News: In 2008, a woman began a series of three epidural steroid injections, the first two of which were administered without complication. The patient was scheduled to receive the third injection on Sept. 16, 2008. When the procedure began, the physician administered two sedatives and positioned the patient facedown on the surgical table. Shortly after, a monitoring instrument alerted the physician and his support staff that the patient had started to lose blood oxygen saturation.

The physician rejected his support staff’s requests to resuscitate the patient and to transport her to an ED. The procedure lasted a short time, but the patient was left with low blood oxygen levels for sufficient time to cause severe brain trauma and quadriplegia for the remainder of her life. The estate was successful in the initial trial, but the state’s supreme court reversed the verdict in 2018 because the jury was improperly instructed on liability.

Background: An anesthesiologist and pain management specialist began treating a patient for chronic back pain in 2008. This treatment included two epidural steroid injection procedures (ESIs) that were administered without complications. On Sept. 16, 2008, the patient arrived at the surgery center for a third ESI. The physician took the patient’s vitals, administered a pain reliever and a sedative, and placed the patient face down on a surgical table. Shortly thereafter, the physician administered propofol (a different sedative) and started the procedure. The patient’s blood oxygen saturation level at this point was recorded at 100%.

After the procedure began, the pulse oximeter sounded an alarm, indicating a drop in the patient’s oxygen level. A surgical technician tried to turn up the oxygen several times, but each time was told by the physician to return to the imaging machine she was operating. A nurse turned up the oxygen being administered to the patient at the physician’s direction. The nurse began performing a jaw thrust maneuver to open the patient’s airway by repositioning her jaw. However, the nurse was having difficulty with the maneuver, and the physician ceased the administration of the epidural and assisted with the jaw thrust.

The surgical technician asked the physician if she should call the nursing director, but he told her not to because the patient was breathing and her airway was good. The surgical technician summoned the nursing director anyway using a surreptitious text message. When the nursing director arrived, the patient was lying face down on the table with five-inch needles in her back and the physician was at the head of the table holding the patient’s jaw to maintain an airway. During this time, the pulse oximeter continued sounding an alarm and registering zero, and the blood pressure monitor was recycling, inflating repeatedly without registering a reading.

The nursing director grabbed a stretcher so that the patient could be turned on her back and resuscitated, but the physician prohibited resuscitation. He instead claimed that the pulse oximeter was malfunctioning and did not show the patient’s true oxygen saturation. He further stated that the patient had a pulse, was breathing, and was fine. The physician directed the nursing director to retrieve a second oximeter which she placed on the patient’s toe, but it also registered a reading of zero oxygen saturation. The physician continued to insist that everything was fine and resumed the procedure as various staff attempted to physically maintain the patient’s airway. The procedure was finally completed 18 minutes after it began.

After completion of the procedure and removal of the needles, the patient was turned onto her back and placed on the stretcher. A pulse oximeter began registering a blood oxygen level in the low 50% range. The patient was then given medication to reverse the effects of some of the medication in her system, and the physician began manually ventilating her with a bag valve mask. Her oxygen levels quickly rose to the 90s, and she was able to maintain that level with oxygen being administered.

The patient was taken to the ED in a state of acute respiratory distress that same evening, but it was too late. She was cognitively impaired and a quadriplegic for six years until her death. The patient’s estate sued the physician, the nursing director, the surgery center, and a related professional corporation. The plaintiffs presented evidence that she suffered a catastrophic brain injury caused by oxygen deprivation during the ESI and that she died from complications of that injury.

A jury found the nursing director not liable but otherwise found for the plaintiffs with an award of almost $22 million, with 50% liability to the physician, 30% to the surgery center, and 20% to the professional corporation. However, after a lengthy appeal process, the state’s supreme court determined that the jury was improperly instructed on liability, reversing the award and ordering a retrial.

What this means to you: Legal procedures aside, this case shows the need for hospitals to implement procedures for the proper management of hypoxia, especially when a patient is anesthetized. If a patient is left for a significant amount of time without adequate blood oxygen saturation — and certainly if he or she has a zero-oxygen saturation — severe harm can result. Hypoxia should be treated as an emergency situation, and oxygen therapy should be approved in a hypoxia situation without the need for physician direction or prescription. While hypoxia itself is a symptom, not a diagnosis, the underlying cause must be determined for adequate treatment. Hypoxia often can be caused by pneumonia, shock, asthma, heart failure, pulmonary embolisms, myocardial infarction, postoperative states, pneumothorax, and abnormalities in the quality and quantity of hemoglobin. In conjunction with the administration of oxygen, medical professionals can use several different techniques to ensure the patient returns to a healthy blood oxygen saturation level.

Another lesson from this case is demonstrated by the way the surgical center functioned. When staff recognize an emergency situation, they must take immediate action. Notifying the anesthesiologist in this case was appropriate. However, when the anesthesiologist did not take immediate action, the staff should have felt empowered to speak up and insist. The nurse should have informed the doctor that she was calling the nursing director despite his protests, rather than taking a clandestine approach. The nursing director should have insisted that the anesthesiologist remove the epidural needles, turn the patient on her back, place an oral airway, and ventilate the patient. While there were many individuals involved, the physician incorrectly disregarded these concerns and the individuals were unable to ensure proper action.

All healthcare organizations must put policies and procedures in place that empower staff to quickly activate the chain of command when faced with an emergency situation that is not being handled appropriately by the person in charge. It is far better to have an angry physician whose orders were not followed than a harmed patient and a lawsuit. Additionally, healthcare organizations should consider policies that mitigate and deter physician bullying, a common cause of staff reluctance to intervene.

Hospitals also should ensure procedures are in place in emergency situations for the transfer of patients to an ED. Moreover, hospitals should develop interfacility transfer procedures where a patient’s needs cannot be fully met due to lack of specialty or equipment. Accurate documentation of the reasons for and the specifics of transfers are critical to ensure a thorough medical record. One particularly attractive option is an electronic sign-in/out system to track patient records and locations. An electronic system easily can be more efficient than an oral and paper transfer system.

More important, though, is developing a set of procedures that prescribe under what circumstances a patient should be transferred. Patients have the right to transfer between medical care facilities based on preference, but the more appropriate focus is on situations where the actual care of the patient depends on a transfer. To ensure intrafacility transfers are conducted efficiently, medical professionals should be familiar with hospital departments and specialty areas. Personnel should be trained on common disorders and illnesses that a facility is not capable of treating. Finally, hospitals must keep a record of nearby medical facilities that can treat disorders and illnesses that they cannot. This allows for the most efficient transfer and can foster collegiality among facilities.

In this matter, the patient’s injury was indisputable, but legal procedure plays a critical role in any malpractice case, regardless of the nature and extent of the patient’s injury. Such procedure can be complicated and necessarily varies from state to state. Healthcare professionals are wise to consult closely with attorneys to weigh the prospective procedural challenges to medical malpractice cases. As demonstrated with this matter, the jury’s incorrect instruction on the issue of liability resulted in the reversal of a multimillion-dollar award. That is not necessarily the end of this litigation, but it is a temporary reprieve and provides the healthcare professionals with another attempt to convince a jury that they provided care within the appropriate standards.

REFERENCE

Decided on March 5, 2018, in the Supreme Court of Georgia; case numbers S17G0732, S17G0733, and S17G0737.