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Vascular Surgery

Comments are accepted only from Vascular Surgery experts.

Large AAA in 56yo male, possible delay in intervention, resulting in rupture and death in hospital.

Compensation: $120 for each expert. Expert(s) requested: 2

4 Responses

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Case Overview

Location: FL
56 years old, Male
Past Medical History: HTN, CAD
Past Surgical History:

56-year-old male with a history of hypertension, CAD.

July 5 (Friday) Goes to ER with 10/10 abdominal and back pain. CT shows large, calcified, partially thrombosed infrarenal aortic aneurysm measuring 8.6 cm in diameter and 11 cm in length. Collaterals had already began to form. IP also has history of aortic dissection in the family. Vascular surgeon is consulted who recommends surgical repair (obviously), elects to do an EVAR, but it is not scheduled until July 8 (Monday). He wanted cardiac clearance.

Cardiology sees him on Friday the 5th, orders an echo to finish off the clearance. TTE echo was done on Saturday the 6th in the morning and he was “cleared”.

After the echo was completed, multiple nursing notations show that he was complaining of extreme abdominal and back pain for the remainder of Saturday night into Sunday morning. They also noted multiple times that no further testing was pending or ordered. He was getting Dilaudid IV multiple times with little/no relief. The surgeon and hospitalists were notified multiple times, no additional radiology or testing was ordered, but they added Simethicone.

At 7a.m. on Sunday the 7th, IP is tachycardic and unresponsive. Rapid response is called and he is now in full cardiac arrest. They work him for about an hour. He is pronounced dead at 7:57 a.m.

Attached you will find a screenshot of the CT scan and treatment plan, etc.

We seek an expert with current and past experience in AAA management, has performed EVAR and/or open repairs of similar AAA's in this case.

Thank you in advance. Files:

4 Responses

Rewarded!

Do you believe there might have been medical error?

10 - Definitely Yes

This is a classic presentation of a symptomatic infrarenal aortic aneurysm. Per the CT read it is not ruptured setting up a clinical picture of an urgent repair (that is admission to the intensive care unit, clearance of possible and expedited repair).

Do you believe there might have been causation (i.e. the medical error resulted in an injury)?

10 - Definitely Yes

Symptomatic aneurysms need to be addressed at the time of admission. As in this case, work up with cardiac clearance and other test is reasonable as long as the patient symptoms are stable and the patient remains hemodynamically stable. However, in the setting, the patient needs to be taken to the operating room on Sunday or Saturday after Clarence was obtained. This is a clear violation of the standard of care.

What makes you a good expert for this case?

My practice and I handle roughly 20 to 30 aortic aneurysm cases a year. Commonly a handful of these present in a symptomatic fashion. We have managed these in the correct way within the standard of care as outlined above.

How often do you encounter cases similar to this one in your practice?

A handle full of aortic aneurysms present this is manner is a given year.

Rewarded! Hired!

Do you believe there might have been medical error?

10 - Definitely Yes

I completed my fellowship at Stanford where we specialized in treatment of complex aortic aneurysms. I furthermore completed an additional aortic fellowship in China. One of the tenants of aortic aneurysm treatment is symptomatic aortic aneurysms ( especially of this size) need to be fixed emergently. Even though the CTA did not read rupture, this should have been done in a more expeditous fashion. Cardiac "clearance" is a misnomer as in this case, would not change decision making and patient should goto OR. Patient has to accept cardiac risk.

Do you believe there might have been causation (i.e. the medical error resulted in an injury)?

10 - Definitely Yes

Please see above however the patient ruptured the aneurysm in the time that was a delay to the operating room. If this was fixed expeditiously, he would not have ruptured.

What makes you a good expert for this case?

I have done countless number of endovascular aortic repairs for aneurysm and dissection. I have testified previously in these cases as well. I have a second non acgme fellowhsip for advanced endovascular aortic work internationally. In my current practice, I do aortic aneurysm repairs regularly and frequently (symptomatic/asymptomatic/ruptured).

How often do you encounter cases similar to this one in your practice?

As mentioned above, I routinely perform operations on these types of cases. We do anywhere from 30-50 a year and a mix of symptomatic/asymptomatic/ruptured. I have done hundreds in my career and would be happy to review this case for you.

Do you believe there might have been medical error?

