Did a woman die because an anesthesiologist inadvertently injected bupivacaine into a blood vessel rather than the surrounding tissue while performing a cervical plexus block? Or did she die from a pulmonary embolism? A jury in Cook County (Ill.) last week blamed the 2006 death on the anesthesiologist's off-target nerve block and awarded $1.2 million to the woman's estate.

Anesthesiologist Ruperto Buscaino, MD, contended that a pre-existing clot, not an intravascular injection, caused Barbara Jeffrey's swift decline, says David C. Burtker, one of the anesthesiologist's defense attorneys.

"A Doppler scan showed that the patient had deep-vein thrombosis, which Dr. Buscaino believes caused the patient to experience a pulmonary embolism," says Mr. Burtker. "This was confirmed on the EKG; the right side of the heart had dilated and expanded. There was a lot of medical evidence to support this diagnosis. Unfortunately there was no autopsy to prove it."

The jury disagreed with the blood-clot theory, ruling Dr. Buscaino did not take sufficient care to protect Ms. Jeffrey from harm while injecting local anesthetic for an endarterectomy to address stenosis of both of her carotid arteries. The lawsuit alleges Dr. Buscaino injected bupivacaine directly into a blood vessel instead of surrounding tissue. The procedure on the right artery took place in October 2006 at Holy Cross Hospital in Chicago. Ms. Jeffrey suffered a heart attack, slipped into a coma and died the following day.

The jury awarded $1.2 million to the estate of Ms. Jeffrey — $400,000 to each of her 3 surviving adult children.

Dr. Buscaino could have avoided problems by aspirating the syringe before committing to an injection site, says John J. MacInerney, the plaintiff's attorney.

"You need to pull back on the syringe, and if you see any blood come back into the syringe — the anesthetic is clear — you need to withdraw and start over," says Mr. MacInerney. "[Dr. Buscaino] testified to delivering 10ccs of anesthetic after aspirating only once. Even the defense's expert said you should aspirate at least once every 5ccs. Our expert said even more often."

As Dr. Buscaino gave the last injection, within a couple of minutes Ms. Jeffrey became agitated and short of breath, says Mr. MacInerney. She then went into cardiopulmonary arrest and slipped into a coma, he adds. "When bupivacaine gets in the bloodstream and goes to the heart, it affects the motor nerves and causes the heart to not conduct properly," says Mr. MacInerney.

But Dr. Buscaino's defense presented an expert pulmonologist during the 5-day trial who said Ms. Jeffrey's reaction took longer than what's typical from a reaction to bupivacaine. The pulmonologist also testified that a pulmonary embolism caused Ms. Jeffrey's death. The day after the procedure, tests revealed blood clots in Ms. Jeffrey's leg.

"This was a case totally based on circumstantial evidence; a lot of cases are. The verdict represents a choice between 2 plausible theories, and it came down on the plaintiff's side this time," says Mr. Burtker. "He's obviously not in agreement with the verdict, and he is convinced his technique and application were appropriate."

Bill Donahue