Failure to direct and supervise postoperative care

Clinical presentation
Following an automobile accident, a patient in his late teens was admitted to a large metropolitan hospital emergency room via helicopter. The patient suffered multiple contusions and abrasions, fractures of the right femur, left tibia and fibula and a possible closed head injury. A CT scan performed prior to surgery was read as negative, and the records indicated the patient was "awake and oriented." Following stabilization, he was transferred to the operating room for an open reduction and splinting.

Physician action
The anesthesiologist was contacted at 2 a.m., and a pre-operative history and physical was performed. With both the anesthesiologist and a hospital CRNA present, the patient underwent a rapid sequence intubation at 3 a.m. The patient received 3200 cc of fluid, had a total urinary output of 400 cc and received 175 cc of Sublimaze within 75 minutes of extubation at 5:30 a.m.

Following extubation, the patient was transferred to the ICU with "spontaneous respirations, stable vital signs, color pink and O2 via face mask at 40%." The anesthesiologist accompanied the patient to the ICU and last saw the patient at 6 a.m. He then went to the hospital sleep room. The postoperative anesthesiology note had been recorded prior to anesthesia indicating "no postoperative complications," as was this physician's routine procedure.

Sometime between the patient’s admission to ICU and 7 a.m., he began to experience respiratory stridor. The CRNA was paged to assist in ventilating the patient. Unsuccessful intubation efforts were made over the next 52 minutes, and following administration of a muscle relaxant, a second CRNA intubated the patient at 8 a.m. with the attending physician (who had been paged by the CRNA) present. No one paged or tried to contact the supervising anesthesiologist. Following intubation, the patient began to seize and went into a coma where he remained for several weeks.

When the anesthesiologist returned to the hospital two days later and discovered the series of events that occurred following surgery, an entry was made into the progress notes regarding concerns at not being called at the time of the emergency. Subsequently, that progress note was removed from the record by the anesthesiologist and another entry made. The "no post operative complication" note was changed to reflect the actual condition of the patient by striking out "no," and further entries were made to document the actual complications.

Allegations

The patient suffered residual neurological deficits including spasticity and memory loss. He could no longer function independently and was confined to a wheelchair.
Failure to exercise the ordinary care that a reasonable and prudent anesthesiologist would have exercised under the same or similar circumstances
Failure to direct and supervise the postoperative care of a patient with potential airway compromise
Failure to be accessible to a postoperative patient not fully recovered from anesthesiology.

Legal principle
Standard of care is reasonable and generally accepted medical practice and treatment based on that used by other reasonable health care providers in the community and throughout the United States, when faced with the same or similar circumstances.

Vicarious liability is a civil liability for the torts of others. Physicians may be vicariously liable for the negligent actions of members of the health care team when the physician is responsible for supervising the actions of others (in this case, the CRNAs).

There were several issues of contention in this case: the interpretation of the CT scan with a subsequent opinion that there had been some traumatic brain damage; the amount of fluids and the administration of Sublimaze toward the end of the case in the presence of possible closed head injury; the physician leaving the patient in the ICU soon after transfer.

Complicating the clinical issues were the actions of the anesthesiologist in removing and altering the medical records. While none of the alterations were made to hide or change pertinent clinical findings, the issues itself would lend to a significant loss of credibility in front of a jury.

Disposition
This claim was settled on behalf of all parties. The anesthesiologist contribution was in the seven figures.

Risk management issues

Medical records should never be altered.

When making late entries, always annotate the entries with the time and date of the entry.

Always specify with those whose actions you may be accountable for, where you can be reached and under what circumstances you should be notified. If possible, incorporate into written guidelines.

Avoid prospective medical record entries.