Daniel E. Holloway
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Wellstar North Fulton complaint alleges airway-management delay after facial gunshot wound

The complaint alleges that a patient arrived at Wellstar North Fulton Medical Center with a gunshot wound to the mandible and that providers failed to timely secure the patient’s airway despite the risk that swelling and bleeding would make airway management progressively more difficult. Providers obtained imaging before securing the airway, attempted intubation nearly an hour after arrival, made multiple unsuccessful attempts in the trauma bay, and allowed a less-experienced surgeon to attempt tracheotomy while the patient was oxygen-deprived. The patient suffered severe permanent brain damage.

System
Wellstar Health System
Facility
Wellstar North Fulton Medical Center
Providers involved
Wellstar North Fulton Medical Center / Mark L. Gravlee, M.D. / Sherieka S. Duncan, M.D. / Stephen A. McBride, II, M.D. / Woodley Mardy-Davis, M.D.
Pattern
Alleged delay in securing airway after facial gunshot wound and progressive swelling risk
Harm
Alleged prolonged hypoxia, severe permanent brain damage, and physical deficits

Overview

This page concerns a public complaint alleging that providers at Wellstar North Fulton Medical Center delayed securing a patient’s airway after a facial gunshot wound, leading to prolonged hypoxia and permanent brain injury.

Chronology

The complaint alleges as follows:

  1. The patient arrived at Wellstar North Fulton Medical Center on March 3, 2023 with a gunshot wound to the right mandible.
  2. The patient was sent for CT imaging before his airway was secured.
  3. The first intubation attempt occurred approximately 50 minutes after arrival.
  4. The patient’s oxygen-saturation level dropped during airway-management attempts and resuscitation became necessary.
  5. The patient was moved to the operating room after multiple airway attempts.
  6. The patient was oxygen-deprived for approximately 27 minutes during a tracheotomy attempt.

Alleged failures

The complaint alleges the following failures:

  • Providers failed to anticipate that swelling and bleeding would make airway management progressively more difficult.
  • Providers delayed securing the airway by performing imaging first.
  • Providers improperly attempted nasal intubation multiple times in the trauma bay rather than in the operating room.
  • A less-experienced surgeon was allowed to perform the tracheotomy despite the presence of the attending surgeon.
  • The facility failed to implement adequate policies for prioritizing airway protection.

Entities and tags

Wellstar North Fulton Medical CenterMark L. Gravlee, M.D.Sherieka S. Duncan, M.D.Stephen A. McBride, II, M.D.Woodley Mardy-Davis, M.D.Gunshot woundMandibular fractureNasal intubationTracheotomyHypoxiaHypoxic brain injuryDelayed treatmentAnesthesia and airwayNegligent hiring or supervisionBrain or spine injuryEmergency medicineAnesthesiologyTrauma surgeryAirway management