislodged tube. Usually that’s one of the first things you check though. Could also be exactly as they said - rare but terrible spasm that spiraled quickly in an infant with decreased pulmonary reserve.
 
Seems high risk to me. If the kid came in through the ER, then he should get an IV.

No atropine in a kid with increased secretions from a FB?

Complete bronchospasm without any oxygenation? If patient goes into cardiac arrest, epi is the first treatment, so I would think it would break the bronchospasm.

My assumption is that the crna wasn't prepared for these scenarios, was late to recognize it, probably lost airway, etc
I would say what I usually do, little kids or babies ( less then 3) should ALWAYS go to facilities that are designed to take care of them.
They have staff that are used to them and understand their particular needs for drug dosage, complications etc. Etc.
If you need a bypass or transplant do you go to your local community hospital? If you are a trauma patient do they field you to the closest hospital or closest trauma center?.
I know that some here are going to come up with the what if?
This was a planned procedure. There was time to set up everything.
I know that many people here say an anesthesiologist would make a difference, i doubt it unless they were peds fellowships or did sick peds all the time.
If the medical center specializes in peds I am wrong. All i know is that in every interview I always ask how much peds and how sick.
Transplants do best with a facility for transplants, same for cardiac and same for peds.
The first question i will ever ask if my grandchild (kids are grown) need a procedure is ....how much do they do kids.
 
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Easy for things to go south in a nine month old unless you do a fair volume of peds, especially airway issues. I did lots of peds in a big community hospital and always had one of my partners available when doing the little squirts.
 
I heard of a death on an elective coin removal about 30 years ago not far from where I was practicing at the time. Kid was being treated for “new” asthma for several months as an outpatient. Eventually they got a CXR. Saw the coin. No idea how long it had been there. Uneventual induction intubation, grabbed the coin easily. Unfortunately the coin had eroded through the esophagus and partially through the aorta. Ugh.
 
I would say what I usually do, little kids or babies ( less then 3) should ALWAYS go to facilities that are designed to take care of them.
They have staff that are used to them and understand their particular needs for drug dosage, complications etc. Etc.
If you need a bypass or transplant do you go to your local community hospital? If you are a trauma patient do they field you to the closest hospital or closest trauma center?.
I know that some here are going to come up with the what if?
This was a planned procedure. There was time to set up everything.
I know that many people here say an anesthesiologist would make a difference, i doubt it unless they were peds fellowships or did sick peds all the time.
If the medical center specializes in peds I am wrong. All i know is that in every interview I always ask how much peds and how sick.
Transplants do best with a facility for transplants, same for cardiac and same for peds.
The first question i will ever ask if my grandchild (kids are grown) need a procedure is ....how much do they do kids.

Unfortunately the anesthesiologist or crna isn't going to dictate where this patient goes. Sad that thry are taken along for the ride by a surgeon who thinks they know better
 
Unfortunately the anesthesiologist or crna isn't going to dictate where this patient goes. Sad that thry are taken along for the ride by a surgeon who thinks they know better
We only have the choice to do the case.
 
Yes and no. Very rarely are these cases such that you as the anesthetist will say absolutely NO. And even then that doesn't change the fact that the cases still stays there, just end up being done by another bloke at the same hospital.
Very rarely, you can only bell that cat once maybe twice every couple of years.
 
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