She had blood in her stool.
She didn't think much of it.
She ignored it for a few weeks.
Then, she began to get worried.
She'd heard on TV about how blood in your bowel movement could be a dangerous sign.
It could be evidence of cancer.
It could be a hemorrhoid.
It could be a polyp.
It could be anything.
She decided to go to her primary care doctor to get it checked.
He did a rectal exam.
She was right. There was evidence of blood in her stool.
He immediately sent her to be evaluated by a gastroenterologist.
He would do a procedure known as a colonoscopy.
That's a procedure, done under light anesthesia where the doctor takes a flexibile fiberoptic tube and inserts it into your rectum. He then threads the tube up your butt in order to visualize your colon using a camera.
If there are suspicious findings, he can cut the abnormal tissue, known as a biopsy, take them out and send them off to the lab for analysis.
She followed her primary care doctor's orders.
She made the appointment with the gastroenterologist.
He examined her and agreed that she needed a colonoscopy.
He explained it would be done in an ambulatory surgery center and she'd be given IV sedation using a drug known as propofol.
The risks were minimal he told her.
She like him.
He appeared confident.
He said he'd done thousands of these colonoscopies.
It would take 10-15 minutes once he began the procedure.
In order to prepare for the procedure she'd need to clean out her bowels the day before.
She'd need to follow his instructions about what medicine to take in order to do a 'bowel prep' and clean out whatever was in there.
Otherwise, if this wasn't done fully, he'd have difficulty seeing anything as he passed the colonoscope through her small intestine and large intestine.
She took the instructions and obtained the liquids and medicines she'd need.
Most people find the prep for their colonoscopy to be nasty. The medicine tastes gross and the prep is often worse than the procedure.
On the day before her scheduled colonoscopy, she followed her doctor's instructions to the letter.
She finished all the medication.
She had a good clean out of her bowels.
She was also told not to eat anything for many hours before the colonoscopy.
She wasn't told why. However, the anesthesiologists tell us it's to make sure that there's nothing in your stomach. If you were to vomit any material from your stomach, you would normally spit that out of your mouth if you were awake. However, when you are sedated, under anesthesia, our natural mechanism for getting rid of vomit material is no longer present.
Instead, if you vomit something up from your stomach while under anesthesia and then take your next breath, you will likely inhale the vomit into your lungs. This is known as aspiration pneumonia and can be deadly as you're about to see here.
Your stomach contents are very acidic and belong in your stomach. If those acidic liquids and food particles get into your lungs, they have the capacity to eat away at the lining of the lungs and impair your ability to breathe.
You should be able to sense the foreshadowing here.
She is brought into the procedure room. She is put onto her left side.
The anesthesiologist attaches a pulse oximeter to her finger to detect her oxygen saturation level.
He gives her a nasal cannula with oxygen.
He gives her IV sedation that includes propofol.
The gastroenterologist begins the procedure and inserts the flexible fiberoptic camera into her butt.
He is about 3/4 of the way through the procedure. He can't get the camera past a kink in her intestines. He's pushing. He's threading. He's manipulating the camera tube. It's just not getting through.
During this interval, the patient vomited some material into her mouth. In her next breath, she inhaled it into her lungs.
The anesthesiologist didn't even realize what happened...until the patient's pulse oximter alarm started ringing.
It showed the amount of oxygen that was perfusing into her body was getting dramatically low.
It was only then that the anesthesiologist suspected that she had vomited and inhaled some stomach contents.
He looked in her mouth.
He found nothing.
He decided to suction out her mouth anyway, even though there was nothing visible there.
He did not attempt to suction past her throat to see if he could suction any material from her airway.
She was not intubated. That meant her airway was not protected.
This procedure didn't call for or require the patient be intubated.
That meant that if she vomited, the anesthesiolgist would have had to see what occurred and immediately suction out her mouth and her airway. In this case, he did neither.
The gastroenterologist asked his anesthesiologist if it was Ok to continue the colonoscopy procedure. He said "Yes."
