Welcome to a new feature of PAAD – Medicolegal Monday, where I will occasionally present a real case from my archives, and discuss the medical and legal aspects of the case. It’s a little longer than the traditional PAAD, but I think you will find it interesting.
Disclaimer for this Special Edition of PAAD: Anesthesiology is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the treating physician, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the publisher nor any editor or contributor assume any liability for any injury and/or damage to persons or property arising from this publication. Details and identifying information of the case have been anonymized.
DON’T TAKE LEGAL ADVICE FROM A BLOG! (Adopted from Opening Arguments podcast)
This is the tragic case of a 3-year-old child who died in the emergency room after aspirating portions of a peanut. His parents called 911 after witnessing him choke and turn blue while chewing on the peanut. Although they lived in a very rural area, an ambulance arrived quickly, and transported the child to a nearby hospital, which was small and unequipped to handle this type of pediatric emergency. Upon arrival to the ER, the child had marked stridor and his oxygen saturation was in the low 90s on 100% rebreather facemask. The ER attending physician, who had never treated this kind of emergency before, acted quickly:
· He called the ER of a larger facility about 10 miles away, but they were full and refused the transfer.
· The ENT specialist on call was contacted and refused to come in, claiming that he had no experience treating airway foreign bodies in children, the hospital had no pediatric bronchoscopy equipment, and the child would benefit more by contacting the regional children’s hospital for immediate helicopter transport.
· The anesthesiologist on call stated he hadn’t treated a child in 20 years but agreed to come in immediately to help.
· The ER attempted to call all the other ENT docs on staff but could find no one who agreed to come in.
· The regional children’s hospital was contacted and they immediately dispatched a helicopter, but the PL-2 pediatric resident who took the request said that their policy was only to transport children with a protected airway.
Approximately 30 minutes later, while waiting for the helicopter to arrive, the child began to tire, his oxygen saturation dropped, and the ER physician and the anesthesiologist felt that endotracheal intubation was needed immediately. They administered etomidate and rocuronium. The ER physician attempted intubation but was unsuccessful after trying several times with different sized endotracheal tubes. He remarked that the glottis was markedly swollen and covered with pieces of the peanut. The anesthesiologist also attempted intubation but was unsuccessful. During the attempts, the patient became hypoxic, developed asystole, and the team instituted CPR. Bag-mask ventilation was unsuccessful. After approximately 30 minutes of multiple personnel trying to intubate the child, they performed a cricothyrotomy and inserted an adult central line dilator into the child’s trachea, which, when attached to a bag, resulted in good chest rise. However, they were unable to achieve return to spontaneous circulation and approximately two hours after the child arrived, he was pronounced dead.
The parents of the child instituted a malpractice claim against the on-call ENT physician who refused to come in, as well as the hospital for not stocking pediatric bronchoscopy equipment, and I was retained as an expert witness by the defense attorneys.
Upper airway foreign bodies are rare when compared to lower airway foreign bodies, and much more hazardous. A peanut located in a mainstem bronchus or more distal usually presents with expiratory wheeze and cough, rarely hypoxemia, and is usually easily treatable with manual ventilation and bronchoscopic removal. Laryngeal or supraglottic foreign bodies, however, present with choking and inspiratory stridor, are much more difficult to treat, and are associated with a much higher rate of mortality.
There were many errors here that are beyond the scope of this discussion. It was a classic case of the Swiss cheese model of errors where the holes lined up perfectly and resulted in the child’s death.
The most important aspect of the anesthetic management of a patient with a suspected laryngeal or supraglottic foreign body is to maintain spontaneous ventilation. This cannot be emphasized enough. As we see from the case, neuromuscular blockade can result in a “cannot ventilate” scenario, but that is all these physicians knew how to do.
The ER physician eventually performed a cricothyrotomy with the equipment he had on hand, but waited too late. Early performance of this procedure can save lives.
On the legal side, do the parents have a valid case of negligence against the on-call ENT doc or the hospital? Medical negligence is classified as a tort, a civil wrong, where action or inaction harmed another person. There are four elements for a successful tort claim:
1. Is there a duty owed to the patient? In other words, did the ENT doc or the hospital owe a responsibility to the patient? The hospital could argue that they were not required to stock pediatric bronchoscopy equipment because they did not treat children, and similar sized hospitals in rural areas likewise did not stock this equipment. The ENT doc, however, was on call, and as part of his contract with the hospital had an implicit contract with all patients in the ER that needed his services.
2. Was there a breach of that duty? By refusing to come in, the ENT doc breached his duty, if for nothing else, in a fiduciary capacity as the proxy caretaker of the child. He should have come in to lend a hand.
3. Was there harm to the patient? Obviously, in this case, there was harm.
4. Was there a causative relationship between numbers 2 and 3? In other words, did the ENT’s breach of duty directly or indirectly contribute to the child’s death? This is a much harder question to answer. The defense team will argue that his presence would not have impacted the child’s outcome, and that it was just tragic awful luck that the family lived in a resource-poor geographic area without the ability to address such a life-threatening emergency.
The defense will argue that the child’s chances of dying would have been much less if he presented to a children’s hospital where experts in pediatric ER, ENT, and anesthesia are plentiful. In court, the jury will rely on the testimony of expert witnesses to determine their decision.
In the end, as with nearly all medical malpractice claims, the case was settled out of court.
At what age should young children be allowed to eat peanuts? Click here for the answer.
How would you ventilate through a transtracheal cannula? There are several methods described but this bench experiment indicates it should be at least 14g.
Great points Michael...I will have to look into the eFONA literature in children. Thanks for the references. I doubt there would be any medicolegal risk in a desperate situation. Doesn't mean family can't sue. In a future ML Monday, we'll explore the reasons families sue. It's usually not the medical care!
I relied on fiberscope and retrograde wire technique to escape CICV situations most of my 30 years of practice... in adults. In recent years, I have converted my approach: "scalpel-bougie-tube", or better to remember, "stab-twist-bougie-tube", is my first choice for impossible upper airway, hands down.
While an ENT was struggling with repeated upper airway attempts a few months ago, I was simultaneously preparing for eFONA (emergency front of neck airway), but he succeeded just before "stab". I was glad. Interestingly, he was a bit uncomfortable with my transitioning preparations (simultaneous efforts to both prevent and prepare for eFONA), despite the rapidly deteriorating situation.
Here is an important article that helps to explain the all too common delay in establishing an airway (in my recent case, and in this tragic Medicolegal Monday case), and suggests ways to prevent potentially the fatal consequences. https://pubmed.ncbi.nlm.nih.gov/32475685/
Finally, a main point: I think I would likely use this eFONA technique on larger, non-toddler children. (BTW, my first choice is to endeavor never to need to use this.) While needle cricothyroidotomy is easy to perform, connecting a tracheal cannula to a ready and effective source of pressurized O2 is problematic for the unprepared, possibly also in our academic centers, too. Scalpel-Bougie-Tube is the 1st line eFONA recommendation of D.A.S., but this appears to apply to adults. Where does the pediatric anesthesiology community stands regarding eFONA, specifically in small children, as in this case. If all you had readily at hand was a scalpel, ped ETT, and ped bougie, would you? Would you be faulted medicolegally for attempting this procedure in the case presented?