Student Training Programs May Pose Significant Liability Exposure to Anesthesiologists
Brian J. Thomas, JD
Senior Claims Attorney & Director of Risk Management, Preferred Physicians Medical, Shawnee Mission, KS
Anesthesiologists are frequently requested to participate in student training programs for emergency medical technicians (EMTs)1, student nurse anesthetists (SRNAs), medical residents and students and respiratory therapists to provide training and supervision for intubation proficiency and airway maintenance. While most professional liability carriers provide coverage for participating in these student training programs, the following case summary underscores the significant liability exposures that can arise.
A 20 year old female, 5’4”, 38.5 kg, with a medical history significant for kidney removal, duodenal obstruction and persistent vomiting for 4 days presented for Roux-en-Y gastric bypass and appendectomy. A nasogastric (NG) tube had been placed on the day of the procedure, but the NG tube had been “sneezed out” approximately two hours prior to the procedure. The surgeon was aware the NG had come out; however, that information was never conveyed to anesthesia.
The anesthesia group had a contract with the county emergency medical services (EMS) program for teaching EMT students intubation. An EMT student being supervised by an anesthesiologist and a certified registered nurse anesthetist (CRNA) attempted a standard intubation. The EMT student intubated the patient’s esophagus on his first attempt. The patient aspirated a “significant amount” of gastric contents that was suctioned. The esophageal intubation was immediately recognized and the CRNA successfully intubated on the second attempt. An NG tube was placed and approximately 600 cc of gastric contents was suctioned from the patient’s stomach.
The surgery was completed without further complication. However, a chest x-ray showed aspiration pneumonia requiring prolonged intubation and ventilation. On the seventh post-operative day, the patient had a period of ventricular tachycardia and it was thought she was having an acute myocardial infarction. The patient was transferred to another facility where she underwent urgent cardiac catheterization. The patient had a complicated medical course following the aspiration requiring various hospital admissions for pneumonia, aspiration, strokes and complications from tracheostomy. The patient was subsequently diagnosed with significant brain damage and was unable to perform activities of daily living.
The patient’s parents, on behalf of their daughter, sued the hospital, the supervising anesthesiologist and his anesthesia practice group.2 Plaintiffs’ allegations included, but were not limited to, failing to employ adequate diagnostic procedures and tests to determine the nature and severity of the plaintiff’s medical status and/or conditions; failing to employ appropriate treatments and procedures to correct such conditions; negligently permitting, without notice to and/or the consent of the plaintiff, an EMT student to attempt intubation; negligently failing to inform the plaintiff of the risks reasonably associated with permitting an EMT student to attempt intubation; and failing to exercise reasonable care in the treatment and management for the complications and sequelae associated with aspiration of gastric contents causing permanent and irreversible brain damage and related injuries.
Plaintiff ’s anesthesiology expert,Corey Burchman, MD from York, Pennsylvania, was prepared to testify that the supervising anesthesiologist violated the standard of care by allowing an EMT student to attempt intubation on a patient with a significant risk of aspiration due to her bowel obstruction. Plaintiff ’s expert additionally criticized the failure to perform a rapid sequence induction. Dr. Burchman was also critical of the response and intervention to the observed aspiration.
The defense anesthesiology expert opined there was no deviation in the standard of care to have performed an esophageal intubation that was recognized immediately with the tube removed and reintubated. The defense expert also asserted that aspiration is one of the recognized risks associated with intubation and not the result of a breach of the standard of care. The defense expert was prepared to testify it was not below the standard of care to allow an EMT student to perform the intubation under supervision. However, the defense expert conceded he would not have allowed an EMT to attempt intubation on this patient due to her increased risk for aspiration.
The plaintiff ’s economic expert estimated the plaintiff ’s lost earnings at present value were $1,606,554. Plaintiff ’s economic expert estimated future care costs for in-home care at $16,155,770 to $21,969,117 and in a care facility at $29,945,398 to $30,246,075.
The anesthesia defendants participated in a court-ordered, pre-trial settlement conference with the hospital and plaintiffs. Based on the significant damages and potential liability exposure, the professional liability carrier for the anesthesia defendants contributed to a $7,000,000 global pre-trial settlement with the hospital.
Brian J. Thomas, JD, serves as Senior Claims Attorney & Director of Risk Management for Preferred Physicians Medical in Shawnee Mission, KS. Mr. Thomas has over twenty-one years of insurance industry experience, including fourteen years devoted exclusively to defending anesthesiologists and their anesthesia practices. Thomas leads Preferred Physicians Medical’s risk management efforts for the development of enhanced risk management tools for its policyholders and is the Editor-in-Chief for PPM’s risk management newsletter, Anesthesia & the Law. He also serves as Senior Claims Attorney managing high severity claim and litigation files in twenty states. Mr. Thomas is a 1995 graduate of Washburn University School of Law. Thomas is a frequent speaker at risk management seminars, national and state professional society meetings, and defense counsel seminars. He can be reached by email at email@example.com or at (913) 262-2585.
1 The term “Emergency Medical Technician” (EMT) encompasses several different levels of training, responsibility, experience and skill. EMT-Basic is an entry level certification including basic airway management. EMT-Intermediate is a step between Basic and Paramedic and includes additional education and skills instruction. EMT-Paramedic requires either a two year degree or a certification program and is the most advanced level of EMT. Paramedic skills include, among others, advanced airway management including endotracheal intubation, forcep use for airway obstruction and emergency surgical airway skills.
2Plaintiffs did not sue the EMT student despite the fact the county employer carried $1,000,000 in insurance coverage for claims against its EMT students.