On 4/22/2011 at 8:30 p.m., a three-year-old male was brought into the emergency department after having fallen from a tree house. The patient had a complex cut of his right ankle and foot, as well as scattered contusions. This patient was seen by an ED physician, who examined the patient’s foot laceration. The ED physician felt the wound was too complex for him to repair. The ED physician then called a general surgeon and a certified registered nurse anesthetist (CRNA).
The general surgeon felt that surgery with general anesthesia was necessary to close the patient’s laceration. The general surgeon consulted with the CRNA to make sure she was comfortable administering anesthesia to the three-year-old patient during surgery. The CRNA took a history of food consumption of the patient from his parents, learning that dinner occurred at 6 p.m., and that after dinner, the patient had grazed on some fruits and nuts. Independently, the general surgeon spoke to the patient’s parents and learned that dinner occurred at approximately 5:30 p.m. and consisted of boiled egg and lima beans.
The general surgeon performed surgery on the patient to close his foot laceration, from 12:30 a.m. to 1 a.m. on 4/23/2011. During surgery, the patient aspirated but the general surgeon was unaware of this fact. Shortly after the surgery, the CRNA extubated the patient, which caused his oxygen levels to drop. Respiratory ventilation was attempted and then the general surgeon performed CPR efforts causing a pneumothorax. The general surgeon inserted a right chest tube and reinserted an endotracheal tube. Thereafter, the patient went into respiratory arrest and died. At the autopsy, aspiratic gastric material was found consisting of nut fragments, which complicated the general anesthesia and endotracheal intubation.
The Board judged the general surgeon’s conduct to be below the minimum standard of competence given that he relied on the ED physician’s description of the foot laceration, rather than his own independent observation and that he failed to a document discussion with the CRNA regarding the patient’s last food eaten. The general physician’s operative note stated that the patient was taken to a recovery room, when in fact the patient never left the operating room and the general surgeon failed to see for himself where the patient went and/or correct the medical record. The general surgeon’s CPR efforts also caused an iatrogenic right pneumothorax that should have been avoided, and which subsequently then required a chest tube placement.
The Board issued a public reprimand and ordered that the general surgeon complete 30 hours of continuing medical education and enroll in a medical record keeping course.
Date: December 2014
Significant Outcome: Death
Case Rating: 5
Link to Original Case File: Download PDF
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