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No One Noticed and No Alarms Sounded When Tourniquet Deflated

Lawsuit: Bolus dose of lidocaine caused patient to code on OR table.

Published: September 25, 2014

A woman who coded in the OR at an Ohio surgery center after a deflated tourniquet released a dangerous bolus dose of lidocaine into her system is blaming distracted doctoring and alarm fatigue, according to her malpractice case.

The woman claims that the lidocaine caused an arrhythmia and initiated her downward spiral. Her suit questions whether her anesthesiologist was paying attention to her and why none of the alarms on the blood pressure monitor, pulse oximeter and EKG sounded. An appeals court earlier this month reversed a lower court's decision to dismiss her malpractice claim.

The patient had just had a ganglion cyst in her wrist removed, in a procedure done at the Fairfield (Ohio) Ambulatory Surgery Center, when the circulating nurse, LuAnne Kaiser, RN, BSN, MSN, who'd been seated at a desk, charting, noticed that the patient's face had turned a "dusky blue," according to court records. When Ms. Kaiser came around to look at the patient, she saw that anesthesiologist Todd A. Armen, MD, was "looking in a different direction at an electronic device in his hand." Court records do not say what the device was or what Dr. Armen was doing. Efforts to reach Dr. Armen were unsuccessful.

Though the blood pressure monitor, pulse oximeter and EKG all had alarms, none sounded, and the patient quickly coded. She was resuscitated with mask ventilation, epinephrine and chest compressions. Initially unable to breathe on her own, she was intubated and transferred to the Fairfield Medical Center, where she stayed for 23 days.

Later, it was determined that the tourniquet cuff on her forearm had prematurely deflated, releasing a bolus dose of lidocaine into her system. No one present noticed that it had deflated, however. The patient sued the surgery center, Ms. Kaiser, Dr. Armen and Fairfield Anesthesia Associates, citing numerous injuries, including cardiac arrest, anoxic brain injury, and memory and speech deficits.

In deposition testimony, the patient's expert, Mark Dershwitz, MD, PhD, a professor at the University of Massachusetts and practicing anesthesiologist, asserted that the premature deflation of the cuff constituted negligence, but that he couldn't say who or what was responsible, only that the "fact in and of itself was a deviation from the standard of care." Meanwhile, Ms. Kaiser and Dr. Armen both testified that they had control over the instrument that could have caused it to deflate.

At the lower court level, the providers successfully argued that since Dr. Dershwitz couldn't assign blame to any specific entity, the patient had no case. But in reversing, the Court of Appeals of Ohio, Fifth Appellate District, cited a legal doctrine that says, in essence, that when a party has been injured by one of two other parties, but it isn't clear by which, forcing the first party to pin blame on one or the other isn't fair to the injured party. Instead, that determination should be left up to a jury.

Calls by Outpatient Surgery Magazine to lawyers representing both sides were not returned.

Jim Burger

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