Chapter Twenty-Four: Overview

Chapter 24 Sub-sections

Once I became known via research publications, clinical articles, presentations on neuroanesthesia, succinylcholine/hyperkalemia, and MH, my evaluation was requested for various clinical problems and legal cases. Attorneys needed a recognized expert in a given area who was believable in testimony, consistent in responses, honest, and durable under pressure. Some, with opposing attorneys, or a judge guiding them in court, became confused and uncertain, and undercut their effectiveness. But all they had to do was not be greedy, and participate only in those areas in which they had expert information. Their expertise needed to be confirmed by their testimony, and they needed to be consistent, i.e., not have to remember what they'd said before. They had to be straight forward without pretensions. Following are some situations that I experienced in evaluations as an expert, some were legal.

Drug Error

This involved the injection of excess epinephrine into the back of an anesthetized patient undergoing lumbar laminectomy. The surgeon was given 7 ml pure 1:1000 epinephrine instead of the usual dilute solution. About five minutes later, a nurse notified the surgeon of the error. Unfortunately, anesthesia personnel were not informed. About 10-15 minutes later, pronounced hypertension and tachycardia occurred, findings similar to those of a pheochromocytoma. The patient suffered a cardiac arrest, and despite resuscitation, a poor result. The problem was directly treatable if the anesthesiologist had known the cause. It would have been difficult for anyone to imagine the need for symptomatic treatment of symptoms of a pheochromocytoma in that situation.

MH Sidelight

This involved a teen who had suffered in the past from what might have been an MH episode and now needed another operation. The parents interviewed two anesthesiologists at the local university hospital, and were assured that no MH triggers would be used. The anesthesiologists together anesthetized the boy, and prepared to intubate his trachea.

To eliminate noxious reflexes related to tracheal intubation in someone who had not been paralyzed, they sprayed his vocal cords with 2% procaine. I was taught as a resident that procaine is not effective for that because of poor mucosal absorption. Lidocaine 4% or cocaine 5% would have been more appropriate. The procaine spray resulted in pronounced laryngospasm, and the boy could not be ventilated. To alleviate this and prevent dangerous hypoxia, they injected a small dose of succinylcholine to relax his cords, knowing full well that it is an MH trigger. They were worried about problems related to the hypoxia caused by the inability to ventilate him. The boy did just fine, despite use of the trigger.

The parents sued, because the anesthesiologists had virtually guaranteed a trigger-free anesthetic, and had violated that promise. They further said that their son now had severe headaches. When the case came to trial, the plaintiff's Canadian expert witness testified that use of succinylcholine in MH susceptible patients resulted in long term debilitating headaches. I testified that I had never heard of such a thing, that the plaintiff's expert, whom I knew well, had not published these results in the scientific literature, nor had it been mentioned at meetings related to MH.

After I testified, the university offered to settle for much less than the plaintiff's request of $500,000. There seemed to be little value for my testimony. The plaintiff's lawyer scoffed at this and refused to consider it. Later, the jury awarded the plaintiff $75,000. I told the defense attorneys that I should share in the amount that I'd saved the university, but their reply was not humorous.

Expert Witness?

Here an expert witness testified in an area in which s/he had minimal expertise. An experienced neurosurgical/anesthesia team had a serious non-fatal neurologic complication related to air embolism during surgery in the sitting position and was sued. The plaintiff's anesthesia ‘expert', from a major academic center, was known to have decidedly modest experience in sitting position cases. When asked by the defense attorney about these types of cases, the response was, "Yes, I do neuroanesthesia."

The confident ‘expert' testimony was that the anesthesia-surgical team was excellent, but, so was Babe Ruth. Babe Ruth occasionally struck out, and that's what the team had done in this case. The jury was convinced, but the ‘expert' had now defined a reputation among peers.

Child with Unpredicted Hyperkalemia Due to Rhabdomyolysis

A boy approximately 20-months in age was anesthetized using halothane and succinylcholine for tracheal intubation. He immediately suffered acute rapid rhabdomyolysis and cardiac arrest. Despite rapid and successful resuscitation, he was brain damaged and the family sued.

I testified that the doctors had not been negligent in the care of this boy, had used typical agents and techniques for his surgery, and that his problem could not have been predicted. However I observed that the jury paid little attention to any testimony or to my defense of the defendant anesthesiologist. At the end of the trial, the jury awarded the boy and his family $3,000,000. After he had interviewed members of the jury, the defense lawyer explained that the jury knew that the anesthesiologist had done nothing wrong, and they were sympathetic. But this was a poor local rural family, with major challenges in caring for their son. They would need the funds, and the university could afford it, especially since the university's supporting state taxes would help ease the financial strain on the university.