So, the GI then continued on for another 10 minutes before pulling the fiberoptic tube out of her rectum.
The patient still had a very low oxygen saturation level.
They moved her into the recovery room.
The anesthesiologist simply elevated the head of the bed a little bit and left her sitting there by herself for thirty minutes.
When a nurse finally came in, she realized that the patient could barely breathe.
The anesthesiologist took another five minutes before coming in to check on the patient and realized his patient was much worse than he thought. He gave her oxygen by mask and had office staff call 911.
An ambulance arrived shortly after and took the patient to the emergency room.
X-rays confirmed she had foreign material in her lungs. She was diagnosed as having severe aspiration pneumonia.
She was started on heavy antibiotics and placed on a ventilator.
The doctors did not believe she'd survive.
Even though they were giving her 100% oxygen through a mask, her lungs were no longer functioning properly. They were severely impaired because of the acidic stomach contents that she had inhaled during her colonoscopy.
The doctors elected to put her into a medically induced coma to ease her pain since she was having such difficulty breathing.
Three days later she was dead.
She died because her lungs were eaten away from the acidic stomach contents.
She died because she aspirated during the colonoscopy.
She died because two doctors violated the basic standards of medical care during her 'simple' 'routine' colonoscopy.
She died because the anesthesiologist wasn't properly monitoring her during the colonoscopy.
She died because the anesthesiologist didn't recognize she had aspirated.
She died because the anesthesiologist didn't suction into her airway.
She died because the anesthesiologist didn't recognize the significance of the pulse oximeter alarm showing dramatically low oxygen saturation levels.
She died because the anesthesiologist told the gastroenterologist to continue on with the colonoscopy even though the patient was having difficulty breathing.
She died because the gastroenterologist didn't stand up to the anesthesiologist and recognize the significance of an abnormally low oxygen saturation level and abort this elective procedure.
She died because the anesthesiologist didn't call an ambulance for 45 minutes after the procedure was over.
The sad reality is that her death was preventable.
The damage she suffered from aspirating during the procedure could have been minimized had the anesthesiologist recognized what happened and taken immediate and appropriate action.
Instead, this otherwise healthy woman died as a direct result of the violations from good and accepted standards of good medical care by these two physicians.
How did I learn about this tragic colonoscopy with a horrible outcome?
One of her daughters contacted me after reading articles and watching videos about people who suffered injury and death as a result of improper medical care during colonoscopy. I met with her and her siblings shortly afterward.
This story was very sad.
I told her surviving daughters that I thought I could help them.
We brought a lawsuit against the gastroenterologist, the anesthesiologist and the ambulatory surgery center.
You would think that with such clear-cut evidence of malpractice they would simply throw their hands up in the air, acknowledge they did something wrong and try and settle this case quickly.
That was not to be.
In fact, the defense attorneys fought this case tooth and nail. They gave no indication they did anything wrong.
They were adamant. They claimed they did everything correctly...except they didn't.
It wasn't until I had an opportunity to question the doctors during their pre-trial question and answer session, known legally as a deposition, that it became clear what had happened.
The sequence of events unfolded as I described earlier.
The anesthesiologist stated that his care and treatment did not deviate from good medical care.
The gastroenterologist said the same thing.
Yet, I knew they were both wrong.
I had multiple medical experts tell me these two doctors could not, in any way, defend this tragic case. There was simply no way.
It wasn't until after I had completed questioning all of the doctors involved and some of the nursing staff at the ambulatory surgery facility did the defense recognize and acknowledge they had a liability problem.
That's the only time they began to negotiate in good faith.
That was two years after this lawsuit had started.
It took a few months for us to complete our negotiations as this case got closer and closer to trial.
In the end, this woman's surviving daughters were able to obtain significant compensation for the harms and losses and untimely death of their wonderful mother.
The sad fact is that her death was preventable.
To learn even more about this case, I invite you to watch the video below...
