Patient was 82 y/o male who underwent significant cervical fusion with instrumentation. He apparently bit his tongue intra-operatively which began to swell in the PACU. Patient was moved to Neuro ICU. Tongue continued to swell. From 10:00pm -11:25pm patient progressed to full airway obstruction and coded. Unable to re-intubate and surgical airway obtained. Unfortunately, too much time elapsed and patient died. Issue to evaluate is conduct of ICU RN in failing to monitor and/or contact intensivist sooner.
We need an RN with ICU experience. Michigan law is very specific. For the year preceding the date of the occurrence ( 7/13/2020) the expert must have devoted a majority of his or her professional time to the active clinical practice in the same specialty. Therefore, I would need an RN who has spent more than 50% of his/her time in the ICU.
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Do you believe there might have been medical error?
This opinion is based on the information provided and may change once the case is reviewed in its entirety. Based on the information provided, there are many points at which there could have been potential medical and nursing errors. I would question medical judgement from the OR to the ICU as well as the nursing judgement in PACU and ICU. I would also scrutinize the communication between departments during transfer. I would take a close look at the objective and subjective patient information in the chart and can effectively identify what should have been done based on both the ICU and PACU standard of care. Any shortfalls in judgement, assessment, or timely intervention could point to a medical or nursing error in this case. I would have to see the "big picture" in the patient's history, surgery details, medications administered, and airway management but medical and nursing staff to render my expert opinion.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Please see the answer above. Causation would be determined by reviewing the same information listed above. Based on the information provided, it does appear that there is a direct causation between inadequate nursing care and a poor patient outcome.
What makes you a good expert for this case?
I would be a good expert for this case because I have almost ten years of experience as an ICU nurse. I was active in ICU for 100% of my time at work during the time frame in question. I also hold a board certification in ICU nursing, or CCRN (Critical Care Registered Nurse) certification. I have a solid track record of excellence in ICU nursing, educating new ICU nurses, providing care as a Rapid Response nurse, and have worked in departments such as Telemetry and PACU. Additionally, I have done expert witness work as an ICU expert witness. The feedback that I have gotten from attorneys is that my report was so thorough that I was able to find several new points to each case that added value to it. I would love to provide my CV and fee schedule to show my experience.
How often do you encounter cases similar to this one in your practice?
The largest case I've worked on has some similarities based on the information provided. ICU nursing care is unique in that most patients are so critical that if there are lapses in judgement the patients can have catastrophic outcomes such as this unfortunate example. I can speak to the details of this in that I can "read between the lines" and tell you everything that should have been done based on the ICU standard of care down to the minute. Airway management is something that is a focus of every single patient in ICU for which I have cared for over the entire course of my career, so I know I can speak to that.
Do you believe there might have been medical error?
Depending on when the swelling was noticed, the patient most likely should never have been extubated. The patients go to the PACU to recover from anesthesia and generally do not leave there until they have met recovery criteria. Re-intubation after surgery often happens in the PACU when there are complications. The question is, if the swelling was noted in the PACU, what criteria did the PACU staff use to decide that the patient should leave the PACU without intervention? And what made them decide to send the patient to the Neuro ICU? A cervical fusion would not generally be sent to the ICU unless they were already worried about complications. If they were already worried about the patient’s airway, then the patient should have been evaluated immediately by an Intensivist (either while still in PACU or immediately upon ICU arrival.)
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This could possibly be a case of failure to intervene, but if the death was truly due to airway obstruction from tongue swelling, then there is no causation. Even if the swelling were a direct result of a medical professional inflicting harm, that harm did not cause the patient to go into respiratory arrest. Respiratory arrest could possibly have been prevented with early re-intubation, but even that does not suggest causation.
What makes you a good expert for this case?
I have been a Critical Care Registered Nurse for ten years, working in a variety of different ICUs and the Rapid Response Team. I’ve been involved in numerous codes involving respiratory arrest, and specialized in Early interventions while serving on the Rapid Response team.
How often do you encounter cases similar to this one in your practice?
Respiratory distress and respiratory arrest are very common situations in Critical Care. Management of respiratory distress is a daily occurrence.
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