This is a case of an air embolism.
Twenty-three year old Natalie B. was born physically and mentally handicapped. One afternoon, an employee of defendant MedLink of Ohio, a home healthcare company, took Natalie to the defendant Uni¬versity Hospitals of Cleveland for dialysis treatment. The employee then left while Natalie had the treatment.
During the treatment, Natalie pulled the catheter from her chest. A nurse found her unresponsive and resuscitated her. Natalie suffered brain damage and she died a month and one-half later after her mother ordered the removal of the feeding tubes.
- The plaintiff claimed that the MedLink employee had been instructed to sit with Natalie during the dialysis treatment because she was known to have removed the chest catheter on prior occasions.
- The plaintiff also argued that the employee had a criminal record for felonious assault and MedLink was negligent in hiring the employee.
- The plaintiff claimed that University Hospital’s employees failed to provide timely and appropriate treatment.
- The plaintiff claimed that Natalie’s brain damage was due to air bubbles that triggered cardiac arrest due to the open catheter site.
This air embolism case includes some important legal issues. The first is abandonment. The MedLink employee had a duty to stay with Natalie during her treatment. Natalie was at risk for injuring herself, and it was the responsibility of the MedLink employee to supervise her. A person who is assigned this type of one to one care has to make arrangements with other staff members to be relieved from a break. A dialysis center is staffed with technicians and nurses. The MedLink employee was not the only person there.
A breach of duty may defined by whether an event was foreseeable. In Natalie’s case, she had removed her chest catheter on prior occasions. There was a real risk that she would do so again. The fact that she had a history of removing the chest catheter placed responsibility on the MedLink employee to provide constant supervision. MedLink employees should have been aware of the risk of air embolism.
Employers are responsible for making sure that their potential new hires have a good moral character and are free of convictions for crimes. In this case, it came out at trial that the MedLink employee had a criminal background. Although the history of assault was unrelated to what happened to Natalie, the damaging information affected the credibility of the employer.
Air embolism – a deadly complication
Air embolism is defined as simply the presence of air in the vascular system, in the venous system or the arterial system. It can cause anoxic encephalopathy as well, which is the lack of blood supply to the brain due to presence of air in the blood system.
It is an air bubble or a block of air that is floating through the venous system which displaces the blood and therefore blocks blood supply to that area. Death is the outcome of a significant size air embolism. Air embolism represents a serious adverse event. The Centers for Medicare and Medicaid Services (CMS) have defined it as one of the never events. CMS and many private payors do not pay for the treatment of a hospital acquired air embolism.
Risk factors for air embolism
Patients with central lines are at high risk for air embolism. They have large lumen tubes that rest close to the heart. Peripherally inserted central lines are also at high risk. There are four elements that have to occur in order for air embolism to occur.
1. There has to be an opening right into the venous system. Natalie’s removal of her chest catheter provided the opening.
2. There needs to be the right amount of air. Most experts readily agree that when there is more than 30 ccs (an ounce) of air in at one time, that’s enough to cause damage to the patient. If the patient gets a 30 ml block of air in the venous system (picture that in a vein traveling into the heart) it actually fills up the right ventricle with air. This displaces the blood. The air acts as a block. As the blood is flowing through the heart it can’t get past the air block.
3. The opening in the venous system has to be above heart level; that’s a critical factor. Air embolism is not as common in IVs in arms because most IVs are started from the elbow down. They are usually below heart level. But in central lines, they are usually in the chest or neck.
4. The patient must increase her intrathoracic pressure. This is accomplished by laughing, coughing, sneezing, yelling, crying, hiccupping or simply sighing. It can cause a change in the pressure and that allows air to be sucked into the venous system in a matter of seconds.
Air embolism treatment
The plaintiff claimed the University Hospital’s employees failed to provide timely and appropriate treatment. Saving a patient’s life depends on quick recognition and quick treatment of this life-threatening problem. The patient should be turned on her left side so that the air pocket will rise to the top of the right atrium or the right ventricle of the heart. The patient’s head should be lowered with her feet elevated. That will also keep the air in the top of the right atrium.
If the patient is fortunate enough to be in a facility that can perform an emergency scan, the radiologist can set up a fluoroscopy machine to identify the location of the air pocket. The physician inserts a needle to suck out the air. In the best scenario, the patient survives without damage. However, in the cases that reach an attorney’s desk, the outcome is invariably either death or a vegetative (comatose) state for a lengthy period.
According to Ohio Trial Reporter a $6.1 million verdict was returned, which included $3.1 million in compensatory damages with ninety percent liability assigned to MedLink and ten percent liability assigned to University Hospitals. The jury also awarded $3 million in punitive damages against MedLink only. The hospital reached a confidential settlement following trial.
As you can see in this case, the jury was faced with a decision to determine if the defendants (both MedLink and the hospital) had a duty to the patient and breached their duty. The jury decided which of the two entities had a higher degree of liability.
Punitive damages were designed to punish MedLink for what happened in this case. Insurance policies do not cover punitive damages. MedLink was expected to pay this money out of their own pocket. What a highprice they paid when their employee left Natalie alone. What a high price Natalie paid.
Pat Iyer MSN RN LNCC is the CEO of The Pat Iyer Group. She works with LNCs who want to skyrocket their careers. Find out how you can shine by checking out LNC Academy Inc.