Welcome to the new Outpatient Surgery website! Check out our login FAQs.
Woman Wakes Up During Surgery
Lawsuit alleges she was helpless to alert the surgical team while suffering excruciating pain.
Publish Date: April 20, 2022   |  Tags:   Breaking News
Medication
MISSED DOSE A propofol line wasn’t connected to the patient’s IV as it should have been, according to court documents.

A Colorado woman who says she experienced intraoperative awareness for 35 minutes during a 2019 hernia surgery has sued the anesthesiologist and nurse anesthetist in charge of her care and the practice for which they work.

Stacey Gustafson, 34, who contends to be suffering from post-traumatic stress disorder recurring nightmares, is accusing U.S. Anesthesia Partners (USAP) of Colorado, James Goldenhersh, MD, and Katherine Palomino, CRNA, for negligence in her care. The trial is set to begin on July 18.

Ms. Gustafson was aware of her surroundings as the surgery began but was unable to move or alert the surgical team, according to the lawsuit. She allegedly felt the surgeon cutting into her abdomen and could hear members of the team talking and telling jokes.

About 22 minutes into the procedure, Ms. Gustafson, with great effort, was able to move her head slightly enough to capture the attention of Ms. Palomino, who immediately left the OR to alert Dr. Goldenhersh, the supervising anesthesiologist. They administered inhalation anesthesia to allow the surgery to proceed, according to the lawsuit.

The lawsuit alleges the initial short-acting dose of IV propofol used during intubation was delivered successfully, but the second dose intended to anesthetize Ms. Gustafson for the surgical procedure was never administered because her IV line had been disconnected. The propofol instead poured onto her pillow, a mistake that reportedly went unnoticed by members of the surgical team until 13 minutes after Ms. Gustafson made the purposeful movement with her head. After the line was reattached, says the lawsuit, Dr. Goldenhersh and Ms. Palomino administered propofol, versed, narcotics and inhalation anesthesia to decrease her awareness and prevent her from feeling pain.

"Following surgery, as Ms. Gustafson was waking up, Dr. Goldenhersh came into the PACU and said that he needed to ask her a question — he wanted to know if she remembered anything from the surgery," states the lawsuit. "Ms. Gustafson began to cry and told him she could feel everything and that she had suffered excruciating pain."

Jennifer Keel, Ms. Gustafson's attorney, characterized the unattached IV line as "a colossal mistake" and says her client will likely suffer emotionally for the rest of her life. "What is truly shocking is that the mistake wasn't discovered even after my client showed awareness and movement," says Ms. Keel. "The fact that the surgery continued for several minutes as my client was paralyzed and in excruciating pain made this error even worse than it had to be."

USAP says in a statement the organization will vigorously defend itself in court: "USAP provides excellent anesthesia care for approximately 225,000 patients in Colorado each year. Our more than 500 clinicians are focused on one thing — patient safety. This is demonstrated by the high-quality outcomes we have across the many thousands of surgeries and procedures in which we provide anesthesia care."

Kate Bailey, the attorney for the defendants, could not be reached for comment.

Adam Taylor

DID YOU SEE THIS?