Medhaps

Knock Out

Posted on 23. Feb, 2010 in Case Reports

Case Synopsis

Just a Broken Jaw

Back in June 3, 1994, Patrick had just been involved in a car accident and was rushed to the emergency room for treatment. He was lucky. All he had were several bruises, a few cuts, and minor scrapes—oh, and also a broken jaw.

The emergency room doctor arranged for an oral surgeon consultation. To fix Patrick’s jaw, the oral surgeon would need to wire his mouth shut with oral fixation wires.

Typically, these wires are passed between the upper teeth and lower teeth to serve as an internal brace to stabilize the jaw for healing. (Just like what a cast would do to stabilize a broken bone.) Because his jaw would be wired shut, Patrick would need to eat and drink through a straw with food passing between the teeth. Common menus would include yogurt, milkshakes or even blended hamburgers.

Wired Shut

So Patrick agreed to surgery and was taken to the operating room the next day. Dr. Noah Pane served as the anesthesiologist who would put Patrick to sleep.

The surgery went as planned. The oral surgeon wired the jaw shut and left the operating room. Approximately 10 minutes later, Dr. Pane woke Patrick up and removed the breathing tube. But something was wrong. Patrick became combative and began choking.

What was wrong? Was he going to vomit? Did he need to be reintubated? Or was Patrick just a rough tough guy who wakes up violently?

Panic!

Dr. Pane quickly administered Diprivan (now famously known as Propofol) and Versed to calm Patrick down. The oral surgeon was called back urgently to cut the oral wires. And Dr. Pane proceeded to put the breathing tube back.

Except that he couldn’t. According to the nurse’s notes, not for 13 minutes. By that time, Patrick had no pulse and CPR was started.

Patrick was pronounced dead 44 minutes later.

What happened?

When waking up from anesthesia, Patrick suffered from laryngospasm where the laryngeal cords contract (spasm) uncontrollably—preventing normal breathing. It is a known complication associated with anesthesia. Immediate treatments include tilting the neck and head backwards, give 100% oxygen, administer a muscle relaxant, and reintubation. Sedatives such as Diprivan and Versed, however, actually worsen laryngospasms.

Dr. Pane was charged with Gross Negligence as well as Repeated Negligent Acts because of this case for departing from standard of care.

View Actual Case File

There’s More!

A few years later, Dr. Pane and Dr. Oscar, another anesthesiologist from his group, had an argument outside the hospital. Dr. Pane was angry, accusing Dr. Oscar for trying to force him out of the group.

Not long after, Dr. Oscar found her car tires punctured while parked at the hospital. This happened over and over again. One night while driving home late at night, Dr. Oscar once again found her tires flat. That was enough. She had the hospital install surveillance cameras in the parking lot to catch the vandal.

Sure enough, it was Dr. Pane.

Case Outcome

Dr. Pane had his license suspended, but stayed. “Stayed” means that the suspension was put off and that Dr. Pane was placed on probation instead. (Dr. Pane was given 35 months probation with certain terms and conditions.)

Analysis by Lyssa

Patrick’s case was a normal procedure that went horribly wrong clearly due to Dr. Pane’s incompetence. He was a trained anesthesiologist and should have be been familiar with laryngospasms. It is a well-known condition. There was absolutely no reason for Patrick to have died.

However, what is even worse is that this doctor was not only incompetent, but paranoid and criminal. Instead of being mature about office politics, he resorted to vandalism and destruction of property. Not only is that unethical, it is against the law.

That man needs to get a grip on reality. After pulling a stunt on a patient such as Patrick like that, he should be lucky to have a job at all.

While this story was short and simple, it is very dangerous and alarming to me, as a simple procedure such as jaw surgery turned into a life-ending tragedy.

Lyssa's DAISE Score - What is this?

Score
7.8

Damage	Anger	Ineptitude	Shock	Ethics
10	7	9	4	9

The DAISE Score

The DAISE (Day-see) Score is comprised of 5 metrics. Each component measures different aspects of the case to determine it's severity. This is done so different cases can be compared and contrasted, along with bringing attention to the many aspects of the stories.