8 - Very Likely

Although the CT did not show frank signs of rupture, this is a very large (> 8 cm) aortic aneurysm that was symptomatic. Symptomatic aneurysms portend to imminent rupture and ought to be repaired urgently. The optimal timing for repair of symptomatic nonruptured abdominal aortic aneurysms has not been well established. The timing for surgery ought to be individualized to a particular patient's clinical details. In this case, it is likely that the patient's complaints of severe back pain were misattributed to his history of L4-5 lumbar fusion. However, chronic back issues and history of lumbar fusion would not account for his severe abdominal pain. In fact, urgent surgical repair is indicated for patients with symptoms that cannot be unequivocally attributed to another etiology, regardless of size. Initial evaluation by cardiology to medically optimize the patient may have been justified. Nevertheless, once the patient was subsequently "cleared" or optimized by cardiology Saturday morning, there was no good reason to delay the surgery further until Monday, given the patient's continued complaints of severe abdominal and back pain. At the very least, when the surgeon and hospitalist were notified multiple times of unremitting abdominal and back pain, they should have considered the possibility that the symptoms were due to the aneurysm and that the patient was progressing to rupture. This consideration should have prompted either bringing the patient to the OR more urgently or, at minimum, obtaining subsequent imaging with CT to confirm frank rupture or to look for interval radiographic changes suggesting impending rupture, such as periaortic fat stranding, periaortic fluid, broken calcification, asymmetry, etc. Any of these CT findings or the patient's continued unremitting pain should have prompted emergency surgical repair.

Do you believe there might have been causation (i.e. the medical error resulted in an injury)?

9 - Extremely Likely

The patient presented with a symptomatic nonruptured aortic aneurysm and died of a frank rupture 2 days after hospital admission. The delay in diagnosis of the rupture and delay in surgical treatment are a breach of the standard of care and, more likely than not, the proximate cause of death.

What makes you a good expert for this case?

I am a board-certified vascular surgeon who has performed open and endovascular surgical repair of abdominal aortic aneurysms in both the elective setting and the emergency ruptured setting. I am experienced in reviewing medical malpractices cases for both plaintiff and defense. I am experienced in giving deposition and trial testimony as an expert witness. I have an active Florida Medical Doctor Expert Witness Certificate.

How often do you encounter cases similar to this one in your practice?

Symptomatic nonruptured aortic aneurysms are less common than ruptured aortic aneurysms and much less common than asymptomatic nonruptured aneurysms. In my 12 years of practice, I have encountered a similar scenario in a patient admitted with a large asymptomatic nonruptured aneurysm. The patient subsequently progressed to becoming symptomatic. Upon being notified, this prompted me to obtain immediate repeat imaging, confirming a rupture. While the imaging was being obtained, I simultaneously called in the OR team for suspected rupture in order to bring the patient to the OR for emergency surgical repair in the middle of the night. The standard of care is to minimize delays when aneurysm rupture is suspected.

Do you believe there might have been medical error?

10 - Definitely Yes

This patient has a large, essentially symptomatic aneurysm. That is considered a surgical emergency and needs repair immediately. The request for cardiac "clearance" is a stalling tactic. The surgical management shouldn't change, as the risk of a cardiac event perioperatively that would lead to his demise is certainly much smaller than his near-certain risk of death from rupture of his aneurysm.

Do you believe there might have been causation (i.e. the medical error resulted in an injury)?

10 - Definitely Yes

Delay in repair = randomized to chance. Rupturing a symptomatic aneurysm IN THE HOSPITAL is inexcusable.

What makes you a good expert for this case?

I am a managing partner in a CT and Vascular practice with 24 years experience. I repair 50 to 60 aneurysms a year, both open and Endovascular. I am happy to discuss this case in more detail at your convenience.

How often do you encounter cases similar to this one in your practice?

We treat 4 or 5 symptomatic aneurysms each year. In each case, the patient is treated on the day of diagnosis. We consider this standard practice for our hospital systems.

Urology - Pediatric Urology

Comments are accepted only from Urology - Pediatric Urology experts.

Testicular Torsion

Compensation: $120 for each expert. Expert(s) requested: 2

2 Responses

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Case Overview

Location: FL
1 years old, Male
Past Medical History:
Past Surgical History:

Baby Boy is delivered on November 19, 2019. He was small for gestational age (2840 grams/ 48.5cm birth length) On admission to Nursery he is evaluated by APRN for pediatric hospitalist. APRN notes normal external male genitalia and scrotal edema.

Baby is seen again on November 20, 2023 by different rounding APRN for hospitalist group. On exam he is noted to have normal external genitalia and descended bilateral testes.

