CRNA kills malpractice caps in Florida?

[BorntobeDO?]

"The case started with a dental assistant who went into surgery for carpal-tunnel syndrome and ended up with a perforated esophagus...
Kalitan filed the malpractice case in 2008 in Broward County and named a series of defendants, including the North Broward Hospital District, an anesthesiologist, a certified registered nurse anesthetist and a company that contracted to provide anesthesiologists and staff to the hospital district.

Kalitan's attorneys said anesthesia was used to put her "to sleep" for the outpatient carpal-tunnel surgery. When she awoke, she complained of chest and back pain but was later sent home. She was rushed to the hospital the next day, with an infection from the perforated esophagus and had to undergo chest and neck surgery. She was place in a drug-induced coma for three weeks while recovering.

A jury awarded Kalitan about $4.7 million, with $4 million of that in non-economic damages, according to court records. But a circuit judge, applying the caps from the 2003 law, reduced the non-economic damages award by about $2 million, which included a finding that Kalitan suffered a "catastrophic injury.""

"A South Florida appeals court ruled last week that the law's limits on pain and suffering damages — known in legal parlance as non-economic damages — are unconstitutional in personal-injury cases, such as the case of Susan Kalitan, who was injured after tubes were inserted into her mouth and esophagus as part of an anesthesia process."

Court ruling a new blow to Florida's medical-malpractice damage caps
Whelp.

---

Members don't see this ad.

 

[anbuitachi]

"The case started with a dental assistant who went into surgery for carpal-tunnel syndrome and ended up with a perforated esophagus...
Kalitan filed the malpractice case in 2008 in Broward County and named a series of defendants, including the North Broward Hospital District, an anesthesiologist, a certified registered nurse anesthetist and a company that contracted to provide anesthesiologists and staff to the hospital district.

Kalitan's attorneys said anesthesia was used to put her "to sleep" for the outpatient carpal-tunnel surgery. When she awoke, she complained of chest and back pain but was later sent home. She was rushed to the hospital the next day, with an infection from the perforated esophagus and had to undergo chest and neck surgery. She was place in a drug-induced coma for three weeks while recovering.

A jury awarded Kalitan about $4.7 million, with $4 million of that in non-economic damages, according to court records. But a circuit judge, applying the caps from the 2003 law, reduced the non-economic damages award by about $2 million, which included a finding that Kalitan suffered a "catastrophic injury.""

"A South Florida appeals court ruled last week that the law's limits on pain and suffering damages — known in legal parlance as non-economic damages — are unconstitutional in personal-injury cases, such as the case of Susan Kalitan, who was injured after tubes were inserted into her mouth and esophagus as part of an anesthesia process."

Court ruling a new blow to Florida's medical-malpractice damage caps
Whelp.

wait was there an esophageal intubation? how do they know the hand surgeons didn't cause the perforated esophagus?

 

[sethco]

ETT and/or OGT for carpal tunnel surgery?!?!??

 

[coffeebythelake]

ETT and/or OGT for carpal tunnel surgery?!?!??

No kidding. Sounds crazy. Some of our neurosurgeons do carpal tunnel cases under GA. Most hand surgeons are much more reasonable bier block or MAC

 

[nimbus]

Since I’ve never intubated a CTR, had to look it up. It was an SRNA training program....


“In 2007, Plaintiff went to defendant North Broward Hospital District (“the Hospital”) for outpatient surgery to treat carpal tunnel syndrome in her wrist. The surgery required Plaintiff to be placed under general anesthesia. Defendant Dr. Robert Alexander (“the Anesthesiologist”) was the anesthesiologist of record providing anesthesia care to Plaintiff during her surgery. The Anesthesiologist's team included the Nurse, as well as defendant Eleidy Miedes, a student nurse anesthetist from the University (“the Student”). All three individuals were present through the coordination of defendant Anesco North Broward, LLC (“Anesco”), a company that contracted with the Hospital to staff it with anesthesiologists and nurse anesthetists. Anesco also contracted with the University to facilitate the clinical training of the University's student registered nurse anesthetists (“SRNAs”) at Anesco's affiliates, including the Hospital. At the time of the surgery, the Nurse was an employee of Anesco as a certified registered nurse anesthetist and an employee of the University as its clinical coordinator for the SRNA program.

During intubation, as part of the administration of anesthesia for Plaintiff's surgery, one of the tubes perforated Plaintiff's esophagus. Prior to the surgery and intubation, Plaintiff had no problems with her esophagus, nor did she complain of any bodily pain unassociated with her carpal tunnel. Plaintiff's hospital records do not indicate which member of the team actually intubated Plaintiff, but the Anesthesiologist testified that it was he, not the Nurse nor the Student, who performed the intubation.