Damage	The amount of damage caused by the perpetrator(s) in the story. This typically will include the patient and family, but sometimes it may include other factors as well, such as the environment, society, etc.	0 = No actual damage 10 = Heaviest damage
Anger	The amount of anger and animosity you feel toward the doctor(s) while reading the story.	0 = Cool serenity 10 = Seething, white anger
Ineptitude	How much of this medhap was caused by the doctor's incompetency and negligence?	0 = Not really the doctor's fault 10 = Should never be a doctor
Shock	How shocked/surprised were you after reading this story?	0 = Hear about it all the time 10 = O..M..G...
Ethics	Or rather, the lack thereof - How much did the doctor breach the code of ethics?	0 = No breach in ethics 10 = Criminal

The final Score is an average of the 5 metrics. The higher the score, the worse the case.

Response by Florence

I once had to undergo surgery and be put under by an anesthesiologist. It made me very nervous, but the doctor was very kind and reassuring and helped me through my nerves. I was fortunate that there were no complications and woke up normally.

Patrick’s case was like a flash of my worse imaginings before I was wheeled into surgery. Except, my operation was more life-threatening. Patrick, on the other hand, was fully expected to live through it. That makes it much, much sadder.

One thing I’d like to say is that I don’t know if we are linking two separate incidences as one. Dr. Pane slashing tires may have had nothing to do with Patrick’s incident. While both were not acceptable, we don’t know what Dr. Oscar may have done to provoke him. It is difficult to make a clear character judgment without more details, so I would suggest restraint there.

Florence's DAISE Score - What is this?

Score
7

Damage	Anger	Ineptitude	Shock	Ethics
10	5	7	6	7

The DAISE Score

The DAISE (Day-see) Score is comprised of 5 metrics. Each component measures different aspects of the case to determine it's severity. This is done so different cases can be compared and contrasted, along with bringing attention to the many aspects of the stories.

Damage	The amount of damage caused by the perpetrator(s) in the story. This typically will include the patient and family, but sometimes it may include other factors as well, such as the environment, society, etc.	0 = No actual damage 10 = Heaviest damage
Anger	The amount of anger and animosity you feel toward the doctor(s) while reading the story.	0 = Cool serenity 10 = Seething, white anger
Ineptitude	How much of this medhap was caused by the doctor's incompetency and negligence?	0 = Not really the doctor's fault 10 = Should never be a doctor
Shock	How shocked/surprised were you after reading this story?	0 = Hear about it all the time 10 = O..M..G...
Ethics	Or rather, the lack thereof - How much did the doctor breach the code of ethics?	0 = No breach in ethics 10 = Criminal

The final Score is an average of the 5 metrics. The higher the score, the worse the case.

Response by Marc

Whoa there! Lyssa, while I completely agree with you that a tragic mistake had been made, I wouldn’t go as far as to characterize Dr. Pane as “clearly incompetent” in this case. According to Quality & Safety in Health Care (2005 Jun;14(3):e3 — published by the British Medical Journal), only 77% of cases laryngospasm are clinically obvious.

Personally, I’m more appalled that the surgeon left the operating room before the patient woke up from anesthesia. Especially as an oral surgeon, he should have been able to perform an emergent tracheostomy to establish an airway and prevented the tragic death. I would have liked to know if he was disciplined, but unfortunately the records do not include his name.

Marc's DAISE Score - What is this?

Score
5.8

Damage	Anger	Ineptitude	Shock	Ethics
10	4	5	6	4

The DAISE Score

The DAISE (Day-see) Score is comprised of 5 metrics. Each component measures different aspects of the case to determine it's severity. This is done so different cases can be compared and contrasted, along with bringing attention to the many aspects of the stories.

Damage	The amount of damage caused by the perpetrator(s) in the story. This typically will include the patient and family, but sometimes it may include other factors as well, such as the environment, society, etc.	0 = No actual damage 10 = Heaviest damage
Anger	The amount of anger and animosity you feel toward the doctor(s) while reading the story.	0 = Cool serenity 10 = Seething, white anger
Ineptitude	How much of this medhap was caused by the doctor's incompetency and negligence?	0 = Not really the doctor's fault 10 = Should never be a doctor
Shock	How shocked/surprised were you after reading this story?	0 = Hear about it all the time 10 = O..M..G...
Ethics	Or rather, the lack thereof - How much did the doctor breach the code of ethics?	0 = No breach in ethics 10 = Criminal

The final Score is an average of the 5 metrics. The higher the score, the worse the case.

Tags: Anesthesia, Death, Loss of License/Stayed