Welcome to another thrilling edition of Medicolegal Monday.
In general, my malpractice expert witness cases consist of about 80% for the defense and about 20% for the plaintiffs. This imbalance isn't because I prefer to defend my colleagues (which I do, of course, but it's not the reason), but rather, that's just the approximate ratio of cases that come to me. Maybe it's just that the plaintiff cases go to expert putzes who are known to plaintiff lawyers because they'll say anything for money. I have nothing against plaintiff cases - I feel strongly that with my background as a pediatrician (and a dad), I should advocate for children and their families that have been wronged by negligence.
One of my favorite things to do is tell a plaintiff's attorney they have no case. This usually occurs when a surgeon's attorney hires me to testify that the anesthesiologist missed a case of postoperative MH when it was really just missed surgical sepsis. On the other hand, one of my least favorite things to do is tell a defendant's attorney that I can't defend their client, as happened here...
This case illustrates the classic Swiss Cheese model of patient harm, where a really bad event resulted when several different unfortunate and preventable events all happened to one patient. It involves a 10-year-old obese female (>99%tile for BMI) whose pediatrician strongly suspected sleep apnea and sent her for an evaluation from a pediatric sleep medicine specialist. The patient underwent a sleep study, which showed an apnea-hypopnea index (AHI) in the 80s (>24 is classified as severe by the American Academy of Pediatrics) and a low SpO2 < 80%. The pulmonologist wrote in his report that it was one of the worst cases of OSA he's ever seen. So, he sent the child home (Swiss Cheese Hole #1) instead of admitting her to the hospital PICU, where she would be kept NPO, planning for a semi-urgent tonsillectomy, like we do here at CHOP. Our patient in the case was then seen as an outpatient by an ENT who scheduled her for T&A....as an outpatient (Swiss Cheese Hole #2) at a free-standing surgery center (Swiss Cheese Hole #3), as the last case of the day (Swiss Cheese Hole #4). On the day of surgery, in the anesthesiologist's pre-op evaluation, there's no mention at all of any sleep apnea. In fact, the box next to the word "Snoring" is left unchecked (Swiss Cheese Hole #5). The patient receives a perfectly normal anesthetic for T&A with the usual amount of opioids (Swiss Cheese Hole #6), and is given more opioids for pain in the PACU (Swiss Cheese Hole #7). She's then sent home with a prescription for Vicodin (Swiss Cheese Hole #8) and, well, you've guessed the outcome by now...found dead several hours later.
Obviously, there's no defending so many clear violations of safety and standard of care in one patient. A few similar types of cases were summarized by Charlie Cote in his great article in A&A found here. Not much more to say about this case but, let's summarize the indications for inpatient overnight stay for tonsillectomy, as taken from the AAP publication mentioned above and some other sources:
· Age < 3 years;
· Severe OSA (AHI>24, we use 10 at CHOP);
· Nadir SpO2 < 80% on sleep study;
· Cardiac complications from OSA (eg, RVH);
· Failure to thrive;
· Obesity;
· Craniofacial abnormalities;
· Sickle cell disease;
· Trisomy 21 (Down Syndrome);
· Neuromuscular disorders;
· Current respiratory infection;
· Any other significant comorbidity.
Post-script: after relaying my thoughts to the defense attorney, I was not contacted by her again, so I don't know the actual outcome of the case. These physicians should consider themselves lucky if they only settled, instead of being brought up on charges of negligent homicide. I know these are strong sentiments, and I also know that many places throughout the country consider it the standard of care to do these high-risk patients as outpatients in a free-standing ASC, but as anesthesia professionals we have an obligation to keep up with experts' standards and guidelines and not succumb to the pressures of their own group or the surgeons they work for. We also need to follow our moral compass in advocacy for children and their families.
Ron,
Sobering description to be sure. You didn't say when case was from. As you know the knowledge of pediatric OSA and related issues i.e. codeine metabolism were evolutionary in nature. Criteria for admission, exclusion from ASC's and avoidance of post-op narcotics developed over time.
Al
What a tragic case! I agree that at first glance it to seems to be a perfect example of Reason's Swiss Cheese model. But as I read this I saw both outcome bias and confirmation bias as strong drivers of how the Drs. made decisions. The surgeon scheduled this case because he/she has scheduled so many seemingly similar case like this at an ASC and never had a problem. Plus the pulmonologist didn't see the need to admit this child so "what bad could happen?". The anesthesiologist proceeded because both the surgeon and the pulmonologist didn't see a problem so it should be ok. And the anesthesiologist got the child through the intraoperative course without incident. Just like all my previous anesthetics this should go just fine, "what bad could happen?". We need to on a daily basis put the brakes on our thinking (or autopilot) and reassess every patient without getting caught in the trap of it worked out fine last time. And if the referral didn't see a problem why should I? This doesn't even deal with if there was a compensation bias or incentive that drove the decisions.
The one thing that I am bothered by on your post is the comment about this being negligent homicide. I am no lawyer and maybe it does meet the definition but that is a hard pill for me to swallow. Should these doctors be incarcerated for these terrible clinical decisions? And which doctors? If we look at this situation as a series of unfortunate latent errors or even confirmation or outcome bias on whose shoulders would the homicide lay? The pulmonologist for not admitting the child? The surgeon for scheduling the surgery as an outpatient in an ASC and possible writing for a post op opioid prescription (hopefully not codeine) or the anesthesiologist for administering the the opioids (at least intraoperatively and in recovery) and discharging the patient home? Yes lots of compounding errors and truly tragic but homicide? Anyway thank you Dr. Litman for these thoughtful posts.