A 27-year-old man arrives at an ambulatory surgery center to undergo elective foot surgery. He denies any past medical history and appears healthy on physical examination by his orthopedic surgeon. This surgery center's policy is to require only minimal pre-op workup; in this case, a hematocrit and a history and physical.

The anesthesiologist evaluates her patient and decides on general anesthesia based on patient preference. She completes a pre-anesthesia evaluation and places it on the chart. It notes a healthy, ASA Class I patient. She also charts that she and the patient discussed anesthesia.

Cardiac arrest three weeks later
The 90-minute surgery proceeds uneventfully. The patient awakens and is discharged after 85 minutes, having fully satisfied the center's discharge criteria. A post-op visit to the surgeon's office one week later is unremarkable.

Three weeks later, the patient's family informs the surgeon that the patient had suffered a cardiac arrest while showering at home. The family found him slumped in the shower, unresponsive and pulseless. A CPR-trained family member begins resuscitation. Paramedics respond quickly, but the patient sustains serious hypoxic brain damage.

He is admitted to the intensive care unit of a local hospital. He dies 23 days after admission, never having regained consciousness.

The patient's family files suit against the surgeon and the anesthesiologist, seeking both economic (loss of income and costs of medical care) and non-economic (pain and suffering and loss of consortium) damages. There is no contention that the anesthesia or surgery was negligent; the case is based on the assertion that the pre-op workup was faulty.

The missing ECG
Staff performed a pre-op electrocardiogram (ECG) on the patient. The facility didn't require an ECG; it appears that the surgeon's secretary had ordered the test by mistake. The ECG reveals a modestly prolonged QT interval (time between the start of ventricular depolarization and the end of ventricular repolarization). In the suit, the family contends that someone should have followed up on this ECG abnormality; and, had the ECG been followed up, treatment would have averted the cardiac arrest.

The anesthesiologist says she never reviewed the cardiogram and was unaware of its existence. She says she didn't seek out a cardiogram since none was required or expected. The surgeon also disclaims knowledge of the cardiogram, stating that it had been ordered without his knowledge or prescription. Both the surgeon and the anesthesiologist insist that the cardiogram wasn't in the chart at the time the patient was operated on. Only during discovery in trial do they learn that their patient had been a cocaine user and that his heart showed changes pathognomic of cocaine cardiomyopathy. The outcome of the case might surprise you.

Answer and Explanations
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