This case study involves a CRNA working in an outpatient endoscopy center.
Indemnity/Settlement Payment: Approximately $75,000
Legal Expenses: Approximately $100,000
(Monetary amounts represent only the payments made on behalf of the insured CRNA and do not reflect payments made on behalf of any other parties involved in the claim.)
A 39 year-old female came to the local emergency department (ED) with complaints of abdominal pain and nausea. The ED practitioner noted the patient was a relatively healthy female despite being a six-pack of beer drinker (4-5 times a week). She presented with mild pain in the right upper quadrant without rebound or guarding. Physical examination and laboratory results revealed the patient:
- slightly jaundice appearance with a bilirubin of over 3mg/dL;
- elevated transaminase (greater than 150U/L); and
- normal alkaline phosphate visit.
While in the ED, the patient underwent an abdominal ultrasound, which revealed a thickened gallbladder with peri-cholecystic fluid without stones. The ED practitioner was concerned that the patient was also suffering from possible liver cirrhosis and to rule this out, a CT of the abdomen and pelvis, a HIDA scan, and ammonia level were scheduled for a week later. The CT scan impression revealed a small to moderate pleural effusion, moderate cardiomegaly, peri-cholecystic fluid suggesting cholecystitis, and early pancreatitis, so the patient was referred to a gastroenterologist for further treatment.
During the initial visit to the gastroenterologist, the patient gave a current social and medical history of current heavy alcohol and tobacco use (1-2 six-packs of beer 4 to 5 times a week and 1-2 pack a day cigarette smoker), greater than six-month history of generalized abdominal pain and nausea with mild distention, short of breath during exertion and occasional lower bilateral swelling in lower extremities. Her previous medical history included total disability due to a prior right hip replacement caused by osteonecrosis and hysterectomy. She denied having a primary care provider, but instead would seek medical treatment from local urgent care facilities as needed.
The gastroenterologist scheduled a EUD/EUS/ECRP for the following week at a local outpatient surgical center. The provider wrote a note that stated, “Due to shortness of breath complaints the patient needs a cardiac evaluation”, but this does not appear to have occurred.
On the day of her scheduled procedure, the pre-operative nurse assessment noted the patient’s weight was 97 kilograms, height as 66 inches, capable of moderate activity, and experiences shortness of breath both at rest and with exertion. An EKG was performed and the interpretation was “Abnormal EGC, sinus tachycardia, possible left atrial enlargement, left axis deviation, abnormal QRS-T angle (consider primary T wave abnormality” which was authenticated by the anesthesiologist.
After obtaining the informed consents, the patient was taken to the operating room to undergo an EGD with planned ERCP under MAC with intravenous propofol sedation. After placement of the appropriate monitors and oxygen, the procedure began following the incremental administration of 220 mg of Propofol. As the endoscope was advanced into the patient’s stomach, her airway became partially obstructed. Nasal oxygen was increased to 5 liters and jaw thrust was performed by the insured CRNA. The anesthesiologist was in room at the time and a request was made to the gastroenterologist to remove the endoscope. The patient’s SpO2 decreased to the mid 80’s, but the respiratory obstruction did not resolve. An oral airway and face mask was placed to provide positive pressure ventilation. While this provided better oxygenation results, it was difficult to maintain oxygenation status so a second anesthesiologist was asked to come to the room and perform an endotracheal intubation. Despite good chest rise and bilateral breath sounds, the CRNA noted that bilateral carotid pulses were diminished. Cardiopulmonary resuscitation with chest compressions and pharmacologic support was initiated, which initially had a positive effect on returning the patient to a hemodynamic state.
The patient was transferred to the local hospital via EMS where she stayed on life support for two weeks. The patient never regained consciousness and was taken off life support one week later after neurological tests revealed no brain activity.
An autopsy was performed and the report indicated that patient had moderate to severe cardiomyopathy and moderate pulmonary edema.
Shortly following the death of the patient, the patient’s father and underage daughter filed a wrongful death lawsuit against the ED, ED physician, gastroenterologist, the surgery center, the anesthesiologist, the insured CRNA and the insured’s employer.
Risk Management Comments
Plaintiff experts stated that this patient was not an appropriate candidate for this procedure at a surgery center due to her cardiac issues and no one bothered to check and see if she had been cleared for surgery by a cardiologist.
There were inconsistencies in the patient’s history prior to undergoing anesthesia. Defense counsel for our insured was concerned that a 39 year-old female going in for a “routine outpatient procedure” and having a bad outcome coupled with clear documentation of cardiomegaly without a cardiac evaluation would be hard to defend.
Our insured was extremely well qualified to perform this procedure and in fact stated that he had performed approximately 200 of these types of cases.
Several experts reviewed the case and gave mixed reviews of the actions of the insured CRNA. While the experts all agreed that it was the physician’s responsibility for gathering information and clearing a patient prior to surgery, the insured should have taken a more active role in reviewing the medical records and assuring the patient was safe for surgery. To make matters worse, the insured stated in his deposition that he did not review the patient’s medical records prior to administering the Propofol.
Resolution
The insured requested that the claim be resolved and an attempt to mediate the case was successful.
Risk Management Recommendations
- Review medical history, evaluating patients and determine if patients are appropriate for anesthesia and determine the proper methods of anesthesia.
- Accurately measure and monitor the level and speed at which anesthesia is administered.
- Monitoring patient's vital signs to ensure safety.
- Provide and document the practitioner notification of a change in condition/symptoms/patient concerns and document the practitioner’s response and/or orders.
- Report any patient incident, injury or adverse outcome and subsequent treatment/response to risk management or the legal department.
The above examples are not intended to establish any standards of care, to serve as legal advice appropriate for any particular factual situations, or to provide an acknowledgement that any given factual situation is covered under any CNA insurance policy. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All CNA products and services may not be available in all states and may be subject to change without notice. "CNA" is a service mark registered by CNA Financial Corporation with the United States Patent and Trademark Office. Certain CNA Financial Corporation subsidiaries use the "CNA" service mark in connection with insurance underwriting and claims activities. Copyright © 2018 CNA. All rights reserved.