Dallas Jury awards $21M for anoxic brain injury under anesthesia at BUMC

[nimbus]

And each surgery was a relatively easy case on a young ASA 1

Thus the medically directing MD was not paying much attention to the case. It’s just conjecture but they could have had a complex procedure on a medically complicated patient at the same time.

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[chocomorsel]

Thus the medically directing MD was not paying much attention to the case. It’s just conjecture but they could have had a complex procedure on a medically complicated patient at the same time.

Ahh, the joys of supervising. You sir are a lucky and likely happy dude!

 

[GassYous]

One other possibility that hasn’t been mentioned—

Was this patient hyperventilated during the case causing cerebral vasoconstriction?

The suit mentions that the ETCO2 was low for several hours, could it be that he had ETCO2 of like 18? Could easily be done if you have too high vent settings and aren’t paying attention.

Also, the case makes it appear that the record was an electronic record, not paper chart. This would make covering up hypotension or hypoxemia harder.

When I see low etco2 I think of hypotension first

 

[DrOwnage]

I think the argument of saying the ETCO2 is ~30 is a dumb argument, given dead space his actual PACO2 is around 35. We routinely hyperventilate people to prevent over breathing. This is just being overly picky. It is weird this guy's ETCO2 wasn't lower... I'm assuming those numbers were fudged. In a healthy person you would have to be pretty dang hypotensive to cause a global massive stroke and I'm sure the ET would be lower than 30.

 

[Dr. Rude]

I think the argument of saying the ETCO2 is ~30 is a dumb argument, given dead space his actual PACO2 is around 35. We routinely hyperventilate people to prevent over breathing. This is just being overly picky. It is weird this guy's ETCOT2 wasn't lower... I'm assuming those numbers were fudged. In a healthy person you would have to be pretty dang hypotensive to cause a global massive stroke and I'm sure the ET would be lower than 30.

The strategy is known as throwing as much **** at the wall as possible and hoping enough will stick.
Perfectly rational from where the plaintiff sits.

"Doctor, what is a normal PCO2? Doesn't hyperventilation lower BLOOD FLOW TO THE BRAIN? Did you have a specific reason for wanting to lower the amount of BLOOD FLOW TO THE BRAIN? Doesn't Blood carry Oxygen? Didn't this patients complication come from his brain not getting enough oxygen?.... etc.,etc.,"

Now try explaining to three retirees, two housewives, two people on disability, two college students, and three people too dumb to get out of jury duty.

 

[LivetoTell]

Could a PFO in the setting of hypotension allow fat emboli to cause the brain injury? I saw the MRI/ CT ruled that out, but is that with certainty? Something just doesn't add up.

 

[GassYous]

Could a PFO in the setting of hypotension allow fat emboli to cause the brain injury? I saw the MRI/ CT ruled that out, but is that with certainty? Something just doesn't add up.

Unlikely to cause global injury

 

[DrOwnage]

The strategy is known as throwing as much **** at the wall as possible and hoping enough will stick.
Perfectly rational from where the plaintiff sits.

"Doctor, what is a normal PCO2? Doesn't hyperventilation lower BLOOD FLOW TO THE BRAIN? Did you have a specific reason for wanting to lower the amount of BLOOD FLOW TO THE BRAIN? Doesn't Blood carry Oxygen? Didn't this patients complication come from his brain not getting enough oxygen?.... etc.,etc.,"

Now try explaining to three retirees, two housewives, two people on disability, two college students, and three people too dumb to get out of jury duty.

"It says here you gave the patient propofol, isn't that what killed Michael Jackson, the KING OF POP!?!"
*Jury gasps*
*Muddled from the back of the court room 'Son of a.."*

 

[Agast]

I think the argument of saying the ETCO2 is ~30 is a dumb argument, given dead space his actual PACO2 is around 35. We routinely hyperventilate people to prevent over breathing. This is just being overly picky. It is weird this guy's ETCOT2 wasn't lower... I'm assuming those numbers were fudged. In a healthy person you would have to be pretty dang hypotensive to cause a global massive stroke and I'm sure the ET would be lower than 30.

The systolic blood pressure of 80 and the ETCO2 of 30 were probably documented after the resuscitation efforts and were the nicest/highest looking of the numbers that popped up while all the pressors were being given.

