by Rachel Pollock, Marketing and Brand Specialist, and
Susie Edwards, Lead Risk Management Representative
Presentation
On October 12, a 70-year-old man came to the emergency department with dizziness, fatigue, pale complexion, tachycardia, left upper abdominal pain, and dark stools. He was seen by a gastroenterologist, who diagnosed upper gastrointestinal bleeding, duodenal ulcer on imaging, and acute blood loss anemia.
Physician action
On October 13 at 10:29 a.m., the patient was prepped and taken to the procedure room for an upper endoscopy by the gastroenterologist. An anesthesia assistant (AA) provided monitored anesthesia care (MAC) under supervision from an anesthesiologist. The procedure started at 10:35 a.m. The supervising anesthesiologist was not present when the procedure started.
The gastroenterologist identified several ulcers with exposed blood vessels. Unable to place clips on the vessels because of movements he associated with the patient's spontaneous breathing, the gastroenterologist asked the AA to make the patient temporarily apneic so he could place the clips. The AA attempted to deepen the anesthesia with additional propofol and maintained an almost constant jaw thrust for airway patency.
At 11:10 a.m., the AA placed a small nasopharyngeal airway to help with ventilation. Soon after, large amounts of blood were seen in the patient's mouth and nose. It was presumed the bleeding was coming from the nasal mucosa following the airway placement. The AA injected oxymetazoline into the nostril, pressure was held, and frequent suctioning of the oropharynx was required. He then performed a direct laryngoscopy, found the vocal cords closed, and was unable to intubate the patient.
At 11:17 a.m., the anesthesiologist arrived and took over intubation attempts from the AA. The anesthesiologist believed they had successfully placed a 7.5 mm endotracheal tube; however, capnography did not show a carbon dioxide waveform. Oxygen saturation was soon noted as 80 percent from the patient's spontaneous breaths after the succinylcholine wore off. A new capnography module was brought into the room, but again no carbon dioxide was detected, indicating esophageal intubation.
At 11:18 a.m., the anesthesiologist removed the endoscopy tube and attempted another intubation, but carbon dioxide was still not detected. The patient developed hypotension, bradycardia, and hypoxia.
At 11:26 a.m., the patient had pulseless electrical activity, and full resuscitation efforts were started. Hand ventilation was described as difficult, and the patient did not respond. At 11:40 a.m., a repeat laryngoscopy showed esophageal intubation. The tube was removed, and another was properly inserted.
By 11:46 a.m., spontaneous circulation was restored. The patient was stabilized and transported to the ICU on full mechanical ventilation. On October 15, an MRI showed diffuse anoxic brain injury, and the patient remained unresponsive. Life support was removed, and the patient died on October 25.
Allegations
A lawsuit was filed against the anesthesiologist and the AA, alleging that they failed to use general anesthetic with a secure cuffed endotracheal tube. It was also alleged that they did not meet the standard of care in managing a patient with bleeding ulcers or known severe upper gastrointestinal bleeding.
Legal implications
A consulting expert for the plaintiff stated that the standard of care for a patient with a known or suspected upper gastrointestinal bleed during an upper GI endoscopy is to use a general anesthetic with either video assisted or traditional rapid sequence induction with a secured cuffed endotracheal tube for airway protection. He believed that the lack of an endotracheal tube was not safe in this instance due to the risk of pulmonary aspiration.
Consultants for the defense were mixed but generally more supportive of the anesthesiologist’s actions. They believed using MAC anesthesia met the standard of care. One expert was critical of the gastroenterologist for not communicating the high probability for blood in the stomach. This could have given the AA more time to intubate before a crisis developed.
This consultant also stated that blood and gastric secretions were filling the patient’s nose, not blood from the nasal airway. Confusion on proper endotracheal tube placement was noted as “understandable” given the malfunction of the ETCO2 tubing; the patient’s increased blood and secretions; and the patient’s unexpected anatomical challenges.
Another defense expert was critical of the poor communication between the gastroenterologist and the anesthesia providers, stating that the anesthesiologist should have been called in sooner either by the AA or the gastroenterologist.
Disposition
This case was settled on behalf of the anesthesia assistant and the anesthesiologist.
Risk management considerations
In this case, poor communication between the surgeon and anesthesia team contributed to the patient’s outcome and was a major weakness in the defense of this case. Communication failures among team members are often cited as common causes of medical errors and adverse events.1 The Joint Commission reported that failures in communication, teamwork, and with consistently following policies were the leading causes for reported sentinel events in 2023.2
However, awareness has grown within operating teams that communication breakdowns can be a fundamental barrier to safe, effective care. A recent report shows that two-thirds of nurses and physicians cite better communication as the most important element to improving safety and efficiency in the operating room.3
To improve patient outcomes, the health care team should consider the specifics of each clinical scenario they face. Factors to consider include patient characteristics (age, level of cooperation, medical comorbidities), surgeon/anesthesiologist preference, and type of surgery being performed. A quick discussion of the risk factors or critical issues for each procedure can facilitate good communication between the surgery and anesthesia teams.4
The time-out before a procedure, when the surgical team pauses to confirm the correct patient, procedure, and site, also provides an opportunity for increased communication. Starting with the procedure, the anesthesiology team “could ask what the surgeon is going to do. Standing up and showing interest is helpful as well as sharing any new procedure” the anesthesiology team might use. “If time permits, engaging in pre- and postoperative surgical rounds goes a long way to better understanding ... Participate in hospital committees, especially OR committees and infection control, where working as a team can be emphasized.”5
Sources
- WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. Geneva: World Health Organization; 2009. Objective 9, The team will effectively communicate and exchange critical information for the safe conduct of the operation. Available at https://www.ncbi.nlm.nih.gov/books/NBK143239/. Accessed August 7, 2024.
- The Joint Commission. Sentinel Event Data, 2023 Annual Review. 2024. Available at https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/2024/2024_sentinel-event-_annual-review_published-2024.pdf. Accessed August 7, 2024.
- The Joint Commission. Sentinel Event. Statistics. 2024. Available at https://www.jointcommission.org/resources/sentinel-event/. Accessed August 7, 2024.
- Smith G, D’Cruz JR, Rondeau B, et. al. General Anesthesia for Surgeons. StatPearls [Internet}. Updated August 5, 2023. Available at https://www.ncbi.nlm.nih.gov/books/NBK493199/. Accessed August 7, 2024.
- Frost EAM. Let’s start with my name: Improving communication in the OR. Anesthesiology News. September 10, 2021. Available at https://www.anesthesiologynews.com/Review-Articles/Article/09-21/Let-s-Start-With-My-Name-Improving-Communication-in-the-OR/64543?sub=A1C5F16D9D2EB0683BAAF5C77F93FB673E9A33C115344984C7CB1233BEED. Accessed August 7, 2024.
Rachel Pollock is available at rachel-pollock@tmlt.org.
Susie Edwards is available at susie-edwards@tmlt.org.