When Plaintiff awoke in recovery, she complained of excruciating pain in her chest and back. The Anesthesiologist was notified, and, unaware of the perforated esophagus, he ordered the administration of a drug for the chest pain and concluded that there was no issue with Plaintiff's heart. Plaintiff was discharged from the hospital later that afternoon. Plaintiff's neighbor picked her up and drove her home.

The neighbor returned the next day to check on Plaintiff. Plaintiff was unresponsive, so the neighbor took her to the emergency room of a nearby hospital. Upon diagnosis of the problem, Plaintiff was rushed into lifesaving surgery to repair her esophagus. Plaintiff's next memory was waking up in the intensive care unit after being in a drug-induced coma for several weeks. Plaintiff had additional surgeries and underwent intensive therapy to begin eating again and regain mobility. She testified that she continues to suffer from pain throughout the upper half of her body and from serious mental disorders as a result of the traumatic incident and the loss of independence because of her body's physical limitations following this incident.”

 

[anbuitachi]

looks like the anesthesiologist intubated and perforated teh esophagus.. wow.

 

[nimbus]

looks like the anesthesiologist intubated and perforated teh esophagus.. wow.

Anesthesiologist intubated but it’s unclear who perforated or if there were multiple attempts.

 

[coffeebythelake]

Anesthesiologist intubated but it’s unclear who perforated or if there were multiple attempts.

Right. Something is missing in that story

 

[Ronin786]

"One of the tubes perforated the esophagus"

Put my money on an OG tube. Never understood why every patient needs their stomach decompressed during GA.

 

[Aether2000]

The Florida Supreme Court threw out medical malpractice caps in 2014.
Florida Supreme Court tosses out medical malpractice cap on damages

 

[anbuitachi]

"One of the tubes perforated the esophagus"

Put my money on an OG tube. Never understood why every patient needs their stomach decompressed during GA.

Unless the patient has ulcer or some super weak esophagus, it's hard to see OG perforating the esophagus since OG is so soft. I imagine it curling up rather than perforating but who knows.

 

[caligas]

I’m going with upper esophageal perf from laryngoscope blade

 

[anbuitachi]

I’m going with upper esophageal perf from laryngoscope blade

miller 4

 

[Psai]

Holy ****

 

[deleted171991]

This is ridiculous. Any esophageal intubation could theoretically perf the esophagus. This was bad protoplasm.

 

[vector2]

Ridiculous the pt got GA, but could also be that stylet was protruding or tube was advanced too far through esophagus with the stylet still in.

 

[dannyboy1]

This is ridiculous. Any esophageal intubation could theoretically perf the esophagus. This was bad protoplasm.

Agree. This patient got GA (maybe it was a surgeon who was bad with local. They do exist). We don’t know why ETT was used, maybe morbidly obese, bad GERD etc. in any case I would argue that an ETT can always be indicated in the setting of general anesthesia. This was obviously not an unrecognized esophageal intubation as the patient woke up. Not sure exactly what the malpractice is. Patient had chest pain in PACU and was appropriately worked up and ruled outfor cardiac and pulmonary source. I don’t think that any of us would suspect this diagnosis in PACU ....

 

[Hamhock]

I too am confused.
I was taught to always blame anesthesia; but I can't seem to here (with the details provided).
Did the record show multiple attempts and report injury or signs of injury to the esophagus?
Or are we really to believe that an anesthesiologist performed an unnoticed traumatic esophageal intubation that spontaneously dislocated into the trachea afterwards?
There MUST be more to this story.
HH

 

[nimbus]

Agree. This patient got GA (maybe it was a surgeon who was bad with local. They do exist). We don’t know why ETT was used, maybe morbidly obese, bad GERD etc. in any case I would argue that an ETT can always be indicated in the setting of general anesthesia. This was obviously not an unrecognized esophageal intubation as the patient woke up. Not sure exactly what the malpractice is. Patient had chest pain in PACU and was appropriately worked up and ruled outfor cardiac and pulmonary source. I don’t think that any of us would suspect this diagnosis in PACU ....

My hope is that the patient was not intubated strictly for educational reasons.

 

[s109442]

I think this is when lightning hits a person, so many infinite factors played a roll here, and the outcome was spectacular in its wrath. This is Nature’s Venom.

 

[Apollyon]

Ridiculous the pt got GA, but could also be that stylet was protruding or tube was advanced too far through esophagus with the stylet still in.

Saw that over 20 years ago, when I was EMS. This copper stylet was 1cm beyond the end of the tube, and doctor wondered from where the blood was coming. Then, he tried to blame it on us (I was still EMT, not yet EMT-intermediate or paramedic)! We were cleared.

 

[chocomorsel]

looks like the anesthesiologist intubated and perforated teh esophagus.. wow.