 

[secretasianman]

It’s possible that to this day, the supervising anesthesiologist still does not even know how what truly happened behind that fudged up chart.

 

[vector2]

It’s possible that to this day, the supervising anesthesiologist still does not even know how what truly happened behind that fudged up chart.

Not just possible. Likely.

 

[secretasianman]

IMO the moment the crna chose not to notify the attending and then proceeded to fudge the chart, he chose to take all responsibility into his and only his own hands. That this isn’t appropriately punished or disincentivized is the biggest tragedy of our system.

Not just possible. Likely.

 

[Pappy Van Propofol]

This is my nightmare. 99.9% of us who live east of the Mississippi have to medically direct CRNAs. We still use paper charts. I rarely have all the facts when things happen when I’m outside of the OR. I guess we can cross our fingers and pray we make it through a career and dodge these bullets.

 

[coffeebythelake]

IMO the moment the crna chose not to notify the attending and then proceeded to fudge the chart, he chose to take all responsibility into his and only his own hands. That this isn’t appropriately punished or disincentivized is the biggest tragedy of our system.

This is fraud and the nurse should lose their license for this.

 

[Dr. Rude]

This is fraud and the nurse should lose their license for this.

Evidence? Like you, I have suspicion, but I would want more than that for a state board of medicine to discipline a physician. Would love to read the depositions. Both discovery and trial.

 

[chessknt]

Evidence? Like you, I have suspicion, but I would want more than that for a state board of medicine to discipline a physician. Would love to read the depositions. Both discovery and trial.

The patients severe anoxic brain injury isn't adequate evidence? Like if this was your brother you would need to see more evidence to know that the vital signs weren't normal? How could such evidence ever be produced?

 

[coffeebythelake]

Evidence? Like you, I have suspicion, but I would want more than that for a state board of medicine to discipline a physician. Would love to read the depositions. Both discovery and trial.

IF "crna chose not to notify the attending and then proceeded to fudge the chart"

 

[Dr. Rude]

https://courtsportal.dallascounty.org/DALLASPROD/DocumentViewer/Embedded/EfOpSHbSb_j6_Y-O5f5k93m6WwOywL2VB4fgLpJmvXsEBfhueJXIsczB4Ulw0SJz9m7TuwxTjteiHRz_o3WAjw2?p=0

The jury apportioned 75% responsibility to the CRNA. 25% to the doc.

 

[chocomorsel]

Unlikely to cause global injury

It’s fat. Not just one globlet of it that targets just one vessel.

 

[lobelsteve]

Youtube nurse.

 

[coffeebythelake]

https://courtsportal.dallascounty.org/DALLASPROD/DocumentViewer/Embedded/EfOpSHbSb_j6_Y-O5f5k93m6WwOywL2VB4fgLpJmvXsEBfhueJXIsczB4Ulw0SJz9m7TuwxTjteiHRz_o3WAjw2?p=0

The jury apportioned 75% responsibility to the CRNA. 25% to the doc.

I would have apportioned 90% CRNA and 10% anesthesiologist, but at least the jury recognized the CRNA was much more responsible for what happened than the supervising physician.

 

[abolt18]

Youtube nurse.

At about 6 minutes in they start talking about how it is SO important to maintain physician supervision and that midlevels need to turn to physicians for guidance. That's a surprising start!

 

[DrOwnage]

Just so many things in this video are wrong. It was tough watching them actually talk about the case. "The pulse ox is a minute behind." Some of the comments are worse though.

 

[abolt18]

Just so many things in this video are wrong. It was tough watching them actually talk about the case. "The pulse ox is a minute behind." Some of the comments are worse though.

Yeah, I made it to 30 minutes and had to quit. But I felt like they were at least attempting to understand it fairly. Too bad the people they had join the conversation don't know diddly about anesthesia...

 

[vector2]

Just so many things in this video are wrong. It was tough watching them actually talk about the case. "The pulse ox is a minute behind." Some of the comments are worse though.

Yeah, the crux of the fraud part is the vitals/vasopressor stuff... and none of them had any clue about the spectrum of routine to "oh sht something's wrong" pressor administration during general anesthesia. To most nurses they think any administration of a vasopressor means the pt is critically ill.

