Daniel E. Holloway
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Children’s Healthcare of Atlanta complaint alleges a retraction let a tumor occlude a child’s airway before his death

The complaint alleges that during surgery to remove a bronchial tumor, the surgeon saw the tumor protruding into the child’s trachea. He then directed the anesthesiologist to retract the patient’s endotracheal tube, which was withdrawn 1.5 centimeters without consulting the attending anesthesiologist. The retraction caused a loss of double-lumen intubation to the left lung, exposing it to possible occlusion by the tumor. The team could not re-establish the airway, and the patient was without oxygen for about 23 to 24 minutes. Another surgeon eventually removed the tumor with a rigid bronchoscopy, but the patient was placed on life support and died on February 4, 2019.

System
Children’s Healthcare of Atlanta
Facility
Children’s Healthcare of Atlanta
Providers involved
Jonathan A. Meisel, M.D. / Christopher S. Fiedorek, M.D. / Emory + Children’s Pediatric Institute, Inc. / Children’s Healthcare of Atlanta, Inc.
Pattern
Alleged endotracheal-tube retraction during tumor-removal surgery that let a dislodged tumor occlude the airway
Harm
Alleged prolonged loss of oxygen and death days after surgery

Overview

This page concerns a public complaint alleging that a surgical team’s breathing-tube retraction let a tumor occlude a child’s airway during surgery before his death.

Chronology

The complaint alleges as follows:

  1. Beginning in mid-September 2018, the patient was treated at Children’s Healthcare of Atlanta for persistent pneumonia and breathing problems.
  2. A September 18, 2018 bronchoscopy found an obstructing right bronchial carcinoid tumor.
  3. On January 31, 2019, the surgeon began a right thoracotomy after the anesthesiologist placed a double-lumen breathing tube confirmed by bronchoscopy.
  4. At 2:45 p.m., the surgeon saw the tumor protruding into the trachea. Eight minutes later, he directed the anesthesiologist to retract the breathing tube, which was withdrawn 1.5 centimeters without consulting the attending anesthesiologist.
  5. The retraction caused a loss of double-lumen intubation to the left lung, and the tumor occluded the left airway. Staff could not ventilate him afterward.
  6. A second surgeon joined the team. After the patient was turned supine, he removed the tumor with a rigid bronchoscopy. The patient’s pulse did not return until 3:17 p.m.
  7. He had been without oxygen for about 23 to 24 minutes, was placed on life support, and was pronounced dead on February 4, 2019.

Alleged failures

The complaint alleges the following failures:

  • The surgeon directed retraction of the breathing tube after the tumor had entered the trachea, without consulting the attending anesthesiologist.
  • The surgeon did not clear the airway or remove the dislodged tumor in time by performing a bronchotomy.
  • The anesthesiologist improperly retracted the tube 1.5 centimeters, losing double-lumen intubation and exposing the left main bronchus to occlusion by the dislodged tumor.
  • The complaint pleads personal injury and wrongful death claims against the surgeon and anesthesiologist, and against their employers under respondeat superior. It attaches expert affidavits under O.C.G.A. § 9-11-9.1.

Entities and tags

Children’s Healthcare of Atlanta, Inc.Emory + Children’s Pediatric Institute, Inc.Jonathan A. Meisel, M.D.Christopher S. Fiedorek, M.D.Bronchial carcinoid tumorEndotracheal tubeThoracotomyDeKalb CountySurgical errorAnesthesia and airwayWrongful deathPediatric surgeryAnesthesiologyPulmonology