A 36-year-old female presents to the surgical center with a history of recurrent laryngeal papillomas. She has no other significant history and is about to undergo removal of a papilloma for the third time. She has been under the care and treatment of her ENT surgeon for several years. He examined the patient two days before the surgical date and determined that

• Her vocal cords were able to be indirectly visualized, and
• She was able to undergo the procedure with general anesthesia by way of an endotracheal tube based upon the size of the papilloma.

Notably, the surgery that had been performed just six months before this procedure required a pre-operative tracheotomy due to the large size of the papilloma as well as the ENT's inability to indirectly visualize the vocal cords. On the day of the third procedures, one of the anesthesiologists asks the surgeon whether he is able to visualize the cords. The surgeon answers in the affirmative, according to testimony. This verbal communication is not documented in the records.

Papilloma falls down over the epiglottis
The patient is brought into the OR suite and anesthesia proceeds to induce, first by administering a muscle relaxant, then midazolam (Versed) and propofol (Diprivan). Once the muscle relaxant takes effect, the anesthesiologist attempts to secure an airway, but is unsuccessful due to the fact that the papilloma has fallen down over the epiglottis and sealed off the airway by creating a ball suction. Following a second failed attempt at intubation, the anesthesiologist attempts a cricoidectomy. That fails as well because of a significant amount of scar tissue.

The OR team decides to attempt another intubation. At this time, the ENT enters the room and immediately starts a tracheotomy. The evidence suggests that by this time, the patient has been without oxygenation for seven to eight minutes and is severely cyanotic. The surgeon takes longer than expected to access the airway because of concerns of excessive bleeding the difficulties encountered with scar tissue. Another surgeon enters the scene and completes the tracheotomy.

The surgery is completed as planned. The patient is eventually discharged to a long-term care facility with a diagnosis of severe anoxic brain injury. About a year after this incident, the patient dies as a result of widespread sepsis.

The issues in this case focused on who would be liable for the lost airway and injuries: the facility, the surgeon or the anesthesia team?

Plaintiff's perspective
The plaintiff's complaint made allegations against the surgeon, the anesthesia team and the facility.

• Surgeon didn't communicate risk. The plaintiff's lawyer argued that the surgeon should have conveyed to the OR team that the patient was high risk due to the size and location of the mass, as well as the fact that she'd had a previous tracheotomy six months before this procedure. Additionally, the suit alleged that the surgeon should have planned to do another pre-operative tracheotomy because the papilloma was located so close to the epiglottis; this fact should have prompted the surgeon to do the tracheotomy in the first place. The plaintiff also criticized the surgeon for being paged when the first intubation failed but not arriving in the OR suite until the anesthesia team was about to attempt a third intubation. Apparently, between five and six minutes passed between the page and the surgeon's arrival.
• Anesthesia team didn't secure an airway in a timely fashion. The plaintiff alleged negligence against the anesthesia team for not doing their own independent exam of the patient to determine the size and location of the mass, and to determine if they could indirectly visualize the cords before administering the muscle relaxant. Further, the team should have waited for the surgeon to be present in the OR before the induction. Even though the team didn't discuss the patient's history of a pre-operative trache, anesthesia should have noted having found the trache scar during the course of an exam. Anesthesia should have considered performing a tracheotomy themselves once the cricoidectomy failed instead of resuming attempts at intubation.
• The facility didn't have a policy concerning the credentialing of anesthesia to perform emergency tracheotomies. Anesthesia couldn't perform the tracheotomy because they lacked the credentialing to do so. The facility was also criticized for not having a trache tray in the crash cart in the OR. This contributed to the delay in securing an airway because once the surgeon arrived and requested a trache tray, the circulating nurse had to leave the room and find one.

Defense's perspective
The surgeon defended on the grounds that his ability to visualize the cords didn't warrant a pre-operative tracheotomy. The fact that he didn't arrive until five or six minutes after he was paged was apparently an issue with the facility's paging system and not due to an unreasonable delay on his behalf. Regarding the visualization of the cords and the allegations of failing to communicate with anesthesia, testimony from the surgeon and anesthesia alike supported the fact that they had communicated with each other verbally, but no one had documented the conversation. Anesthesia also believed that it was reasonable to induce without the surgeon in the room since this was a practice that was exercised regularly at this particular facility.

Communicate and document
Early in the discovery phase of this case, the defendants entered into a confidential settlement with the plaintiff. The apportioned contributions from each defendant were as follows: 40 percent for anesthesia, 40 percent for the surgeon and 20 percent for the facility. Relative to the allegations against the facility, the case settled before a full and adequate defense was developed on behalf of the facility.

This case teaches us that once again communication and documentation is key. Ideally, the surgeon would have been present for the induction and whenever the mass obstructed the airway, prompt intervention with a tracheotomy could have been employed. Whether a pre-operative tracheotomy should have been instituted is irrelevant - that is strictly a medical judgment call. What is vital in a case like this is identifying high-risk factors and prompt intervention whenever complications arise. What do you think? How would your facility address a high-risk patient like this one?