STEMI Intubation
Case #70
A 52-year-old man presented to a free-standing ED with sudden onset of chest pain that radiated to his back.
He was rapidly diagnosed with a STEMI and the transfer process to a large academic hospital was initiated.
However, the patient went into ventricular fibrillation and was defibrillated multiple times.
The ED physician elected to intubate the patient for transport.
RSI medications were given but he was unable to intubate the patient.
When EMS arrived, they placed an LMA.
At the receiving hospital, the patient was intubated by anesthesia, reportedly without any difficulty.
He was taken to the cath lab and a proximal LAD lesion was stented.
The patient developed cardiogenic shock, slowly declined, and died about 2 weeks later.
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The patient’s family contacted an attorney and a lawsuit was filed, alleging negligence during the intubation.
The plaintiff’s expert opinion is shown here:
“I’m an attending Emergency Physician in Houston. Thanks again for all you do - it is much appreciate and gives us docs some much needed education on something we otherwise would only hear horror stories about.” - Dr. Lesnick
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The plaintiff has offered to settle this case for $1.2 million.
The plaintiff filed their proposed settlement contract as well:
The defense has refused to settle and has now hired their own experts.
A neurocritical care doctor was hired.
An EM physician with nationally-recognized expertise in airway management was hired:
A cardiologist also offered an opinion for the defense:
The lawsuit was settled. The details are confidential.
MedMalReviewer Analysis:
I find the plaintiff’s expert witnesses to have made very poor arguments. At points, they are objectively wrong in their claims. The EM expert claims “paralyzing a patient and then being unable to intubate should not happen”. It is certainly a terrible scenario, but absolutely happens to excellent EM physicians operating well above the standard of care. He seems to be claiming that the EM physician was negligent for using RSI medications, which is simply incorrect. He also states the patient “appeared competent” after the first rounds of V fib. He clearly does not understand the concept of competence vs capacity, which betrays his naivety in regards to medicolegal issues (extremely concerning for someone who is functioning as an “expert” witness).
The plaintiff’s cardiology witness also offers several bizarre opinions. He implies the patient should not have been labeled with “prior tobacco abuse” because he had quit 31 years earlier. That is the literal definition of prior tobacco abuse.
The glaring issue in both plaintiff’s expert opinions is the claim that it was the intubation that caused his bad outcome. I see no support for this opinion. They never show that he was hypoxic during this period. They simply note a few minutes of intubation attempts followed by LMA placement (exactly what a good clinician would do in this scenario). They make the absolutely bizarre claim that they know with certainty that it was his intubation, not the cardiac arrest, not the cardiogenic shock, not the prolonged time on balloon pump, etc… that led to his bad outcome. They claim that the patient would have survived a catastrophic MI with V fib arrest and cardiogenic shock with no impact on his health status. It is absolutely ridiculous to claim this with any degree of certainty.
Lets assume, arguendo, that it was the intubation that caused his bad outcome (a claim for which they offered no good evidence). There is no proof that the doctor was negligent during the intubation attempt. Not only are their claims of causation very suspicious, their claims of negligence are also faulty.
The plaintiff’s expert witnesses conflict each other on the degree of myocardial damage. The EM doctors claims “this problem was resolved” by placing a stent, and “his cardiac condition was resolved acutely”. However, the cardiologist admits he sustained some cardiac damage, although claims it was extremely limited.
Early defibrillation and high quality CPR is more important than intubation. This EM doctor provided excellent care and was sued for it. The plaintiff’s EM expert witness is an ACEP fellow, and the cardiologist is an ACC fellow. Most readers will have serious questions about their claims despite their credentials. I sincerely hope the defense prevails in this inappropriate lawsuit.
This is the first time I’ve seen the plaintiff disclose the actual contract for a settlement. It’s interesting that they explicitly prohibit any discussion or sharing of the settlement details. There’s nothing that the plaintiff’s bar loves more than publicizing their successes.
Disagree with the lawsuit assessment? Something I miss? Drop a comment below!
This crap needs to be submitted to ABEM for censure. The only way to get them out of the game is to make it where no attorney can use them as an expert.
These physician experts selling their opinions seem like real jerks.