This just seems insane to me. Why intubated? LMA unless she’s huge and surgeon doesn’t want a block. It happens. However excruciating chest pain would throw me off. For an esophageal tear to happen would require a little more muscle than usual.
But of course, it’s easy for us to play MMQB.

 

[narcotics999]

This just seems insane to me. Why intubated? LMA unless she’s huge and surgeon doesn’t want a block. It happens. However excruciating chest pain would throw me off. For an esophageal tear to happen would require a little more muscle than usual.
But of course, it’s easy for us to play MMQB.

I knew an eye surgeon who wants GETA for CATARACT! Seriously...

Luckily, he only wants to work with one anesthesiologist (group head).

 

[dannyboy1]

This just seems insane to me. Why intubated? LMA unless she’s huge and surgeon doesn’t want a block. It happens. However excruciating chest pain would throw me off. For an esophageal tear to happen would require a little more muscle than usual.
But of course, it’s easy for us to play MMQB.

But we intubate all of the time. It is hard to argue that endotracheal intubation in the setting of general anesthesia is not an accepted standard of care. Sure you can also use an LMA but there are many ways to skin the cat. It’s not like LMA is entirely without risk. This patient got paid because there was a catastrophic iatrogenic injury, not because of any negligence or deviation from accepted standards of care.

 

[Ronin786]

Unless the patient has ulcer or some super weak esophagus, it's hard to see OG perforating the esophagus since OG is so soft. I imagine it curling up rather than perforating but who knows.

Lots of case reports out there and we had a case during residency (not mine). Not as implausible as you would think.

 

[Arch Guillotti]

This just seems insane to me. Why intubated? LMA unless she’s huge and surgeon doesn’t want a block. It happens. However excruciating chest pain would throw me off. For an esophageal tear to happen would require a little more muscle than usual.
But of course, it’s easy for us to play MMQB.

What if the patent has severe reflux, history of gastroparesis or gastric outlet obstrction?

 

[anbuitachi]

Lots of case reports out there and we had a case during residency (not mine). Not as implausible as you would think.

Yea for sure. im wondering if some people use rougher OG tubes. but i guess people are just weak

 

[Ronin786]

Yea for sure. im wondering if some people use rougher OG tubes. but i guess people are just weak

Inadvertent insertion of nasogastric tube into the brain stem and spinal ...

 

[WholeLottaGame7]

Inadvertent insertion of nasogastric tube into the brain stem and spinal ...

Sweet googly moogly

 

[anbuitachi]

holy crap! on medicine, we had to get Xray before any NG/OG can be used. in the OR we do not, and just put it on suction.. imagine if that is put on suction, you'd be like what is all this clear fluid

though in the above, it looks like they put a small bore feeding tube which definitely has a much higher risk of complication since it has a metal stylet in it

 

[pgg]

Inadvertent insertion of nasogastric tube into the brain stem and spinal ...

Oops

GIS is full of intracranial NGT adventures but that sets a new standard.

 

[Psai]

Inadvertent insertion of nasogastric tube into the brain stem and spinal ...

Minimally invasive endoscopic spinal surgery.

 

[DocVapor]

Minimally invasive endoscopic spinal surgery.

Transnasal spinal drain for AAA repair?

 

[sigrhoillusion]

What if the patent has severe reflux, history of gastroparesis or gastric outlet obstrction?

True. but "per the patient" she had no issues with her esophagus prior to her CTS procedure...

 

[sigrhoillusion]

Minimally invasive endoscopic spinal surgery.

This is the thing of nightmares... everything we do to patients has risks. Maybe it was just rumor, but a "spinal NGT" was said to have happened at the place where I did my anesthesia residency. Didn't do much digging into the claims...

 

[chocomorsel]

What if the patent has severe reflux, history of gastroparesis or gastric outlet obstrction?

Yeah, like I said it happens they need to be intubated on occasion.

 

[sigrhoillusion]

This is the thing of nightmares... everything we do to patients has risks. Maybe it was just rumor, but a "spinal NGT" was said to have happened at the place where I did my anesthesia residency. Didn't do much digging into the claims...

Yup... looking at the authors of the articles, it definitely happened there. That being said, no anesthesiologist is an author on the article so this probably happened post-op (don't have access to full article) so we might be in the clear!!!

 

[chocomorsel]

True. but "per the patient" she had no issues with her esophagus prior to her CTS procedure...

He was asking me about need for an ETT in general. Not specific to this case.
I bet she was fat or the doc was doing it for “teaching” purposes.

 

[sigrhoillusion]

He was asking me about need for an ETT in general. Not specific to this case.
I bet she was fat or the doc was doing it for “teaching” purposes.

The key is to use the Glidescope so EVERYBODY can see you perf the esophagus...

 

[pgg]

The key is to use the Glidescope so EVERYBODY can see you perf the esophagus...

You mizpelled glid-o-scope.