Case Summary:
On May 28, 2014, the plaintiff, a forty-four year old automotive mechanic, was working on his car during his lunch break when the carburetor backfired, spraying hot gasses on his face, chest and right hand. The plaintiff was taken to the emergency department of a nearby hospital where his injuries were assessed by the emergency department staff. On arrival to the emergency department, the plaintiff was alert and oriented and was able to describe his history of present illness with the emergency department physicians.
With concern that the plaintiff had suffered an inhalation injury, caused by hot gasses from the vehicle carburetor, the attending ER physician recommended that the plaintiff undergo voluntary intubation under sedation, so as to protect his airway in the event of swelling, and to transport him for burn care via ambulance.
The defendant’s ambulance service responded to the ED’s call for patient transport. Two of the defendant’s paramedics were dispatched. Upon arrival, the plaintiff was noted to be sitting up on a hospital bed in the emergency department. After evaluating the plaintiff, the defendant, paramedics contacted “Medical Control” and requested permission to bypass the “20-minute wait” rule for ventilated transports; an order designed to ensure the smooth operation of the transport ventilator before leaving the ER, which was granted by Medical Control.
Because the “test lung” was not located in the vent bag as required, no test of the vent was performed prior to placing the patient on the ventilator and departing. After placing the patient on the ventilator, the defendant paramedics listened for lung sounds, which were noted as “diminished with minimal chest rise”.
The plaintiff’s ETCO2 was noted to be initially in the 60’s, but then dropped to the 40’s as recorded by the defendant paramedics prior to their departure. Both paramedics were stationed in the back of the ambulance tending to the patient during transport.
During the ambulance transport, the plaintiff’s ETCO2 was 80-90mm Hg. The defendant paramedics listened for lung sounds and thought they were diminished on the left, leading them to withdraw the ET tube ½ cm. After listening for lung sounds again, the tube was backed out another ½ cm. The plaintiff’s ETCO2 continued to rise and the defendant paramedics contacted Medical Control with a request to change the patient’s respiratory rate from 16 to 20. Medical Control consented to the change but no improvement was observed or noted.
Upon arrival at the hospital, the plaintiff was brought to the emergency department for evaluation. The defendant paramedics reported diminished lung sounds and high ETCO2 levels to the receiving physician. The defendant paramedics claimed they were not advised of any issue with the patient during transport, but assumed that they were having trouble with their monitoring devices. The devices, however, were evaluated and found to be in good working order by the defendant’s ambulance company following the subject incident.
Upon his arrival at the ED at 6:45 pm, the plaintiff was found to be in poor condition, with abnormal arterial blood gas (pH 6.97, PCO2 107, PO2 59), and was subsequently diagnosed with hypoxic-ischemic brain injury.
According to the experts retained by the plaintiff, the care and treatment rendered the plaintiff during his ambulance transport fell well below the standard of care expected of the average qualified paramedics, in several important respects.
First, the defendant’s request for a waiver of the “20-minute rule” was unfounded, leaving the paramedic crew without the ability to properly assess the operation of the portable ventilator before leaving the emergency department. Had the 20-minute rule been followed, it was probable that the problem the defendant paramedics encountered en route could have been identified and addressed while still in the ED, thereby sparing the plaintiff the brain injury he ultimately suffered.
Second, and more significantly, the defendant paramedics deviated from the applicable standard of care in failing to promptly employ a standard paramedic protocol when evidence of ventilator failure, or insufficient patient ventilation was encountered. The required protocol abbreviated D.O.P.E. involves immediate evaluation of the ventilated patient to identify – and where indicated, remedy – evidence of (D)islodged endotracheal tube; airway (O)bstruction; (P)neuomothorax; or (E)quipment failure. The record revealed no evidence that the defendant paramedics took any of the required defense maneuvers, resulting in prolonged hypo-oxygenation and resulting brain injury.
Had the defendant paramedics followed the required protocol, and no evidence of improvement detected, the paramedics would have been required to remove the patient from the ventilator and apply a bag-valve-mask (BVM) device onto the ET tube to ventilate the patient. If this maneuver resolved the situation by evidence of better oxygenation and reduction in CO2 levels, then the ventilator was likely malfunctioning and continued use of the BVM would be appropriate until arrival at the destination facility.
Instead, the defendant paramedics observed significant evidence of insufficient ventilation, including dangerously high levels of CO2 throughout most of the ten-minute transport, without taking the appropriate remedial measures, resulting in permanent hypoxic-ischemic brain injury.
The plaintiff, a husband, and father of seven children, has not made any meaningful recovery with respect to his brain injury and remains in a skilled nursing facility, unable to eat, drink, speak, walk, talk, or perform any other activity.
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