Orthopedic Surgery, Orthopedic Anesthesiology, Anesthesiology
Ref. # 22687
A 36 year old New York man fell three stories off a roof and was taken to the ER, where he was diagnosed with a displaced open fracture of the left elbow, a closed left femur fracture, and non-displaced pubic rami fractures. Six hours after admittance, the patient was taken to the OR, where surgery was performed in two stages. First, a repair of the elbow fracture was performed under IV regional anesthesia. The attending anesthesiologist then left the OR and did not return for the second stage, an open reduction and internal fixation of the left femur fracture. A CRNA administered spinal anesthesia for this procedure. The patient quickly became apneic and sustained cardiopulmonary collapse. He required CPR and defibrillation for at least seven minutes before rhythm was reestablished. He suffered anoxic brain damage and died four days later. A medQuest orthopedic surgeon reported that, in light of the multiple trauma, a general surgery consult was required. The delay in transferring the patient to the OR constituted negligence, as did the "bizarre" anesthesia plan that was selected. A medQuest orthopedic anesthesiologist opined that the selected anesthetic strategy was inappropriate for this patient, who was noted to be healthy. Intubation was not expected to be difficult. Furthermore, the risks of using more than one regional anesthetic technique (Bier block and spinal) for a multiple trauma patient outweighed the benefits. After the spinal was administered, the downward trend of the patient's blood pressure should have alerted the attending staff to hypovolemia. The patient's severe metabolic and respiratory acidosis suggested a significant period of hypoxia, seemingly contradicting the "timely and appropriate" response to and management of the arrest as documented in the clinical report. The patient's death was avoidable.