Madigan again

[Gastrapathy]

Madigan must pay $12.3M in operating-room fire that disfigured child

The child was undergoing a routine procedure to remove a cyst from his forehead when a surgeon's electric scalpel ignited a high-concentration of oxygen being used by an anesthesiologist, engulfing the child's boy's face in a fireball and disfiguring him...

www.seattletimes.com

Madigan again. SDN wouldn’t let me necro the last Madigan malpractice thread

---

Members don't see this ad.

 

[pgg]

Tragic

Thread over in the anesthesia forum: $12 Million after Baby's Oxygen Mask Ignites and severely burns

 

[HighPriest]

That’s extremely devastating. I don’t know the surgeon. I know the anesthesiologist. Always a good guy, but this was clearly a severe and inexcusable oversight - a clearly avoidable situation. Textbook situation with regards to what to avoid. And at a high cost. I feel awful for the patient, his family, and frankly the physicians. They should have known better, but I can’t imagine carrying that guilt.

I’m surprised actually. The anesthesiologist involved always struck me as pretty risk adverse.

I dealt with an airway fire as a resident. Not associated in any way with the military. It was one of the worst things I’ve ever seen. Young lady who had laryngeal laser surgery. Fire essentially destroyed her entire trachea. She ended up with just a tube of scar for a trachea and main stem bronchi. And worst of all, the responsible ENT just disappeared the minute she was transferred to tertiary care. Absolutely terrible, avoidable problem.

When I do tonsils with an anesthetist I don’t know very well, my first question before I cut is “what’s the exploratory O2?” Every time. Rarely I get an irritated response. But this is why.

 

[Gastrapathy]

So sad. I hope the surgeon was misquoted. I do wonder how much the presence of a SRNA was part of the equation but maybe that’s wishful thinking. $12M doesn’t seem like enough.

 

[ArmyTiger]

If I remember from what I've heard, it was thought to be a combination of inadequate drying time for the chlorhexidine prep prior to draping, resulting in wet prep left under the surgical drapes, and a failure to communicate that anesthesia was using high concentration O2 with a leak under the drapes close to the operative site. I think the surgeon in question likely sounded better in the deposition as a whole than the excerpt, he's got a very good reputation, especially as one of the few Army pediatric surgeons.

 

[pgg]

There but for the grace of God ...

 

[militaryPHYS]

Truly devastating.

Awareness is key. So much is known and preventable but I don't think widest dissemination is always ensured (Surgeon, CRNA, SRNA, etc). I think yearly review of the common preventable injuries in each specialty should be mandatory for all providers (military and civilian). I hate to have one more required task but in this instance I think we would all understand and take the time to review.

 

[pgg]

Fire risk is an explicit part of the surgical timeout at my MTF and in most but not all of the hospitals where I've moonlighted over the years.

The American Society of Anesthesiologists requires 20 (I think) hours of patient safety related CME for maintenance of certification per 10 year cycle. It also comes up periodically during our q3month online MOC stuff. I'm not sure what kind of time or emphasis fire risk gets in surgeons' CME.

 

[HighPriest]

We talk about it all of the time, for obvious reasons. Most of the surgery we do carries a potential fire risk since we're usually working close to the circuit.

Fires caused by chlorhexidine, draping close to mask ventilation (or even LMA or uncuffed tubes) is something they talk about just about every month in an ENT residency. I don't know of any specific requirement related to airway fires and CME, but safety is part of our CME.

I haven't read the deposition, but it seems like this is basically a textbook example of how to cause a patient to catch fire. If I work on the face, and the patient isn't going to be intubated with a cuffed tube for some reason, I do everything that I can to not use cautery, I use betadine instead of chlorhexidine (or if I use chlorhexidine, we time it), and frankly I just don't drape the face. I may lay some blue towels around the head and over the chest, but I just don't drape so that I know I'm not trapping oxygen. Faces don't get infected that often. You can still be sterile without a drape. In an adult with a small cyst, I'd take it out in clinic without a full drape, so I don't think the drape adds anything but potential fire risk.

It's also pretty reasonable to use less than 90% oxygen. Of course that goes back to communication. If I'm doing a tonsil and the anesthetist needs to up the O2, I ask them to let me know and I stop what I'm doing until we can come back down (as long as that's possible, and the patient isn't bleeding, of course. If you have 90% oxygen flowing right next to your bovie, you're asking for a fire. But I'm sure that was a communication breakdown.

The rest of it, in my opinion, was just poor planning. But I am of course making assumptions about the case.