Legal Finagling Regarding Use of Succinylcholine

I was a consultant in two lawsuits involving complications related to use of succinylcholine in patients with upregulation of acetylcholine receptors, and testified in one trial. Because the malpractice coverage of the individual anesthesiologists was considered insufficient for proposed damages, the plaintiff's attorneys also sued the pharmaceutical company that manufactured the succinylcholine, alleging that the package insert did not clearly state the risks. But succinylcholine is a commonly used drug right from the start in anyone's residency, and anesthesiologists do not need to read its package insert, nor do they, in general. The risks are clearly known throughout one's career, and mishaps sometimes occur because of multiple interacting factors.

I believed that adding the pharmaceutical company to the suit was inappropriate and nonsense. In one of these cases, the jury increased the award to the plaintiff significantly because of this approach.

Peri-tonsillar Abscess, a Major Challenge

This problem involved a teen with a peri-tonsillar abscess. Rapid sequence anesthesia accomplished a secure airway and the oral surgeon drained the abscess.

Unfortunately, while moving to the recovery room after surgery, the patient semi-awakened and thrashed around, pulling out the intravenous catheter and the endotracheal tube. Swelling inside the mouth prevented successful ventilation, and life saving drugs could not be administered intravenously, resulting in a disaster. The failure in care occurred during transit, due to the impossibility of rapid venous access, and not having adequate restraint during emergence.

Plagiarism – Actual?

A university attorney requested evaluation of a journal article and its author as regards plagiarism. The author of the article, the department chair, was accused of publication without due credit, and the investigation involved the author, the accuser, who was a research advisee, and the editor-in-chief of the journal. The latter and I discussed this a few months later at an anesthesia meeting.

The author sued the university, because it was discrediting him, and the university counter-sued. The research advisee and I discussed this directly. There had been eight drafts of the material. It was difficult to analyze the manuscript's progress and confirm plagiarism. The case was ultimately settled. Several years later, I met a Ph.D. who was a former member of the department, who told me that he had evidence regarding preparation of the drafts that would conclusively settle the question regarding plagiarism. He refused to share the information except off the record, verbally.

Athlete's Heat Stroke

I evaluated a case of heat stroke death. This was a young healthy athlete weighing more than 280 pounds. Successful highly competitive athletes take care of themselves and pride themselves in keeping fit and not having difficulties in front of others. Elite athletes have a warrior mentality, in part in not letting anyone know they're tired, frightened, or hurt. This attitude develops early in their lives, once they became competitive. It becomes a stable part of their competitive nature.

Two factors appeared to play roles in this heat stroke death: acclimatization vs. conditioning. Acclimatization is adaptation to a different climate or differing environmental conditions such as hot humid vs. hot dry vs. cold humid, or higher altitude. Acclimatization requires several days to weeks, depending upon the degree of difference from the original environment. It is less of a stress in someone who has been conditioned prior to experiencing the new environment.

Conditioning implies physical fitness, particularly with aerobic exercises, although non-aerobic exercise, such as workout with weights, is also a form of conditioning. Someone conditioned to a specific type of exercise is less bothered by it, and has lesser changes in heart rate and body temperature, less fatigue, and lessened other physiological responses as opposed to someone who is not conditioned.

This athlete was not strongly conditioned when this episode occurred. The weather was hot and humid and he lacked acclimation for working out in it. This athlete's heavy muscular build impeded heat loss, as there is greater insulation, and cooling is difficult. During harsh exercise, the athlete produces considerable body heat, and the marked increase in metabolism produces even more heat, and with an increase in body temperature due to insulation and accompanying dehydration.

In mammals, metabolism increases 7% per centigrade degree increase in body temperature. Since normal body temperature is 37º C, an increase to, say, 42º C is five degrees above normal, and thus there is an increase in whole body metabolism of 35%. This can occur during a period of exercise, wherein metabolism is already increased, due to the exercise.

If an athlete uses energy enhancing drugs -- the information is frequently incomplete regarding this -- there is added a drug-related stimulation of metabolism and heat production, and cutaneous vasoconstriction, further limiting heat loss. These drugs may also inhibit gastric emptying and limit some aspects of digestion. Nausea and vomiting may occur. These factors cyclically further stress the entire body milieu, with catecholamine release, hypoxia, serious acidosis, and circulatory problems such as hypotension, low cardiac output, renal failure, muscle breakdown.

Pride and leadership responsibilities in this athlete apparently led him to conceal his problems. His coaches and teammates had difficulty in determining how serious his situation was, and were unable to easily halt his efforts and prevent him from overdoing it. He needed massive fluid loads and cooling. These were delayed because the severity of his problems was not realized in due time. His condition moved rapidly from severe to virtually moribund. Survival was unlikely once he was well into the final episode of his heat illness.