 

[BLADEMDA]

Crna is a man. It was a paper chart

Lawyers lie and exaggerate everything to get the most amount of money. I will wait to actually hear the real facts of this case before assigning any blame to anyone including the CRNA.

I suspect this was a very unusual case where the patient had some undiagnosed Cardiac issues like a PFO or something else. The low ETCO2 makes me think HYPOTENSION vs EMBOLUS pretty quickly in this age group. Either way, if I was the attending on this case and became aware of an ETCO2 of 18 my approach would be there is a HUGE issue going on that needs fixing ASAP. I would likely place an arterial line (yes, even in a 28 year old) if hypotensive and drop a TEE probe. I would also get help from my Physician colleagues.

Still, there is no guarantee the outcome would have been different but the process leading to the outcome certainly would have been.

 

[BLADEMDA]

Depending on likely diagnosis, consider:
1. Treat the problem, if diagnosed. Go To relevant event if ACLS, Anaphylaxis, Hemorrhage, Hypoxemia, Local Anesthetic Toxicity, Myocardial Ischemia, Pneumothorax, Total Spinal Anesthesia, Transfusion Reaction, Venous Air Embolism. For sepsis: refer to local guidelines (IV fluids, invasive monitoring?, send lactate, blood cultures, appropriate antibiotics).
2. Transesophageal echo if unclear cause.
3. More IV access.
4. Place arterial line.
5. Steroid for adrenal insufficiency. (e.g. hydrocortisone 100 mg IV).
6. Send labs: ABG, Hgb, electrolytes, calcium, lactate, type & cross.
7. Foley catheter if not present. Monitor urine output.

STANFORD MANUAL FOR HYPOTENSION

http://web.stanford.edu/dept/anesthesia/em/semv3.1.pdf

 

[BLADEMDA]

Capnogram with progressive decline in EtCO2 generally associated with increases in dead space i.e. cardiac arrest, large pulmonary emboli (air, gas, blood or fat) and severe bronchospasm.​

Fat Embolism - OpenAnesthesia

www.openanesthesia.org

 

[Radetzky]

You don’t need a PFO to get cerebral fat embolism. But most cerebral fat embolism has a high degree of reversibility and is unlikely to cause life ending brain injury. It’s also unusual to not have pulmonary involvement. I mean sure it could happen but probably 1000 less likely than a blood pressure of 80 (probably lower) and beach chair position

 

[BLADEMDA]

You don’t need a PFO to get cerebral fat embolism. But most cerebral fat embolism has a high degree of reversibility and is unlikely to cause life ending brain injury. It’s also unusual to not have pulmonary involvement. I mean sure it could happen but probably 1000 less likely than a blood pressure of 80 (probably lower) and beach chair position

This case was a 1 in 5 million type event leading to 21 million in damages. Sure, it could be just untreated hypotension but Amyl has hinted there may be more going on here.

"Although there are reports of excellent recovery in patients with CFE, some do not survive. " (CFE=Cerebral Fat Embolus)

https://www.ahajournals.org/doi/10.1161/STROKEAHA.115.011440

Fat embolism syndrome with cerebral fat embolism through a patent foramen ovale: A case report

Fat embolism syndrome with cerebral fat embolism, rarely observed at our neurology department, is often associated with long bone fractures. Its diagnosis is based on medical history and supportive imaging data and is usually not difficult. However, its ...

www.ncbi.nlm.nih.gov

 

[vector2]

This case was a 1 in 5 million type event leading to 21 million in damages. Sure, it could be just untreated hypotension but Amyl has hinted there may be more going on here.

"Although there are reports of excellent recovery in patients with CFE, some do not survive. " (CFE=Cerebral Fat Embolus)

https://www.ahajournals.org/doi/10.1161/STROKEAHA.115.011440

Fat embolism syndrome with cerebral fat embolism through a patent foramen ovale: A case report

Fat embolism syndrome with cerebral fat embolism, rarely observed at our neurology department, is often associated with long bone fractures. Its diagnosis is based on medical history and supportive imaging data and is usually not difficult. However, its ...

www.ncbi.nlm.nih.gov

The pt in that CFE case report had multiple punctate foci on MRI. The pt in OP had global anoxic injury…which is not consistent with emboli

 

[aneftp]

On another topic, this is something I will never ever understand. The 4:1 direction in states east of the Mississippi is ubiquitous, but by and large all of these states, including ones in the south, have pretty lame compensation, even in true partnerships I’ve talked to.

