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Postoperative Aspiration Failure to Intubate Lawsuit

Knox-Hicks v. Suburban Hospital

Intubate FailureThis failure to intubate wrongful death claim was filed in Montgomery County after a man was not intubated in a timely manner after his tumor removal surgery. It was filed in Health Claims Arbitration on February 1, 2018, and it is the 59th medical malpractice case filed in Maryland this year.

Summary of Plaintiff’s Allegations

At Suburban Hospital, a 27-year-old man underwent surgery to remove his right-sided acoustic neuroma – a noncancerous tumor growing on the main nerve from the brain to the inner ear. Before surgery, the man was in general good health with no facial, cerebellar function, or motor reflex abnormalities. The surgery was completed without any reported complications and the man was taken to the post-anesthesia care unit in “satisfactory condition.”

Over the next few hours, the man developed large amounts of oral secretions with diminished breath sounds. He was transferred to the intensive care unit, where he started coughing up thick, white secretions. He was alert and oriented with no facial asymmetry. Later that night, a nurse noted that the man’s head and face were asymmetrical, he was unable to swallow, hoarse, and had a swollen and numb tongue. She spoke with Anesthesia and Neurosurgery, who planned to add a Cetacaine spray to the treatment plan.

Early the next morning, the man was awake, alert, and oriented. He continued to show head and face asymmetry with swelling, hoarseness, and a persistent inability to swallow. A nurse noted that the man’s most significant issue was the discomfort in his throat. The man spent the day forcibly coughing and self-suctioning. There is no documentation that a physician was notified of his change in condition, but a head/brain CT scan taken that day revealed a small, rounded density in the lateral right cerebellar hemisphere. If you take this Complaint at face value, the inaction is terrifying.

The man’s status remained relatively unchanged until he developed persistent nausea and had a vomiting episode on the morning of his fifth day after surgery. His nausea got worse as the day progressed. That afternoon the man suffered a sudden and severe change in mental status. A change in mental status is a big deal. He became disoriented with poor judgment, poor safety awareness, and poor concentration. His mental status continued to deteriorate, his blood pressure rose, and he became more agitated. Another head CT showed fluid in the fourth ventricle, one of the fluid-filled cavities in the cerebellum. The doctor determined that the man was suffering from delirium and ordered a treatment plan of low-dose Haldol, continued hydration, and basic lab testing. The plan did not include intubation, sedation, paralytic agents, monitoring of arterial blood gases (ABG), or other diagnostic tests to check for reversible intrinsic brain injury.

The man’s mental status continued to worsen. That night, his eyes fixed open, he showed minimal response to noxious stimuli, and an ABG revealed alkalosis and hypocarbia. Later ABGs showed severe respiratory alkalosis, finally prompting the doctor to place an arterial line and administer paralytic and sedative agents. A third head CT showed bleeding in the space between the brain and the tissue covering the brain, concerning for an increasing intracranial hemorrhage or cerebral edema.

In the hours that followed, the man deteriorated even further. He was eventually transferred to Johns Hopkins Hospital with diagnoses of subarachnoid hemorrhage and altered mental status. A cerebral angiogram performed at Johns Hopkins revealed no cerebral blood flow. After two brain death examinations, the man was pronounced dead.

Additional Comments

  • According to the claimant’s expert witness, a physician specializing in the fields of neurology, neurocritical care, and vascular neurology, the man died because he suffered from frequent postoperative aspiration – fluids breathed into his airway. The inadequately treated aspiration caused a fatal combination of hypoxemia (oxygen deficiency in the blood), cerebral hypoxia (reduced supply of oxygen in the brain), cerebral edema (brain swelling caused by excess fluids), and diffuse cerebral ischemia (insufficient blood flow to the brain). If the man had been intubated and given sedative and paralytic agents sooner, he likely would have survived.

  • Hypoxic-ischemic injuries primarily affect grey matter structures in the brain, including the cerebellum, because they require a relatively large amount of oxygen to function. The density is seen on the man’s first head CT was the first major sign that something was wrong with his cerebellum.

  • The second head CT showed a ventricle fluid buildup, which occurred in conjunction with a delirium diagnosis. Excess fluid in the brain’s cavities has been shown to cause decreased cognitive and motor functioning.

  • When an ABG reading shows alkalosis and hypocarbia, it means there is a disturbance in the blood’s acid-base balance and a lack of carbon dioxide in the bloodstream. This imbalance usually occurs as a result of hyperventilation.

  • Most wrongful death medical malpractice cases involve older victims. The fact that this man was so young makes the death even more tragic and also may increase the trial and settlement value of the claim. In addition to the Maryland cap on non-economic damages in medical malpractice cases, his surviving wife and two children would have a claim for his future lost wages.


  • Montgomery County


  • The Johns Hopkins Health System Corporation
  • Johns Hopkins Community Physicians, Inc.
  • Suburban Hospital Healthcare System, Inc.
  • Suburban Hospital, Inc.
  • Five Bethesda internists
  • Three Bethesda neurosurgeons
  • A Frederick critical care doctor
  • A nephrologist
  • Four physicians’ assistants
  • A registered nurse

Hospitals Where Patient Was Treated

  • Suburban Hospital
  • Johns Hopkins Hospital


  • Failing to recognize that the man was at an increased risk for aspiration due to dysphagia that began in the immediate postoperative period.

  • Failing to recognize that the man’s self-suctioning was insufficient to remove secretions in his lower respiratory tract, resulting in aspiration, hypoxemia, and hypoxia.

  • Failing to intubate, sedate, and administer paralytic agents to the man after he exhibited persistent dysphagia.

  • Failing to appreciate the significance of the head/brain CT findings as evidence of an acute process.

  • Failing to recognize that the man’s evolving postoperative neurologic symptoms resulted from a compression or injury to his brainstem that occurred during his surgery.

  • Failing to ord
    er the appropriate diagnostic studies in a timely manner, including CT perfusion imaging, MRI blood flow imaging, and transcranial Doppler, which would have revealed reduced cerebral blood flow.

Specific Counts Pled

  • Wrongful Death: The man suffered death as a result of the defendant’s negligence.

  • Survival Action: Between the occurrence of the man’s brain stem injury and his untimely death, the man suffered significant pain, mental anguish, and economic loss.

  • Loss of Consortium: The man’s spouse spent considerable time caring for him up until his death and suffered a loss of his companionship as a result of his death. Most high-value intubation error cases are when the victim lives but needs ongoing care because of severe brain injuries

  • This is going to be an expensive case to try. Plaintiff will need at least 5 experts and probably more if it intends to pursue the claim against all of these defendants. Although the case was filed very close to the statute of limitations so it may be that many of these defendants will be dismissed.

  • The crux of this case will be when in doubt, intubate the patient. By intubating this man, he would have been placed in the safest situation possible because the airway would be protected and ventilation assured.

  • The difficulty in swallowing – called dysphagia – does not mean the man should have been intubated. But it should put doctors on notice of a potential airway obstruction like aspiration.

Plaintiff’s Experts and Areas of Specialty

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