Baby is discharged on November 21, 2023. APRN notes at that time "normal external genitalia".

Baby begins seeing out patient pediatrician on November 22, 2023. The Peds MD notes "testes down" and genitalia grossly normal.

Follow up visits with Peds MD occur on December 4, 2023, January 24, 24 and April 1, 2024. At each visit, Peds MD notes testes down.

Baby is subsequently seen on May 20, 2024 by Peds MD. During this visit, Peds MD notes that the male left testicle was "not palpable". Her plan was to reevaluate in one month.

On June 19, 2024 at 2242, Mom brings Baby to emergency room with complaints that Baby is having groin pain and swelling. He had reported discomfort with diaper changes for two days and poor appetite. The ED MD notes swelling to the left inguinal area and that he was unable to palpate the left testicle. An ultrasound is completed and interpreted as showing "A heterogenous, ovoid shaped structure within the left goin, favored to represent the undescended left testicle. It is difficult to determine if this represents an enlarged left testicle with intratesticular lesions-herterogeneity versus the left testicle and an adjacent prominent epididymis. There is color flow at the periphery and internal vascular waveforms are noted. Intermittent torsion of the undescended left testicle with areas of infarction are a consideration." Baby is transferred to facility with peds urologist at 0205.

Baby seen at 0314 by peds urologist. He notes Mom only noted left groin swelling and inflammation last night. He further noted that family has never seen testicle within the scrotum. Mom states left groin became hard and left scrotum became more enlarged which prompted visit to ER. Peds Urologist noted that on repeat scrotal sonogram, there appeared to be some congestion of the cord and flow to the cord itself. There was artifact when patient was crying, however, he found no convincing intratesticular flo.w. He recommended surgical exploration.

Surgery begins at 0541. Peds Uro notes left testicle to be located just outside the external ring with a severe inflammatory fibrinous phlegmonic type of reaction. The testicle was fixed within the inguinal position and demonstrated necrosis of with 540 degrees of clockwise torsion. The testicle was untwisted and appeared nonviable, necrotic black testicle, epididymis and distal cord structures.

Exploration and fixation of the right testicle revealed evidence of bell clapper and almost complete inversion anatomy of the testis.

Questions:

1. Given the surgical description and findings on ultrasound, is it likely the left testicle had ever descended as described by the APRN's after birth and the outpatient pediatrician?
2. If the answer is yes to 1, why would it then be in the inguinal canal.
3. Was an emergent or urgent referral to a pediatric urologist warranted in May 2024, when the pediatrician first notes undescended left testicle? This would have been around the 6 month visit after birth.
4. Assuming an urgent referral is made to a peds urologist on May 20, 2024 by the pediatrician, would the standard of care of necessitated the peds urologist to complete an ultrasound of the testicle and take the Baby surgery for the undescended testicle before he begins exhibiting symptoms on June 18, 2024?
5. Simply put, I am determining whether an earlier referral by the pediatrician on May 20, 2024 to peds urologist would likely have changed the outcome. Files:

2 Responses

Rewarded!

Do you believe there might have been medical error?

2 - Extremely Unlikely

I assume that the baby was delivered on November 19, 2023, not 2019 as noted in the narrative. At birth and on days 1 and 2 both testicles were noted to be descended. At 4 subsequent visits by an MD up to April 1, 2024, both testicles were noted to be descended. On May 20, 2024, the left testicle was nonpalpable. The pediatrician appropriately recommended a follow-up evaluation in 1 month. Before the follow-up visit occurred, the baby developed torsion of an inguinal undescended testicle. According to the ED note, the pain/swelling had been occurring for 48 hours. An emergency inguinal US was performed and showed absent flow to the testis. The baby was transferred to a facility with a pediatric urologist, who performed emergency inguinal exploration. The torsed testicle was necrotic and was removed. Torsion of an undescended testicle is an uncommon but well documented phenomenon. Below are several recent articles regarding this problem: https://pubmed.ncbi.nlm.nih.gov/29264215/ https://pubmed.ncbi.nlm.nih.gov/38313930/ https://pubmed.ncbi.nlm.nih.gov/34631427/ https://pubmed.ncbi.nlm.nih.gov/31272681/ https://pubmed.ncbi.nlm.nih.gov/29429568/ https://pubmed.ncbi.nlm.nih.gov/37455785/ Torsion of an undescended testicle is unpredictable. When a baby has an undescended testicle, referral is appropriate and orchiopexy is recommended to maximize the fertility potential of the testis. Even if the baby was recognized as having an undescended testicle at an earlier age and he had been referred to a pediatric urologist or pediatric surgeon, it is unlikely that the baby would have undergone an orchiopexy by 6 or 7 months. In fact the Guidelines by the American Urological Association on undescended testicle recommend orchiopexy by 1 year if the condition was recognized at birth and by 18 months if the condition was recognized after the neonatal period. 1. Yes, but I think that the testicle had retracted to an undescended position. 2. This is to position to which retractile testicles typically ascend. 3. Referral would have been appropriate but is not the standard of care at that point, based on the previous documentation that the testis was descended. 4. No. In fact, the AUA Guidelines specifically recommend not performing an US in this setting. In reality, often in this setting I am able to palpate the inguinal testis even if the pediatrician was unable to palpate it. 5.In my opinion, earlier referral would not have changed the outcome..