Seriously, what gives? How is it that USAP Orlando isn’t blowing everyone out of the water when they become partners? Texas USAP divisions and even colorado crush a lot of usap Florida people.

Could payor mixed be that much better in the Midwest compared to Tennessee or North Carolina?

Usap Orlando people who work a full schedule make the same as Usap Texas region. I know this for a fact with people in Houston Dallas and Orlando.

They all making in the 700-800k range.

If u want to compare apples to apples. Because they were the original 3 areas that sold out in 2014 to form Usap.

Now what is considered a “full schedule “. Usually 3-4 beeper calls a month. 2 in house calls a month. One overnight weekend Average 50-55 hours.

Those who work less will make less. Person in my neighborhood original partner just covers Cush Asa 1-2 patients community hospital and gives up most of all his/hers/they call so makes less.

 

[Radetzky]

The pt in that CFE case report had multiple punctate foci on MRI. The pt in OP had global anoxic injury…which is not consistent with emboli

Exactly, the imaging features are different.

 

[BLADEMDA]

Exactly, the imaging features are different.

You are just assuming this was a slam dunk instance of gross negligence with no other cofounding morbidities. That may indeed have been the situation but it is also possible that there was more going on in the OR leading to hypotension with possible low saturations causing the hypoxic injury. The CRNA did lie about the vitals which made things worse for his defense. Again, Amyl has hinted we aren't getting the entire story with just "simple untreated hypotension" And I tend to agree with her.

As a side comment, I notice often many CRNAs permit much more hypotension for longer periods of time than I feel comfortable with in the OR. They are both slow to recognize critical hypotension in a hypertensive patient and slow to treat it.

 

[Radetzky]

You are just assuming this was a slam dunk instance of gross negligence with no other cofounding morbidities. That may indeed have been the situation but it is also possible that there was more going on in the OR leading to hypotension with possible low saturations causing the hypoxic injury. The CRNA did lie about the vitals which made things worse for his defense. Again, Amyl has hinted we aren't getting the entire story with just "simple untreated hypotension" And I tend to agree with her.

As a side comment, I notice often many CRNAs permit much more hypotension for longer periods of time than I feel comfortable with in the OR. They are both slow to recognize critical hypotension in a hypertensive patient and slow to treat it.

Not assuming at all. I was just making a point that cerebral fat can occur without PFOs and also that the imaging is not consistent.

And I seem to have got confused with another case I read which involved beach chair position, my apologies. I’m sure you’re right and there is something unusual that happened here.

 

[Hoya11]

You are just assuming this was a slam dunk instance of gross negligence with no other cofounding morbidities. That may indeed have been the situation but it is also possible that there was more going on in the OR leading to hypotension with possible low saturations causing the hypoxic injury. The CRNA did lie about the vitals which made things worse for his defense. Again, Amyl has hinted we aren't getting the entire story with just "simple untreated hypotension" And I tend to agree with her.

As a side comment, I notice often many CRNAs permit much more hypotension for longer periods of time than I feel comfortable with in the OR. They are both slow to recognize critical hypotension in a hypertensive patient and slow to treat it.

or allow dangerous combinations of hypotension and hypocapnia, hypotension and bradycardia, hypotension and borderline hypoxemia...

when i am asked for hypotension for ortho cases on otherwise healthy people, i do try to make sure other parameters are compatible with end organ oxygen delivery.. that understanding is not there for them

 

[gasdoc77]

or allow dangerous combinations of hypotension and hypocapnia, hypotension and bradycardia, hypotension and borderline hypoxemia...

when i am asked for hypotension for ortho cases on otherwise healthy people, i do try to make sure other parameters are compatible with end organ oxygen delivery.. that understanding is not there for them

Burst suppression for total shoulders🤔. Let's not give ortho any ideas🤣

 

[Ashers]

Burst suppression for total shoulders🤔. Let's not give ortho any ideas🤣

I've worked with one shoulder guy who wanted TIVA for all of his cases (his brother is ortho spine), but some crna at some point told his TIVA is the best anesthetic. So what everyone did is hang something (eg Mag) and tell him that was the anesthesia. Then PACU thought they all got TIVA because he requested it. It was absurd.

