This case involves a male patient in his 60s who had a past medical history of respiratory issues who underwent a cervical discectomy fusion to treat spinal cord compression. Immediately following the surgery, the patient complained of difficulty breathing, throat swelling, and difficulty swallowing. He complained throughout the afternoon into the evening. It was alleged that the nurses did not deliver all of the complaints to the treating physician. The following day, the orthopedic surgeon returned the patient to the operating room to explore the source of complaint. The exploration did not yield any abnormal findings and he was taken back to the post-anesthesia care unit. Several hours later, the patient began complaining of breathing problems and anxiety. Nurses reported that they called the anesthesiologist immediately, but the physician reported being called 20 minutes later. When the physician reported to the post-anesthesia care unit, a Code Blue was called. The patient was intubated but suffered anoxic brain injury and remained in a vegetative state for a couple of weeks until he expired.
Question(s) For Expert Witness
- 1. Do you routinely treat patients similar to the one described in the case? Please explain.
- 2. How should complaints of breathing problems and potential loss of airway be documented? When should nurses contact physicians?
- 3. Did the patient's history and trouble breathing after the first procedure warrant the nurses monitoring him more intently after the second procedure?
Expert Witness Response E-018595
I routinely treat patients that have either had a cervical fusion or are undergoing one. Furthermore, respiratory compromise is of great importance to the practice of anesthesia. I have certainly treated patients that have suffered an anoxic brain injury, and the reasons for such injuries range from incidences at birth through major trauma injuries. Being a CRNA at a world-class trauma center has exposed me to patients of all ASA classes, and provided me with much experience in the development and management of such patients. Breathing issues and the potential for loss of airway should be documented when a significant change or rapid decline is apparent and detected in the vital signs. PACU RNs also have the ability to escalate care by increasing oxygen content delivery as well as changing the method by which oxygen is delivered. A diligent RN should notify the covering MD when such an event occurs and/or according to the PACU orders (standing orders or otherwise). In short, yes the RN should have closely watched the patient, particularly after a previous event. However, the word ‘immediately’ is open to interpretation and may be influenced by multiple situational factors such as RN: Pt ratio and the general culture of the PACU. ‘Immediately’ is not always feasible and identification of respiratory issues depends on the nurse’s clinical expertise, however, it seems obvious to assume that the sooner the MD was alerted, the quicker an intervention could occur. Additionally, vital signs need to be reviewed to establish when hypoxemia occurred and if any issues with intubation occurred. Anesthesia records of the re-intubation during the surgical take-back may shed light on possible vocal cord paralysis or deviation of the trachea.