Surgical Resident Performs Unsuccessful Emergent Tracheotomy

This case involves a middle-aged male patient who presented to the hospital with a seizure. The patient developed an allergic reaction to the blood pressure medication he was given during his ED course and his airway began to swell uncontrollably. Intubation was indicated for airway protection from the swelling, but the anesthesiologist was unable to successfully intubate the patient after multiple attempts. In an attempt to save the patient’s life, an unsupervised general surgery resident performed an emergent cricothyrotomy and subsequently an open tracheotomy. The resident didn’t communicate to the attending about a difficult airway page from the emergency room. By the time the attending surgeon arrived, the patient’s clinical status had deteriorated significantly. The patient suffered from cardiac arrest and passed away. An expert in general surgery was sought to discuss the expected level of communication between the resident and attending surgeon in a case scenario like this.

Question(s) For Expert Witness

1. How often do you perform emergency cricothyrotomies and/or tracheostomies?

2. What is the expected level of communication between the resident and attending surgeon, particularly in the emergency department?

Expert Witness Response E-139683

I am the director of surgical critical care and a trauma surgeon who supervises a large number of residents at a large research university in the Northeast. I have done at minimum 10-15 crichs in my life. I am an expert witness in a cricothyrotomy case right now. Just in looking at the brief details of the case, I don't think there is really case here. A resident at a trauma center has to do what he has to do to save that individuals life, even if it is with a limited knowledge base. Now there may be some wiggle room in how or where the attending interjected if at all, but I would need to see the full records and would only give my most honest opinion. The standard of care is for the resident to notify the attending immediately of anything like this, that is a no-brainer. The question is going to be is it causative. Most residency programs have an attending notification standard (this is an RRC requirement) so I would suggest getting the attending supervision policy from the residency and looking at it in that context. If you pull that, and it is a clear violation of their own standard, you may be able to use that as leverage for a quick settlement. That could be a possible angle, but going after a resident has its own problems.