Legal Review & Commentary

Morphine overdose leads to brain injury

News: A woman underwent reconstructive breast surgery following breast cancer treatment. While in recovery, the woman suffered a morphine overdose that ultimately led to the woman suffering a brain injury. The plaintiff suffers significant lapses in judgment, memory, and executive function. A $1.67 million bench verdict was entered in favor of the plaintiff in Florida.

Background: Following breast cancer treatment, a woman underwent breast reconstructive surgery. During the surgery, the woman received 10 milligrams of morphine. She was prescribed 16 milligrams of morphine to be administered in 2 milligram shots upon arrival in the post-anesthesia care unit (PACU). The woman also was placed on a patient-controlled pump for morphine in the PACU from which she received 8 milligrams of morphine. Although the woman had used morphine and other opioid-based painkillers in connection with past surgeries, she was not considered "opioid tolerant." Opioid tolerance develops in patients who use a daily dose of opioid medication, or multiple doses per day, over a prolonged period of time, thereby conditioning their livers to break down the medication. By comparison, the woman's sporadic past use of morphine would not have allowed her to build a tolerance.

When the woman was transferred to a floor, she was not placed on telemetry for monitoring. Instead, a baby monitor was utilized to monitor for alarms from the PCA pump in the woman's room. The standard orders from the PACU, which were written by a physician earlier that day, were still in effect: The nurses were to assess and document the woman's level of arousal and respiration rate once per hour for four hours, and to notify a doctor if her systolic blood pressure dropped below 90, pulse rate below 60, or respiratory rate below 10. Under the hospital's "Nursing Service Clinical Alarms Policy," telemetry floor nurses were required to use baby intercoms for patients hooked up to PCA pumps. A registered nurse on the floor activated the baby intercom in the woman's room, so that telemetry staff would be notified immediately if the pump malfunctioned. Another floor nurse acknowledged that the baby intercom would pick up sounds from any other local alarm in the woman's room, such as the alarm from a pulse oximeter.

After about an hour of being on the floor, the woman's husband complained to the floor nurses that the woman was not breathing. An evaluation revealed that the woman was breathing one to two times per minute and that she had an oxygen saturation level of 75%. She was given supplemental oxygen, and physicians prescribed a drug used to counter the effects of opioid overdose.

Due to her injuries, the woman requires permanent medical care, therapy, and treatment. She will also require future attendant care, supervision, and assistance, because her brain injury makes her dangerous to herself and others, and also because she cannot properly care for herself due to significant lapses in judgment, memory, and executive function.

The woman sued the hospital and claimed that a portable pulse oximeter should have been utilized — and that had such a device been used it would have been audible to the staff without an intercom because of the room's proximity to the nurse's station. The defendant argued that the woman was not at high risk for respiratory depression from morphine and that her vital signs had been normal. The defendant further contended that the use of oximetry on the floor was not feasible. Had the woman needed constant monitoring, she would have been placed in the PACU or ICU. The experts agreed on several important points. They concurred that the woman had taken a significant amount of morphine and that respiratory depression is the main hazard of morphine use. They also agreed that each patient reacts differently to the drug, and it is difficult to predict who may suffer respiratory depression as a side effect. Both acknowledged various factors that can increase a patient's risk for respiratory depression, including age, morphine tolerance, the cumulative effect of morphine doses over a short period of time, and whether a patient gets drowsy or falls asleep while on the drug. Both agreed that the woman did not have a tolerance to opioids, and both seemed to accept the reality that she would be apt to fall asleep after a day of surgery. Finally, both acknowledged that the hospital's health care workers have a duty to observe patients as required by the relevant standard of care, regardless of what may be indicated on doctor's orders or by hospital policies.

The matter went to a bench trial and the court awarded a total of $1.6 million.

What this case means to you: This is an unfortunate outcome to a procedure that has become routine and in reality was not the issue in the woman's anoxic brain injury. One can only assume that the surgery went as expected, and had it not been for the lapse in the post-operative care that the patient received, she would have survived and lived out her life as she and her husband fully expected her to do.

There is no discussion as to the type of anesthesia that the patient received, any effect that it may have had on her pain, or how it was to be managed post-operatively. Generally, morphine has a cumulative effect, particularly in the presence of other central nervous system depressions. The morphine administered during the procedure was to be supplemented by an additional 16 milligrams of morphine in 2 milligram doses while in the PACU, but the narrative does not provide a time frame for completion of the eight separate doses. Since there was also an order for a patient-controlled pump, there is always the possibility that the initial order for the 16 milligrams in equally divided doses was the formula for the PCA, of which she received 8 milligrams of the original 16 milligram dose. If the patient actually got the initial 10 milligrams in surgery plus an additional 16 milligrams and then 8 milligrams more over her stay in the unit, she most likely was at risk for respiratory depression.

Whatever the order, the patient's past use of morphine and the possibility of tolerance needed to be substantiated rather than assumed. Pain management in a post-surgical setting is always based on patient monitoring and response. The PACU nurse receiving the patient from the surgical suite should have verified and documented the patient's vital signs on arrival and at pre-established intervals over her stay in the unit. Electronic monitoring in such units is a standard of care, so the assumption is that when she was transferred to the floor her vital signs were stable. It can also be assumed that her pain was suitably managed and that a full report was provided between the PACU nurse and the nurse who was to assume responsibility for the patient on the floor.

Once on the floor, the nurse there would have taken a full report from the PACU and assessed the patient for post-surgical stability to include vital signs and break through pain. Generally when a patient is transferred to another unit, standard policy is to reassess the patient every 15-20 minutes, 1-2 hours, and then at diminishing frequency, based on the patient's condition and stability.

In this case, the physician ordered the assessment to be done every hour with parameters for four hours. Obviously, since she was in crisis within an hour, this was not adequate to detect respiratory compromise. The nurse had responsibility to assure the patient's ongoing stability, and knowing that she had already received at least 18 milligrams of morphine, in addition to anesthesia and any other pre/post-operative medications, the assessments initially should have been more frequent.

From the narrative, it appears that hospital policy dictated telemetry floor nurses use "baby monitors" for patients on PCA pumps. There is a disconnect here, as was there an assumption by the physician that the patient would be on telemetry and be actively monitored — or was the assumption by the floor nurse that because a "baby monitor" was in use that the telemetry nurses would assume responsibility for monitoring the PCA alarm? Since the patient was not assigned to telemetry, it would not appear that the telemetry nurses had any responsibility to monitor the alarms, and the "baby monitor" was not an appropriate substitute to pulse oximetry or some other electronic surveillance device.

The floor nurses violated the accepted standard of care, which is to frequently monitor a patient who has received high doses of a central nervous system depressant for respiratory compromise. They apparently assumed that responsibility fell to the telemetry staff, who in reality had no responsibility for this patient. Why she was not assigned to the telemetry unit remains unclear, but that may have made a difference in the outcome. The patient arrested and sustained an anoxic brain injury because of this mismanagement of what should have been a routine case.

The experts agreed on several key points that clearly established liability on the part of the hospital in respect to the standard of care provided by the floor nurses. At this point, it may have been prudent for the hospital to have entered into some sort of mediation that would have spared a trial and given more control in terms of settlement to the hospital. On the other hand given the woman's impairments from her brain injury, the $1.6 million over her lifetime may well have been a reasonable financial settlement for both sides.

Reference

U.S. District Court, Southern District of Florida, Case No. 09-23360.