An anesthesiology expert witness advises on a case involving a patient in Vermont with diaphragmatic nerve injury who died post-operatively following opiod administration. The patient was a forty-two-year-old female patient with a past medical history of severe abdominal trauma following a motor vehicle accident requiring multiple surgeries. The accident left her with diaphragmatic nerve injury. She was advised by her pulmonologist to avoid general anesthesia due to her decreased ability to properly ventilate resultant from the injury she sustained. Aside from the residual nerve damage, the patient made a good recovery. The patient was later diagnosed with severe and intractable endometriosis after presenting to her primary care physician complaining of chronic menorrhagia and abdominal pain. Her physician referred her to a gynecologist who recommended that she undergo a hysterectomy after medical management failed to resolve her symptoms. Given the patient’s age and the fact that she already had three children and did not plan to have any more a hysterectomy was considered. The patient was placed under general anesthesia for the procedure despite her medical records showing that she had suffered a diaphragmatic nerve injury and alternative anesthesia should be used in any future surgical procedures she was to undergo. The hysterectomy was performed without any complications however the patient suffered respiratory arrest shortly after the procedure due to respiratory depression resulting from administration of large doses of opioids. The treating surgeon failed to place orders for post op C-PAP to assist the patient’s breathing and neglected to use spinal thoracic analgesia as an alternative to general anesthesia. The patient did not recover and died shortly thereafter.
Question(s) For Expert Witness
Should this patient’s previous history of diaphragmatic injury have been considered in her surgical care?
Expert Witness Response
A diaphragmatic nerve injury may represent a contraindication to regional anesthesia as it compromises respiratory accessory muscles and leaves a patient dependent on diaphragmatic breathing intra-operatively. The patient’s pulmonologist was correct in advising this patient that alternative methods of anesthesia should be used. In addition, the decision to conduct the procedure open instead of laparoscopically would have weighed on the decision to use general anesthesia. It would seem that the principal issues here were post-operative analgesia management. The patient's previous injury is key here and should have been considered by the anesthesiologist and surgeon when planning the procedure and anesthetic. There are alternative anesthetic options that could have been used to perform a n open hysterectomy. Additionally post-operative opiate administration should have been very carefully monitored, perhaps even in a monitored unit given this patient’s past medical history. This patient’s death most likely could have been avoided had better pre-operative planning been carried out by her caregivers. I believe that with proper management this patient would not have suffered the respiratory distress that ultimately lead to her death.
About the author
Dr. Faiza Jibril
Dr. Faiza Jibril has extensive clinical experience ranging from primary care in the United Kingdom, to pediatrics and child abuse prevention at Mount Sinai Hospital, to obstetrics in Cape Town, South Africa. Her post-graduate education centered on clinical research and medical ethics. Dr. Jibril is currently Head of Sales in the US and Canada for Chambers and Partners - a world leading legal ranking and insights intelligence company.