Do you believe there might have been causation (i.e. the medical error resulted in an injury)?

1 - Definitely No

At birth and on days 1 and 2 both testicles were noted to be descended. At 4 subsequent visits by an MD up to April 1, 2024, both testicles were noted to be descended. On May 20, 2024, the left testicle was nonpalpable. The pediatrician appropriately recommended a follow-up evaluation in 1 month. Before the follow-up visit occurred, the baby developed torsion of an inguinal undescended testicle. According to the ED note, the pain/swelling had been occurring for 48 hours. An emergency inguinal US was performed and showed absent flow to the testis. The baby was transferred to a facility with a pediatric urologist, who performed emergency inguinal exploration. The torsed testicle was necrotic and was removed. Torsion of an undescended testicle is an uncommon but well documented phenomenon. Below are several recent articles regarding this problem: https://pubmed.ncbi.nlm.nih.gov/29264215/ https://pubmed.ncbi.nlm.nih.gov/38313930/ https://pubmed.ncbi.nlm.nih.gov/34631427/ https://pubmed.ncbi.nlm.nih.gov/31272681/ https://pubmed.ncbi.nlm.nih.gov/29429568/ https://pubmed.ncbi.nlm.nih.gov/37455785/ Torsion of an undescended testicle is unpredictable. When a baby has an undescended testicle, referral is appropriate and orchiopexy is recommended to maximize the fertility potential of the testis. Even if the baby was recognized as having an undescended testicle at an earlier age and he had been referred to a pediatric urologist or pediatric surgeon, it is unlikely that the baby would have undergone an orchiopexy by 6 or 7 months. In fact the Guidelines by the American Urological Association on undescended testicle recommend orchiopexy by 1 year if the condition was recognized at birth and by 18 months if the condition was recognized after the neonatal period.

What makes you a good expert for this case?

I am a board certified pediatric urologist. I perform > 100 orchiopexies per year and have seen several boys with torsion involving an undescended testis.

How often do you encounter cases similar to this one in your practice?

Approximately once every 4 or 5 years.

Rewarded!

Do you believe there might have been medical error?

4 - Unlikely

There were multiple different documentation events suggesting normal testis then one documentation of undescended testis. This is not uncommon - it is called an ascended testis or can be a normal finding with growth (originally undescended but due to a long gubernaculum, looks descended until pelvic growth outpaces gubernaculum stretching). Either way, presentation after 2 days of symptoms is ominous - likely too long to save the testis with surgical intervention.

Do you believe there might have been causation (i.e. the medical error resulted in an injury)?

4 - Unlikely

Unsure what’s being asked here. Causation - no. Associated findings yes - torsion is more common in an undescended testis. Unfortunately patient presentation too late after symptoms started.

What makes you a good expert for this case?

Significant experience with undescended testes, ascended testes and testis torsion including multiple papers.

How often do you encounter cases similar to this one in your practice?

I encounter each of these diagnoses multiple times every week (unfortunately).

Anesthesiology - includes all Subspecialties

Comments are accepted only from Anesthesiology - includes all Subspecialties experts.

Failure to secure IV, monitor, and assess patient in prone position on OR table.

Compensation: $120 for each expert. Expert(s) requested: 2

7 Responses

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Case Overview

Location: NJ
57 years old, Female
Past Medical History: Other heart conditions, Cancer, Breast Cancer, CVID, Etc.
Past Surgical History: Mastectomy, Colorectal, Etc.