 

[amyl]

You don’t need a PFO to get cerebral fat embolism. But most cerebral fat embolism has a high degree of reversibility and is unlikely to cause life ending brain injury. It’s also unusual to not have pulmonary involvement. I mean sure it could happen but probably 1000 less likely than a blood pressure of 80 (probably lower) and beach chair position

This wasn’t beach chair

 

[amyl]

Please understand that there are on going appeals and that’s why I cannot discuss here. In my opinion, only knowing part of the story, some critical information was deemed inadmissible in this case. I don’t have the whole story at all.
I understand the imaging is inconsistent with embolism but I wonder how often patients actually display the textbook presentation of FES. I have a hard time believing that the patient was that hypotensive to cause severe brain injury without some arrhythmia or some other clue things were doing poorly

 

[nimbus]

Please understand that there are on going appeals and that’s why I cannot discuss here. In my opinion, only knowing part of the story, some critical information was deemed inadmissible in this case. I don’t have the whole story at all.
I understand the imaging is inconsistent with embolism but I wonder how often patients actually display the textbook presentation of FES. I have a hard time believing that the patient was that hypotensive to cause severe brain injury without some arrhythmia or some other clue things were doing poorly

If there was an electronic anesthesia record, there wouldn’t even be a question about the vitals. A large part of the case seems to rely on whether the recorded vitals were real or fictitious. The plaintiffs argument is that the BP/vitals written on the anesthesia record were made up and the patient’s injury was due to untreated or undertreated hypotension.

 

[The Duck Knows]

Please understand that there are on going appeals and that’s why I cannot discuss here. In my opinion, only knowing part of the story, some critical information was deemed inadmissible in this case. I don’t have the whole story at all.
I understand the imaging is inconsistent with embolism but I wonder how often patients actually display the textbook presentation of FES. I have a hard time believing that the patient was that hypotensive to cause severe brain injury without some arrhythmia or some other clue things were doing poorly

What about an anaphylactic reaction to Roc or ancef?

I had a case recently that sounds similar. Healthy woman in her 40s. First BP after easy intubation was normal. After ancef 50/30. The memory of a recent m&m in the back of my mind had me push solid doses of ephedrine and phenylephrine but immediately start mixing epi. A few 10 mcg epi boluses and a high phenylephrine infusion kept her MAP above 65 and the requirements came down as the case moved along. Slightly higher peak pressures but never difficult to ventilate. Went through the Stanford manual.

Wouldn’t surprise me if a similar scenario combined with some of the typical excuses (gotta position the patient and not hold up the surgeon, probably just the tucked arms or the surgeon on the cuff, he’s a healthy guy, yada yada yada) and hesitancy to jump to epi could have been the real story here. MAP of 40 and hitting that pressure=cerebral perfusion end of the curve is a place we don’t venture much. I don’t have any research on it, but I wouldn’t want my brain to rely on those kinds of pressures for more than a few minutes.

Side note: I really don’t like paper charts and bad EMR systems. Doesn’t make sense to me that there isn’t some financial penalty for HCAs offering up Meditech and acting like it isn’t an direct risk to patient care

 

[deleted1147063]

A lot of people don't realize that the reason we give epi in anaphylaxis is not (just) for the hemodynamic effect, but for immunosuppression. So, indeed, hesitancy to jump to epi can kill a patient (in severe cases).

 

[sevo00]

A lot of people don't realize that the reason we give epi in anaphylaxis is not (just) for the hemodynamic effect, but for immunosuppression. So, indeed, hesitancy to jump to epi can kill a patient (in severe cases).

Correct. I Remember that from residency. Helps stabilize mast cells and prevent further release of histamine

 

[repititionition]

Youtube nurse.

SDN is the only place where I can speak the truth: I can tell if a person is stupid based on looks alone. There are multiple contemporary physical/appearance signals that people use to attempt to convey intelligence. Taken in aggregate, they end up having the opposite effect.

Importantly, I also recognize that I can NOT tell if a person is smarter than me based on looks alone.

 

[BLADEMDA]

What about an anaphylactic reaction to Roc or ancef?