I'm not sure that having additional training is going to stop poor planning. It might help communication. But I don't think this happened because people were unaware that fires can happen and what the causes are. They just weren't thinking, and they weren't talking. Every hospital I've worked at (so far as I can remember) has a time out that includes fire risk. That's your reminder to, you know, not cause a fire. If they're not paying attention to that, they're not going to pay more attention to an annual online training module.

 

[orbitsurgMD]

Even open facial structures can entrap high oxygen concentrations, even from nasal cannula feeds. Eyelashes and eyebrows can be a fuel-oxygen matrix (I would suspect beard hair would do the same) The flashover ignition velocity is similar to the fire spread on a match tip, fast enough you may barely register it happened until after the fact.

 

[militaryPHYS]

They probably weren't thinking or talking about it because it had been a long time since they thought about fire hurting someone...because it happens so rarely. Anesthesia, the surgeon and the nurse all had an opportunity to decrease the fire risk but none of them did. That isn't just a breakdown in communication, it is a failure of knowledge related to risk of harm to the patient.

I doubt the American Board of _______ or Academy of __________ wants to put out an annual report of preventable injuries that occurred this year combined with the usual ones, but it's what they should be doing to improve patient safety.

 

[HighPriest]

They probably weren't thinking or talking about it because it had been a long time since they thought about fire hurting someone

I’m sure that’s what it was. But ultimately that’s their fault. I think about airway fire every time I do a tonsil. Which is a lot. I’m not saying I’m paranoid about it, but it crosses my mind before I cut. That doesn’t make me immune to the possibility, but it means I wouldn’t do what they did here.

If my mental image of this is correct, they really did exactly the opposite of what they should have done.
If you don’t know about air trapping, or fuel sources, or oxygen concentration, you probably shouldn’t be working around the face or airway. Because that’s all basic stuff. Could annual training fix it? Maybe. But in my opinion checking this stuff is part of doing the surgery. We don’t have annual training on how to operate. If you operate when you don’t know how, that’s just negligence. This was negligent.
If they get to the fire risk part of a time out and you don’t understand why, that’s a problem with your general surgical knowledge.

If i cut someone’s carotid artery because it was a tough case, that’s a terrible accident. If I do it because I wasn’t aware it was there, that’s on me.

Maybe it was a total accident. But it doesn't read that way. Of course, there may be bias in the reporting. What gets me is the surgeon stating that there was no way to avoid it. That's basically never true. You may have done everything possible to prevent it, but clearly something went wrong, so it was avoidable. It may be that 10 other guys would have done nothing different. Hindsight is 20/20. But it's avoidable. Just like the carotid injury hypothetical, if you would have done something differently it could have been avoided - even if you didn't know that at the time. Just own up, admit mistakes were made, and if you need to defend yourself then explain WHY you didn't avoid what could have been avoided.

Lets say you have an airway fire during a laser laryngeal surgery. Could it have been avoided? Yes. Was the Oxygen low enough? Was the tube too close? Was it not a laser tube? Did you have a pledget or something else in there? Even if you did everything right, could it have been done without a laser? Yes. Would 99% of all surgeons use a laser? Yes. So it was standard of care, and therefore not negligence, and a terrible accident. But it WAS avoidable.

 

[militaryPHYS]

100% agree with you. This was negligent and 100% avoidable. I was just thinking of ways we can help prevent similar situations in the future. They were negligent because they were likely complacent. The only times providers are "forced" to learn or stay up to date is when they re-certify. CME, sure, but we all know how good and bad CME can be. It can also be gundecked. We hope that everyone does the right thing and maintains lifelong learning. But many don't.

Ortho has switched to offering an annual exam (short, done at home) in addition to having to read certain articles. This is done instead of the every 10 year re-cert. I agree with it and think it makes sense and forces people to stay up to speed every year.

 

[Gastrapathy]

I do wonder how often a pediatric general surgeon does this kind of case in the real world. In my place, this would be ENT plastics. Low volume centers and physicians are more likely to make basic mistakes. There was just a thread about how Madigan was a top 10 surgical residency. Maybe so

 

[absolutdokta]

Aw geez. Don’t know the anesthesiologist but I have interacted with the surgeon on several occasions.

....I’ll just leave it at that.

 

[HighPriest]

I’ll try to be as political as possible and say: there are certain places where your best option isn’t your typical option due to lack of availability. You know, BFE community and the general surgeon is doing parotids. And, as long as he does them regularly and as long as the nearest ENT isn’t 15 minutes away, you do what you gotta do.
There are certain situations where there isn’t really a right or a wrong answer no matter how much we might want there to be. For example, a GS or an ENT doing a thyroid.
There are certain places and situations where the wrong guy is trying to do a case when a more appropriate guy is just down the hall, but he does it anyway because he’s convinced himself that he should be able to do it. It’s not that big a deal, and he’s done it before.
In some instances that’s just the art of medicine - it isn’t easy to admit that maybe someone else should have done what seems like a basic case. Knowing your limits is tougher for the “easy” stuff.
In other cases, it’s just bare arrogance.

