41 y.o. male with a past medical history of Class Ill Obesity (BMI
91.5), HTN, Asthma presented to trauma center due to an accidental gunshot wound to the hand/left wrist.
IP underwent a debridement in the ER, while trauma surgery admitted him for additional pain management and likely additional surgical intervention. It should be noted that IP is approximately 575 lb with a sleep apnea hx.
On day 2 of admission, a rapid response was called on the admission floor due to IP being unresponsive for an unknown downtime after morphine administration. The record shows the morphine was given at 11am and was found approx 3-4 hours later in this condition. His oxygen level was 53% and apneic. Staff attempted to give Narcan with no success. IP required transfer to the ICU and was intubated.
Diagnostic show that he had an aspiration event during this time and was treated properly with antibiotics. He was extubated 3 days later. Upon extubation he was found to have profound acute bilateral hearing loss. Neurology was consulted and they diagnosed with conductive hearing loss of unknown etiology and because of weight limitations with the CT scan and MRI machines, they were unable to do any further diagnostics. Notes theorize it was intubation or sinus infection related? IP was referred to him to outpatient ENT audiology.
AUDIOLOGY EXAM ATTACHED.
IP to get bilateral hearing aids might be eligible for cochlear implants down the road. Neurology and other notations within the record do state that there was no hearing issues prior to the hypoxic and intubation event.
We are attempting to correlate the in-hospital hypoxic event and/or intubation to the sudden onset of hearing loss. Internal research has shown studies in neonates, however it is limited in adults. What about an event like this would be an etiology for the hearing loss?
Neuro note screen attached
We appreciate your time and opinions. Questions encouraged.
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Do you believe there might have been medical error?
Typically, morphine is a long acting medication and is avoided in patients who may tend to accumulate them in fat reserves in the body. Opioids are fat soluble and settle in fat cells only to slowly get released over time. The fact that this patient has sleep apnea should've prompted the providers to prefer short acting medications like oxycodone. If the pain was related to nerve injury or inflammation there are other medications that work better such as NSAIDS, high dose Tylenol or gabapentin. Topical options should've been explored. From a neurological standpoint, a stroke of the AICA branch or basilar artery cannot be ruled out. Patient has risk factors.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As mentioned above, choice of medication was under the prescribers control. Also, there should've been iv access to give narcan.
What makes you a good expert for this case?
I have experience in handling critical patients that fit the profile. I have board certification in internal Medicine, neurology and neurocritical Care.
How often do you encounter cases similar to this one in your practice?
Opioid overdose is common and I have cared for hundreds of such patients. Same goes for morbidly obese patients. I have also cared for hundreds of patients suffering from neurological issues that require the ICU.
Do you believe there might have been medical error?
It is hard to know as there are limited details provided here for the hours prior to him being found with hypoxia. I would need to see more of the chart to know what happened here.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I have never seen or heard of hearing loss in isolation from anoxic brain injury, but would be curious to know if there were any other neurological deficits noted after the anoxic event. Hearing loss is very rarely due to injury from the brain itself. I think it is much more likely that the hearing loss was due to an alternative cause such as administration of an aminoglycoside agent or high doses of loop diuretics. In a review of literature regarding this topic, there is not any significant literature describing a phenomenon of isolated hearing loss after hypoxic/anoxic injury.
What makes you a good expert for this case?
As a board-certified neurointensivist, I regularly evaluate patients with anoxic brain injury and other acute neurological problems.
How often do you encounter cases similar to this one in your practice?
While I manage cases of anoxic brain injury, I have not previously seen hearing loss in this setting, which is why I think that they are not likely to be related.
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