I had a case recently that sounds similar. Healthy woman in her 40s. First BP after easy intubation was normal. After ancef 50/30. The memory of a recent m&m in the back of my mind had me push solid doses of ephedrine and phenylephrine but immediately start mixing epi. A few 10 mcg epi boluses and a high phenylephrine infusion kept her MAP above 65 and the requirements came down as the case moved along. Slightly higher peak pressures but never difficult to ventilate. Went through the Stanford manual.

Wouldn’t surprise me if a similar scenario combined with some of the typical excuses (gotta position the patient and not hold up the surgeon, probably just the tucked arms or the surgeon on the cuff, he’s a healthy guy, yada yada yada) and hesitancy to jump to epi could have been the real story here. MAP of 40 and hitting that pressure=cerebral perfusion end of the curve is a place we don’t venture much. I don’t have any research on it, but I wouldn’t want my brain to rely on those kinds of pressures for more than a few minutes.

Side note: I really don’t like paper charts and bad EMR systems. Doesn’t make sense to me that there isn’t some financial penalty for HCAs offering up Meditech and acting like it isn’t an direct risk to patient care

Anaphylaxis is generally resistant to treatment with our usual medications: Ephedrine or Phenylephrine. I have treated presumed reaction to Rocuronium twice in my career. Both times low dose Epi and Vasopressin were used successfully to restore the BP and stabilize the patient. So, if we assume anaphylaxis as the cause here of the persistent hypotension then the CRNA ignored the fact that the patient remained hypotensive despite routine vasopressors and didn't seek help or assistance. If this is what actually occurred then the verdict was correct. In no instance should a patient remain critically hypotensive for long periods of time without every measure being deployed to restore BP. As it stands, the CRNA failed in his duties to notify the attending of the persistent hypotension which clearly played a role in the development of the brain damage.

 

[Urzuz]

What about an anaphylactic reaction to Roc or ancef?

I had a case recently that sounds similar. Healthy woman in her 40s. First BP after easy intubation was normal. After ancef 50/30. The memory of a recent m&m in the back of my mind had me push solid doses of ephedrine and phenylephrine but immediately start mixing epi. A few 10 mcg epi boluses and a high phenylephrine infusion kept her MAP above 65 and the requirements came down as the case moved along. Slightly higher peak pressures but never difficult to ventilate. Went through the Stanford manual.

The patient developed anaphylaxis to the antibiotic, presumably given before they made incision....and you did the case...?

I really hope that the case was urgent/emergent, but when you say she is a healthy woman in her 40s I can only assume it was elective. And if it was elective, I have no idea why you would do a case where you are actively pushing epinephrine and running a "high phenylephrine infusion" to keep a BP compatible with life...

 

[Radetzky]

A lot of people don't realize that the reason we give epi in anaphylaxis is not (just) for the hemodynamic effect, but for immunosuppression. So, indeed, hesitancy to jump to epi can kill a patient (in severe cases).

I’ve talked to several immunologists about this and they were all unconvinced this is a clinically important effect.

 

[The Duck Knows]

The patient developed anaphylaxis to the antibiotic, presumably given before they made incision....and you did the case...?

I really hope that the case was urgent/emergent, but when you say she is a healthy woman in her 40s I can only assume it was elective. And if it was elective, I have no idea why you would do a case where you are actively pushing epinephrine and running a "high phenylephrine infusion" to keep a BP compatible with life...

Definitely wasn’t a slam dunk diagnosis, and if it was anaphylaxis it was a very mild case. Told the surgeon to hold off on incision and got an available colleague in the room to help. Went through the treatment algorithms. Didn’t have any issues ventilating and BP was responsive to small epi boluses plus phenylephrine infusion. I’m sure I could have cancelled the case and taken her to the ICU, but it was a case that couldn’t wait more than a day or two, so we proceeded. Documented it in as many places in the chart as I could so that future anesthesiologists will be aware and talked to her and her family about it.

 

[vector2]

I’ve talked to several immunologists about this and they were all unconvinced this is a clinically important effect.

That's all well and good, but based on the plausible basophil/mast cell b2 mechanism, my personal anecdotes of nothing working but epi, and the fact that a randomized trial of epi vs. anything else in human anaphylaxis is never going to happen, I'm gonna continue with the standard of care.