In this case, I don’t know which it was, but I do know that this would have been a very common, very standard case a 30 second walk down the Madigan main drag. I also know it isn’t the first time an avoidable complication has happened for the same reason.

But, there may be more to it than I appreciate, and hindsight is 20/20.

 

[HighPriest]

What always burned me about that, however, is that it is one of the ways military medicine -should- be better than the civilian side. You have no financial incentive to do a case that could be done by a guy with more experience. You don’t need to worry about whether that guy takes the insurance. You don’t have to worry about schedules (because no one is that busy). You don’t really even need to worry about resident training (because we always offered to have gen sure residents come scrub any case they sent to us). So the only reason to do something that isnt up your alley is arrogance - justified or not.

There is a pediatric ENT, an ENT facial plastics, and at least one PRS guy at Madigan at any given time. Seems like maybe some decisions could have been made more aptly before the kid even got to the OR.

 

[DondeEstaElBano]

Absolutely horrifying.

Interesting that the active duty father was awarded $1.5 million himself as well...

 

[Gastrapathy]

@HighPriest I saw the opposite at my MTF. Cases were so hard to come by that everyone took anything they could get. It wasn’t about money but when everyone is low volume, they don’t give away cases.

 

[HighPriest]

@HighPriest I saw the opposite at my MTF. Cases were so hard to come by that everyone took anything they could get. It wasn’t about money but when everyone is low volume, they don’t give away cases.

Yeah, I’ve seen that too. But not so much at MAMC. At least not for us. Again, I don’t think it -is- the way it should be. I’m just saying that should be the way it is. (Sending cases to the appropriate department) But, that brings us back to the skill rot issue.

 

[militaryPHYS]

The good thing is that with the continued push for HRO and Patient Safety initiatives, there really is no excuse if you aren’t doing the right/best thing for the patient. Even overseas, if something comes through which we aren’t doing regularly we fly them out. Stateside (especially at a large MTF) it is even easier. The command may ask why we are spending the money to send out but patient safety is a conversation ender. There should be no question. It may worsen skill atrophy in that area, but without the right resources or experience scrubbed in next to you, the case shouldn’t be done.

 

[HighPriest]

We are, of course, assuming that this wasn't a case he usually does. I honestly don't know. I just think the peds ENT or plastics ENT guy probably does it more often. Hell, I think a general ENT probably does cases like this more often than most peds general surgeons, but that's just a hunch.

 

[Gastrapathy]

Yeah, maybe he does. Just wouldn’t be the practice pattern at places I’ve been.

 

[HighPriest]

Yeah, maybe he does. Just wouldn’t be the practice pattern at places I’ve been.

Or me. Just benefit of the doubt, regardless of how dubious.

 

[Per5everance]

I would argue a forehead cyst (not a lot of details) is very doable for a pediatric surgeon. I am training at a civilian tertiary care program with ENT, Plastics, OFMS residencies/fellowships all with pediatric faculty and our pediatric surgeons (gen surg residents) remove simple forehead cysts. If it was complex, we would send it to plastics.

 

[HighPriest]

It's do-able by anyone. Only question is do they do them with any frequency? It's never a problem until you light some kid's face on fire. if a case goes well, i wouldn't bat an eye that a peds surgeon did it. But it didn't, so here we are.

 

[Cooperd0g]

Medicine's lip service to HRO makes me sick and laugh all at the same time.

 

[Gastrapathy]

Medicine's lip service to HRO makes me sick and laugh all at the same time.

But but pilots...honestly this stuff has bled out into the civilian world. There’s a cadre of former pilots and astronauts making a living telling us about checklists. When I was “introduced” to TeamSTEPPS, I almost cried.

 

[militaryPHYS]

Eh, I'm OK with it. Any profession which places people's lives on the line should be held to a higher standard (i.e. HRO). Even if errors are rare (<1%), that still leaves room for improvement since we are talking about serious morbidity or mortality for the 1%.

We may be part of the majority of the profession who has self-discipline and responsibility for 100% safety, but rare errors and/or the 1-5% of our profession who aren't responsible are the problem. Sure, it is reactionary procedure based on minority events/persons, but important none-the-less.

 

[Cooperd0g]

I didn’t say I don’t think medicine becoming HRO is dumb or a bad idea. It is the fact that medicine says they are HRO, but only pays lip service to the principals that sickens me.

 

[dr zaius]

It's never a problem until you light some kid's face on fire.

Words to live by.