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So much wrong with this case. From Doximity.
SPENSER HAYWARD, MD
October 2, 2024
Free Access
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.
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."
SPENSER HAYWARD, MD
Do You Think the Child’s Symptoms Were Caused by the Foreign Body or Untreated Asthma?
By Spenser Hayward, MDOctober 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.
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
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.
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.
