Negligence cases concerning positioning injuries

AORN Journal, August, 2004 by Ellen K. Murphy

Every perioperative nurse knows the critical importance of properly positioning patients to prevent intraoperative pressure injuries. In the May issue of the AORN Journal, Mona Lisa Macapagal, RN, CNOR, provided an excellent review of the basic considerations for positioning a patient for prolonged back surgery. (1) Key among her messages was the need for ongoing monitoring of the patient's position during the procedure and repositioning if indicated. This column reviews the facts from three recent appellate court decisions that involved intraoperative, position-related injury.

LOGSDON V MILLER

The plaintiff in Logsdon v Miller (Lexis/Nexis no 2055 [Tex App 2002] unpublished) developed reflex sympathetic dystrophy in her left arm and hand after a seven-hour reconstructive jaw surgery in 1999. On the day of surgery, the anesthesiologist and the circulating nurse positioned, supported, and padded the plaintiff. She was placed supine with her arms at her sides, her elbows straight, and the palms of her hands facing her hips. Postoperatively, the plaintiff woke with numbness and pain in her left arm and hand. The anesthesiologist's postoperative note attributed these symptoms to antecubital tendon stretch secondary to prolonged wrist extension.

The underlying question in this suit was whether the plaintiff's wrists were placed in a joint-neutral or extended position. The plaintiff sued the anesthesiologist and the nurse's employer hospital, alleging that the anesthesiologist and circulating nurse were negligent in failing to properly pad, tuck, position, and monitor her during the procedure. The attorneys for both the anesthesiologist and the hospital moved for summary judgment--they claimed there was no reason to go to trial because the plaintiff had supplied no evidence to support her claim that the standard of care had been violated or that the reflex sympathetic dystrophy actually was caused by the positioning.

The trial court judge granted these motions, and the plaintiff appealed. The appellate court noted that the plaintiff had produced an affidavit and deposition testimony from her treating neurologist and another medical expert. The medical expert's opinion was that the positioning of the left arm with the elbow straight and the left wrist extended for a prolonged period of time constituted negligence. The anesthesiologist responded that the expert could not refute the anesthesiologist's own interpretation of the words he had documented in the medical record and that positional injuries occur despite proper positioning.

To decide that a case should not go to trial, an appellate court must find more that a scintilla (ie, trace) of evidence on the plaintiff's side. The court found that the anesthesiologist's note and the plaintiff's expert's affidavit provided more than a scintilla and allowed the case against the anesthesiologist to proceed.

The court failed to find more than a scintilla of evidence, however, regarding the appropriate standard of care for the circulating nurse. They accepted the defendant employer's assertion that this type of injury can occur in this type of prolonged case even if the patient is positioned correctly and in a way that is consistent with the standard of care. The plaintiff's medical expert had opined that the nurse was negligent in the positioning, but the court did not find his conclusion sufficient to warrant a trial because he never set forth the appropriate nursing standard of care, how he was familiar with it, or how it differed from that for an anesthesiologist.

OWENS V SILVIA

Another jaw reconstruction case, this one unexpectedly prolonged, occurred in Rhode Island (Owens v Silvia, 838 A2d 881 [RI, 2003]). The plaintiff sued the anesthesiologist, nurse anesthetist, and the hospital presumably as the employer of the perioperative nurses. He had already settled his claim against the surgeon.

The plaintiff alleged that the negligence of OR team members during an 11-hour jaw reconstruction surgery caused him to suffer permanent injury to his left arm and to his sciatic nerve. He asserted that the blood flow to the left side of his body was radically diminished during approximately 12 hours of immobility for what was expected to be a two- to four-hour procedure. The plaintiff claimed this caused him to suffer permanent injury to his left forearm and left sciatic nerve and caused lesions to his left buttock, both heels, and forehead.

The plaintiff's sole expert witness, an anesthesiologist, was prepared to testify that, during this long procedure, something applied focal pressure to the patient's left forearm. He said that it could have been the sled, sheet, blanket, or even the gel pack, but something restricted blood flow to the patient's forearm, causing a compartment syndrome.

The defense challenged this offered testimony, pointing out that such a theory has not been tested in the scientific literature. The expert responded that this is because medical ethics would not allow such tests on human participants.