Patient went to hospital for colorectal surgery and was placed in the prone jack knife position without proper anesthesia. Patient made surgeon and anesthetic nurse aware she was still awake and could feel everything. Surgery was stopped and it took 45 minutes for someone to come and reinsert the IV line. While waiting 45 minutes, patient experienced severe shoulder pain and begged to be let off of the operating table. Patient's pleas were ignored and IV was set and surgery commenced. There is no documentation during said 45 minutes. We have OR notes and a sworn statement from the patient regarding the incident.

Patient ended up with an irreparable torn deltoid and cannot move her right arm. She is in constant pain and cannot resume everyday tasks. Files:

Questions & Answers

Q: was this a conscious sedation case with sedation administered by a RN or a monitored anesthesia care case (MAC) provided by a credentialed anesthesia provider?
A: —

7 Responses

Rewarded!

Do you believe there might have been medical error?

9 - Extremely Likely

Positional errors do happen under anesthesia however they are often found after the patients is woken up post operatively. In this case, there was a combination of what seems like an infiltrated IV (this the patient being awake) in addition to the position issue. This was an awake patient actively describing pain with position which should always be immediately responded, assessed, and changed if necessary. There was an error performed here.

Do you believe there might have been causation (i.e. the medical error resulted in an injury)?

9 - Extremely Likely

The patient was awake and was prone for a colorectal surgery. The fact she has an injury to the deltoid says it all. It’s not secondary to anything else but the position during the surgery. We can discuss the patient’s pre conditions however it likely would not contribute given the complete torn deltoid.

What makes you a good expert for this case?

I am a double board certified anesthesiologist and pain management physician. I review these type of cases quite often for our internal PI/QI committees.

How often do you encounter cases similar to this one in your practice?

At least once a month we encounter a position error.

Do you believe there might have been medical error?

9 - Extremely Likely

It sounds like the IV infiltrated. Very concerning that patient awareness may have been ignored

Do you believe there might have been causation (i.e. the medical error resulted in an injury)?

9 - Extremely Likely

Failure yo recognize awareness under anesthesia

What makes you a good expert for this case?

I am board certified in anesiology and critical care medicine. I am an expert in these areas and have taught these specialties for ten years.

How often do you encounter cases similar to this one in your practice?

This is common, IV infiltration can be recognized earlier

Do you believe there might have been medical error?

9 - Extremely Likely

This patient was awake and complaining of arm pain during the procedure. Her positioning should have been checked and adjusted during that time. It appears it was not, that is unjustifiable. The patient also asked for the surgery to be stopped, the fact it was not constitutes all further medical treatment as assault and should be prosecuted as such unless the patient lacked capacity for medical decision making (developmental delay, ward of the court, child, conserved status, altered mental status etc) which does not appear to be the case.

Do you believe there might have been causation (i.e. the medical error resulted in an injury)?

9 - Extremely Likely

Positioning injuries can happen during anesthesia because patient are unable to complain. In this case the patient was awake and complaining and it appears nothing was done. Unless her deltoid was torn preoperatively (does not appear to be the case) this injury was caused by a lack of care during positioning and not paying attention to the patients complaints

What makes you a good expert for this case?

Associate professor at academic medical center, in charge of quality for the department of anesthesiology.

How often do you encounter cases similar to this one in your practice?

Positioning injuries happen with about 1 pct of cases, but we have never had an injury as severe as this in a patient who was actively expressing their discomfort

Rewarded!

Do you believe there might have been medical error?

6 - More Likely Than Not

While it is difficult to make a definitive opinion given the limited information, the scenario that is posed leads to many other questions about the case. This does not list what type of anesthesia was employed. I am led to assume that it was a MAC case if the patient was able to speak and tell anyone during the case that she was hurting. If the original anesthesia plan was MAC, a functional IV was absolutely necessary for the case. If there was a CRNA involved in this case, who was the supervising physician? Is this a state that allows for independent CRNA practice. If the surgeon was the supervising physician, why was he not involved in the decisions pertaining to the patient's positioning injury and acute pain in the surgical position? It is the obligation of the anesthesia clinician to document the circumstances that led to losing the IV and it sounds like that documentation is missing. There is also no documentation for why there was such difficulty in placing the IV or how many attempts were made. I would find this negligent given the obvious circumstances that were occurring. This can be documented after the immediate incident is addressed. In addition, if it was taking an excessive amount of time to place the IV, it begs the question why the patient would not have been repositioned back to supine, especially if she was saying that her shoulder was in pain? While the patient may have some memory of these events, given administration of medications presumably, her recollection may be flawed. I would be interested in the notes of the circulating RN and surgeon's operative note. However, the past medical history of this patient implies she has some frailty and fragility. I would like to review more clinical notes pertaining to her preoperative status of any pain. It would also be helpful to know what kind of surgery was planned and if this occurred after incision was made. Did losing IV access occur at a point of the surgery when the procedure could have been aborted in order to place the patient back into supine position? This would have given the team the best ability to place a new IV efficiently. It also may have led to the discovery of her deltoid injury at this point rather than continuing to leave her in pain and in the jackknife position.

