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Palacios v. Kaufman

Dr. Stephanie Roundtree, an anesthesiologist in Georgia, details why she concludes defendants met the standard of care in their treatment of the patient.

The Expert: Dr. Stephanie Roundtree, an anesthesiologist in Georgia, details why she concludes defendants met the standard of care in their treatment of the patient.

By Dr. Gary F. Gansar, MD, FACS
Senior Physician Medical Director, AMFS

During testimony in a 2016 Georgia medical malpractice trial, Dr. Stephanie Roundtree, a Georgia anesthesiologist, explains how difficult cases of bronchospasm are handled within the standard of care. The plaintiff claimed negligence by anesthesiologists during a bronchoscopy led to brain damage. However, Roundtree, as an expert for the defense, details why she concluded that the defendants met their standard of care.
The expert explains that when an anesthesiologist encounters difficulty with ventilation of a patient, she must entertain a differential diagnostic list of possible causes. The most commonly encountered reason is severe bronchospasm, so the initial treatment should be to immediately try the administration of a bronchodilator such as albuterol as “puffs” administered down the endotracheal tube. This drug is the most powerful bronchodilator and the one most specifically affecting only the bronchial tree. Therefore, it is much less likely to cause systemic side effects. Administered as an inhaled mist, the medication acts directly on the smooth muscle in the bronchial tree, so it is rapid and efficient.
The expert emphasizes that the defendant in this case was right to immediately try albuterol to address the ventilation problems, and that it was appropriate as well for her to increase the general anesthetic to try and break the spasm. Then, while administering 100% oxygen, she attempted to physically break the spasm by hand bagging ventilation of the lungs through the endotracheal tube. When she realized that nothing was working, the anesthesiologist called for help. Roundtree felt that all of these steps were appropriate and within the standard.
Once another anesthesiologist arrived to help, he recognized that the end tidal CO2 level was essentially zero. This CO2 level, measured at the very end of an exhaled breath when it should be at its highest level of between 35-45 mmHg, was instead not registering any amount. For that reason, the doctors figured that the problem must be with placement, plugging, or kinking of the endotracheal tube. The tube was subsequently removed and replaced under direct visualization utilizing a GlideScope laryngoscope to assure its proper placement. This would take about 30 seconds. The expert testifies that it was appropriate to remove the original tube, and that this exchange did not contribute to the patient’s anoxia since there was no effective ventilation taking place anyway.
The documentation during the code in this case implies that the patient’s pulse rate had fallen into the 20s and was not addressed. Roundtree testifies that she doubts that this would not be addressed since a loud alarm would have been going off in front of four anesthesiologists and a physician assistant for several minutes.
Roundtree explains that the treatment for bronchospasm that occurs during an operative procedure is to place the patient on 100% oxygen, take them off of the ventilator and ventilate them by hand using an Ambu bag, give a beta-2 agonist of which albuterol is the strongest, and deepen the degree of anesthesia by giving more anesthetic agent. If all of this is done and no change noted, then it should be repeated. Systemic epinephrine is not used preferentially because it has beta-1 and beta-2 agonist properties and is therefore not a specific treatment for bronchospasm. It will have systemic effects on blood pressure, heart rate, and can lead to arrhythmias. This would only be used if the bronchospasm was combined with cardiovascular collapse. Given to a stable patient, the administration of IV epinephrine can lead to disastrous consequences and is therefore indicated only when the patient is unable to maintain cardiovascular stability. Regardless, it is not as effective to treat the bronchospasm as albuterol.
The plaintiffs claimed that the patient may not have suffered from anoxic brain damage had the epinephrine been administered earlier. But Roundtree believes that 5 doses of epinephrine were eventually administered and she plainly explains that it is unlikely that this finally broke the bronchospasm. She explains it is a nonselective [for the bronchial tree] beta agonist that, given intravenously first, is metabolized by the liver, so it does not reach the target receptors in the tracheobronchial tree directly or in effective doses. She feels that the bronchospasm was eventually overcome by the persistence of their treatment while adhering to the basic principles for dealing with bronchospasm. Giving the epinephrine sooner therefore was unlikely to change anything that happened.
In fact, the expert concluded that none of the caretakers could have done anything differently to have changed the course of events, and that all of their actions were appropriately within the standard of care. The jury agreed, rendering a decision for the defense.

About the Author Dr. Gary F. Gansar, MD, FACS

Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.

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