There is controversy concerning the effectiveness of dantrolene in a case like this. Dantrolene diminishes energy metabolism in skeletal muscle, and, therefore, heat production (Lin et al, 2004). Skeletal muscle is about 40% of body weight, and dantrolene could markedly diminish overall heat production, and conceivably tide the patient over until other measures take effect.

Oral Examinations by the American Board of Anesthesiology

For 20 years, I was an associate examiner for the American Board of Anesthesiology oral examination, the final step in the ladder of academic success for a budding anesthesiologist. It is the end of the beginning of the anesthesiologist's career, and s/he now can proceed to the middle ground, whether private practice or academia, and begin a mature stage of development.

Candidates must first pass a computerized written cognitive exam immediately following their residency. A year later, they take the oral exam, which is a measure of applied judgment in varying clinical situations rather than cognition. The most effective way to pass is for the candidate to imagine that the patient is directly in front of the candidate, lying on an operating room bed, and that s/he is providing the best possible comprehensive care, with detailed explanations of interpretation and the care that is provided. Examiners interrupt or alter the exam's progress as they see fit to determine the candidate's ability to adapt.

The exam period is a week, and takes place each six months in varying areas of the country, with several hundred candidates each time. Each candidate's examination consists of two 35 minute periods, with a 10 minute break in between. Two examiners in each room, four different examiners total, grade independently. Since perhaps 60 hotel rooms may be needed for the exam, at least 120 examiners are needed, plus extras in case of illness. The exams take place in the hotel rooms of the examiners.

Examiners are not given their questions until the evening prior to the exam day, and are not to discuss these with other examiners more expert in the exam's topics than they may be. At the end of each 35-minute portion of the exam, a monitor in the hall knocks on the door, the candidate leaves, and the two examiners grade the candidate's performance. The sheets are handed to the hall monitor and only then can they discuss their grades. They cannot alter grades because of this discussion.

Early in my career as a board examiner, there was tolerance for smoking, the policy being that if the candidate wished to smoke, then so could an examiner, but otherwise examiners were not to smoke. Arthur Keats, my senior examiner, was a smoker, and directly solved the problem: As the candidate was ready to begin the exam, Arthur would ask, in a harsh tone,

"Do you mind if I smoke?"

No candidate ever said yes, but, if one had, Arthur would have respected her/him and perhaps gone a slight bit easier.

This examination is a serious stress to candidates, and their nervousness is palpable. Two examples: a department chair, who is now a former President of the Association of University Anesthesiologists, and I had a candidate who collapsed at the end of the examination. At the knock on the hotel room door, he dropped his head sharply onto the table, broke his glasses, and sobbed uncontrollably. We tried to reassure him and ease his overwhelming discomfort. As senior examiner, I wrote the report to the board.

Candidates have three opportunities to pass each phase of the exam, each opportunity a year apart. If they fail the oral exam on all three attempts, they must re-take the written to again be eligible for the oral exam. Generally, more than 90% pass within the three year period. I counseled one candidate who had failed the oral exam on eight occasions, and passed it on his ninth. He was an excellent clinician, but, for him, the exam pressure was unreal. On one occasion his senior examiner, Jack Michenfelder, asked him what drug he would use to begin anesthesia in the proposed patient (I was not present).

The candidate said, "I could use drug A or drug B or drug C."

That's an ungradeable answer, since no judgment is involved. Jack slammed his fist on the table and said, "I don't care what you could do, I want to know what you will do."

The candidate was unable to respond to any question thereafter, so the two examiners and he sat in silence until the exam ended with the knock on the door.

Book Reviews – the Same Review, Twice

I found it fascinating that, in checking my records after retirement, there were two book reviews of works by Stanley A. Feldman, the British anaesthetist, who twice published monographs reflecting his continued interest in muscle relaxants. My first review was when I was a beginner in study of relaxants (Gronert, 1974). I did not remember the initial review when I did the second review (Gronert, 1996).

It was my opinion that in both, he was careless, error-prone, and poorly organized. The second review was requested by Jim Eisenach, book reviewer for Anesthesiology and now Editor-in-Chief. When I realized the number of careless errors, I sent Jim detailed notes of the errors (not to be published) to support my critical review, which Jim accepted. The then Editor-in-Chief of Anesthesiology suggested that my review was overly brusque and might offend our overseas friends. Jim in turn said that the Editor-in-Chief had no say in the decision to accept my review. The review was published unchanged. Feldman's opening statement in his preface was apropos: ‘Academia should encourage debate on established thought. It should strip away covering veneer of certainty and lay bare illusion' (Feldman, 1996).