Do you believe there might have been causation (i.e. the medical error resulted in an injury)?

7 - Likely

Again, I would need to review the preoperative notes from physicians, nursing and the anesthesia personnel to determine if there was any reason for the patient to have pre-existing conditions related to her arm pain. Assuming there was none, it appears the positioning into jackknife/prone position led to her torn deltoid somehow. If it is factual that the patient was aware enough to complain of pain and the team did nothing to reposition her, there is causation. Also, given that the patient was complaining of pain in her shoulder and the team continued to anesthetize her more deeply knowing her position was painful and there was a subsequent injury, this is indicative of less than the standard of care by continuing on without repositioning her arm and continuing with the case. It also begs the question of how the patient got turned into the jackknife position. Did she position herself that way and then they began giving her sedation? Or did they sedate her and the team actively repositioned her from supine which would make her more likely to have incurred an injury. More details are needed here.

What makes you a good expert for this case?

I have been practicing anesthesiology as a physician for 20 years. I regularly cover general surgery cases which require repositioning. I also work in a care team model with CRNAs utilizing medical direction.Therefore, I understand the laws guiding the practice of nurse anesthetists and the training of these types of clinicians. I am currently the Department of Anesthesiology Chairperson and participate in the Quality and Safety Team for my facility. This duty involves review of charts and addressing service recovery when patients have complaints or concerns after their anesthesia care. In this role, I have become adept at reviewing the medical records in these scenarios and knowing where to look for specific information to investigate why complications may have occurred. I have participated in several legal cases to assist the attorneys to determine if there is negligence and have represented both plaintiffs and defendants. I practice full-time in the clinical setting and have the experience to guide what is the standards of care in my specialty.

How often do you encounter cases similar to this one in your practice?

My main facility of practice cares for many surgical oncology patients. Patients with cancer have unique circumstances especially when it comes to frailty and fragility. It appears this case involves a patient with known history of cancer. At least 25% of the practice involves general surgery for both elective and emergency cases. The addition of minimally invasive surgical approaches requires patients are repositioned safely for surgical care at least 50% of my practice. Therefore, I am keenly aware of how much vigilance is required to careful position a patient to avoid injury such as this one. I am a Diplomate of the American Board of Anesthesiology and a Fellow of the American Society of Anesthesiologists. I am active in my state anesthesia society currently and have practiced my specialty in several states across the country. In addition to my role as the Department Chairperson, I am the physician lead for our Anesthesia consensus group for the entire health system which covers quality and safety practices for 40 hospitals across 6 states.

Do you believe there might have been medical error?

8 - Very Likely

It is not clear given the provided case information if this was a sedation case with local anesthesia, a MAC case( monitored anesthesia care) or a procedure requiring general anesthesia. Was the procedure performed in the operating room suite or off site. Was there an initial IV placed that infiltrated or was an IV started after the patient was placed in a jackknife position? Who placed the initial IV- the conscious sedation nurse or the anesthesia team.? Regardless, if the IV infiltrated or otherwise was not working and the patient was aware enough to tell the sedation provider the procedure should have been halted if possible. It's not clear as to why, if this was done in the surgical suite, it would take 45 minutes for"someone to come and reinsert the IV line". The scenario would seem to indicate that this procedure was not performed with anesthesia department involvement. If the patient was aware and able to complain about arm pin during the 45 minute delay and her complaints were ignored then this would rise to a level of negligence in my opinion. As standard of care in my institution, positioning is routinely documented and includes monitoring and padding of pressure points. The patients complaints would indicate that there was a problem with her positioning and a prudent course wouls have included repositioning and/or additional padding to alleviate the discomfort prior to re establishing sedation/anesthesia.

Do you believe there might have been causation (i.e. the medical error resulted in an injury)?