When things go wrong in the night, hospitals must have a protocol that defines how information will be communicated between nurses and physicians. As you'll see in this case, waiting until a crisis is unleashed to alert the surgeon can evolve into a legal nightmare.

Laryngeal edema
In 2005, a surgeon documented the presence of a solid 7mm left thyroid nodule in the throat of a 46-year-old woman. He performed the hemi-thyroidectomy and biopsy. The procedure went well, without any complications. The patient's blood loss during the procedure was negligible, but she was admitted to the hospital for observation. At about 5:30 p.m., the surgeon visited the patient for an evaluation and noted complaints of anxiety and difficulty breathing. He recalled that she was more anxious than usual because of the surgery and because she'd been without her anti-anxiety medication for more than 24 hours. After examining the patient, the surgeon prescribed medication to help her sleep and went home.

At 6:50 p.m., the patient complained of neck pain and difficulty breathing. The nurse noted that the area around the incision was taut. About 20 minutes later, the patient registered the same complaints. The nurse described her as very anxious. Meanwhile, the left sides of her neck and face were swollen. The nurse paged the surgeon then and again at 7:30 p.m., but he didn't respond until 8 p.m. The same nurse who examined the patient with the surgeon at 5:30 p.m. filled him in on what had happened since he left the hospital. While her charting didn't specifically reflect it, the nurse later testified that the patient's condition hadn't changed significantly since 5:30 p.m., and she was merely updating the physician and letting him intervene if he deemed it necessary. The surgeon ordered lorazepam for anxiety.

The nurse updated the surgeon again at 8:45 p.m. about the patient's new complaints of neck pain and difficulty swallowing. The surgeon ordered morphine. By 9:30 p.m., the patient was "resting comfortably." Around 10 p.m., the patient couldn't urinate. The surgeon, contacted again, ordered a straight catheter.

The surgeon didn't hear anything further from the nurses until the nursing supervisor contacted him at about 4 a.m. The patient was coding. The surgeon testified that he jumped out of bed and raced to the hospital. When he got there, he saw a physician and nurses trying to intubate the patient. They weren't having any success, so the surgeon immediately performed a tracheostomy. Although it took just seconds, the patient died. An autopsy conducted by a pathologist on staff at a sister hospital determined that the patient died from acute laryngeal edema as a result of mast cell activation.

Lessons learned
The patient's estate and the hospital settled the case for an undisclosed amount (see "Patient's Post-Op Breathing Difficulties Lead to Death"). The surgeon was dropped from the suit. This case holds 2 valuable lessons:

• Surgical facilities should implement policies that emphasize clear documentation of the communications between physicians and nurses when reporting deviations from the baseline assessment and airway emergencies. In this scenario, the nurse reported difficulty swallowing and the physician ordered morphine, suggesting that he believed the difficulty was pain that was not related to an obstruction. The plaintiff cited the absence of ongoing education and training in the area of emergent airway management for the nursing staff.
• Proof of continuing education in the identification and treatment of impending respiratory distress can be helpful to reduce corporate liability. Evidence of continuing education and training can rebut allegations that the facility was negligent in its retention, education, training and supervision of staff.

Clear communication, education and preparation won't prevent post-op emergencies, but they'll put you in a better position to have a positive outcome, both in your facility and in court.