This case involves a child who was diagnosed with sickle cell disease and asthma during his first year of life,¹ and was frequently hospitalized for ear infections, upper respiratory infections, and sickle cell pain crisis. At age one, the child’s pediatrician referred him to an ENT clinic for an evaluation of his symptoms. Dr. B, an ENT surgeon, reviewed the medical records and performed a physical examination. He recommended the patient undergo a Bilateral Myringotomy Tympanostomy and Tubes (BMT) and adenoidectomy to eliminate the recurring ear infections and reported mouth breathing. Dr. B noted that because of past medical history of sickle cell disease, the patient should be hospitalized following the surgery for close observation and potential complications. The child’s parents elected to follow Dr. B’s recommendation and scheduled surgery.
The day before surgery, Dr. G, an anesthesiologist, reviewed the case and noted that the patient was at a very high risk of brain injury and death due to the sickle cell disease and asthma. Dr. G recommended the pediatric team admit the patient the day before surgery to receive proper hydration. Her request was not addressed. On the day of the scheduled surgery, Dr. G raised her concerns to Dr. B about the possible outcomes. Again, Dr. G’s concerns were ignored, and surgery proceeded as planned.
The morning of surgery, Dr. B discussed the standard risks associated with the procedure and anesthesia with the child’s father. However, he did not address the specific concerns presented by Dr. G that the patient had a considerable risk of brain injury and death because of the sickle cell disease and asthma.
During the procedure, the child experienced respiratory difficulty and an abnormally increased heart rate that eventually decreased. The anesthesiologist tried to control the breathing throughout the procedure by adjusting the ventilator settings, but was unsuccessful. The fluctuating heart rate was not monitored regularly and medication to control it was not administered. The child’s blood pressure was also not monitored and decreased dramatically.
During the procedure, the surgeon was informed of the poor ventilation, heart failure, and low blood pressure signaled by the monitoring devices, yet decided to continue with the surgery. One hour into the surgery, the patient went into asystole. The surgical team performed cardiopulmonary resuscitation (CPR) for appoximately 10 minutes until they regained rhythm.
Postoperatively, the child was diagnosed with permanent global neurological impairment due to anoxia from cardiac arrest. He now suffers from multiple daily seizures and is immobile and nonverbal. He requires 24-hour nursing care, ventilator assistance, and a feeding pump. Medical experts estimated his life expectancy to be no more than 21 years old.
The child’s parents filed a medical malpractice action in Maryland. The case proceeded to trial with a $14.2M verdict, including $770,000 in noneconomic damages, awarded to the child and his family. The court found that the anesthesiologist failed to manage the patient’s cardiopulmonary deficits during the procedure and allowed the procedure to continue without gaining control of the cardiopulmonary system or ensuring the patient was stable to continue with the surgery.
The ENT surgeon was found negligent for not addressing the medical device alarms and anesthesiologist’s concerns about the cardiopulmonary deficits and for failing to perform the procedure in the standard time (approximately 25 minutes). The court also found that the physician breached the duty to inform the child’s parents of the serious increased risk of the patient’s comorbidity because of the sickle cell disease and asthma.
Treatment of any patient should be a coordinated effort by a comprehensive care team who can collectively address concerns and collaborate on the best course
of treatment with the team lead.
In this case, the care team included the pediatrician, ENT physician, anesthesiologist, and other ancillary staff members. When the anesthesiologist reviewed the patient’s records, she recommended the patient be admitted to the hospital for fluids and other medical treatments to reduce risk of brain injury and death. Her advice was ignored, but as a vital member of the team and expert on the side effects of anesthesia, she should have cancelled the procedure. If any member of the care team voices valid concerns, all alternative options should be considered and explored.
Another issue was the clarity of the informed consent and the explanation to the parents of the risks and benefits of the procedure. In this case, the ENT surgeon provided an explanation of the procedure's risks and benefits using standard terminology without explaining the specific risks to this child, i.e., death and brain injury, given his history of sickle cell disease and asthma. As the anesthesiologist reviewed the documentation and consent, she should have asked why the increased risk of death and brain injury was not included.
In conclusion, every care team member is an expert in their specialty. The surgeon is an expert in performing the procedure, the anesthesiologist is an expert in providing anesthesia during the procedure, and the pediatrician is the expert in medically managing the patient before and after the procedure. Accordingly, every care team member should listen to one another to provide the best treatment possible for the patient.
Robert Parhizgar is a Senior Risk Management & Patient Safety Specialist. Questions or comments related to this article should be directed to RParhizgar@CAPphysicians.com.
¹O’Neil, Madeleine. “Family wins $14M medical malpractice verdict over son’s botched surgery.” Maryland The Daily Record June 27, 2022.