This was a tragic case.
A preventable case.
This woman should be alive today.
But she's not.
The anesthesiologist is still administering anesthesia.
The GI doctor is still doing colonoscopies.
The patient's family was furious when they learned what happened.
You should know that the doctors involved didn't tell her surviving family the real truth about what happened.
A lawsuit seeking money as compensation for the death of their mother.
Seeking compensation for the taking her at an early age.
Seeking compensation for the loss of their best friend and companion.
This was a close-knit family.
Mom was the cornerstone of this family.
All four lived near each other in Brooklyn.
They spent holidays together.
They spent their weekends together.
It wasn't unusual when mom told her oldest daughter that she saw blood in the toilet when going to the bathroom.
That prompted her to see a gastroenterologist.
He told mom he needed to look inside to see why she was bleeding.
It wasn't a gyn issue.
He got her worried.
It might be cancer.
It might be a polyp.
It might be a hemorrhoid.
"The way to look inside is to do a colonoscopy," he said.
Even though she was in her mid-sixties, she never had one.
He told her to follow these instructions to prepare for her colonoscopy.
She followed his instructions to the letter.
Then again, nobody likes that liquid.
She did exactly what he said to do.
The next day, she was ready.
She arrived on time.
She wouldn't feel anything.
She wouldn't remember anything.
She'll wake up feeling refreshed.
She was ready.
She was the designated driver.
Behind the scenes, she didn't know what was going on.
Here's what took almost two years to find out...
During the colonoscopy, the GI doctor inserts a small, thin, fiber-optic tube into her butt.
He looks around.
He needs to see what's in there.
If he finds polyps, he'll remove them and send them off to pathology for evaluation.
He needs to find out where the bleeding is coming from.
He's moving that probe further and further up her colon.
Except he got stuck.
She had a kink in her colon.
He was trying.
He kept pushing.
The anesthesia doctor heard an alarm trigger on a device used to monitor the patient's oxygenation.
It's called a pulse-oximeter.
That device triggered an alarm.
It meant one of two things...
Either the device malfunctioned or...
There was a problem with the patient getting sufficient oxygen.
He needed to know what the problem was.
He first went to look at the pulse-oximeter device and how it was hooked up.
Everything looked connected.
He reset it and waited for the oxygen levels to return to normal.
They were dropping.
That meant the problem was with the patient.
Nor did he know what caused this sudden drop in her oxygen levels.
Remember, he doesn't know what's going on at the other end with the GI doctor and what he encountered in her colon.
The GI doctor, still hearing the alarm, asked the anesthesiologist if everything was Ok.
He replied distantly "Yes. Her O2 sat levels are dropping. Everything's fine though."
He kept trying to push his way through the kink in the colon.
Kept trying to get the colonoscope further up so he could see what's past this kink.
The anesthesiologist now checks the patient's mouth.
He sees there's some fluid in her mouth.
The anesthesiologist decides to suction the fluid in her mouth.
He suctions the fluid around her cheek and the back of her throat.
You should know that during this colonoscopy the patient is lightly sedated.
She is given a medication known as propofol.
She's not intubated.
That's where an anesthesiologist inserts a tube down her airway in order to keep an open airway.
It protects the airway and ensures that if her airway closes down, she still has the ability to breathe.
Here's what I learned when I questioned the two doctors involved in this case...
An involuntary reaction.
It caused her to vomit.
That meant that fluid and stomach contents were now up in her mouth.
That explained why there was fluid in her mouth.
That didn't yet explain why her oxygen levels were falling.
When someone vomits stomach contents into their mouth while under anesthesia, the next thing that happens is that the patient breathes in.
Because the patient has no gag reflex while under anesthesia, they don't cough.
That gag reflex prevents liquids from entering the airway.
When you're under anesthesia, without a gag reflex, you simply breathe in whatever is in your mouth and throat.
That went right into her lungs.
When a foreign object or liquid goes into the lungs that shouldn't be there, that's known medically as pneumonia.
The action of how those stomach contents got into her mouth and then her lungs is medically known as aspiration pneumonia.
That can be life-threatening.
In this case, the anesthesiologist had no clue.
He never considered the possibility that she aspirated.
He was first worried about the machine malfunctioning rather than the patient having a medical emergency.
Rather than tell the GI doctor to STOP what he was doing while he corrected her oxygen levels, he told him to keep going.
He'd just suction out the fluid in her mouth and she'd be just fine.
Except she wasn't.
He never suctioned beyond the back of her mouth.
He should have suctioned down her throat, past her vocal cords.
The reason why her oxygen saturation levels were dropping was because she couldn't get air into her lungs.
There was fluid in her lungs.
There was stomach contents in her lungs.
Her lungs were not able to properly inflate and exchange air.
If this continues for a certain period of time, the patient will suffer brain damage.
The anesthesiologist never considered the possibility that she had aspirated.
He never figured out why her oxygen levels had dropped dangerously low.
He never learned from the GI doctor the triggering mechanism for this aspiration.
My medical expert confirmed that when he got stuck advancing the scope, he should have stopped.
Rather than risk a perforation by trying to push through, he should have abandoned the procedure.
But he didn't.
He kept going.
He didn't know why her oxygen levels had dropped.
Neither did the anesthesia doctor.
When they put the patient in the recovery room, the anesthesia doctor told the nurse to keep her head elevated.
Then he left to go administer anesthesia to another patient.
She was gasping for air.
She couldn't breathe.
There was fluid in her lungs, but he didn't know it.
Her oxygen levels did not improve.
He went on to do his next procedure.
The anesthesiologist sees the patient is having difficulty breathing.
He doesn't summon an ambulance for another 15 minutes.
There's talk of calling an ambulance immediately.
They delayed calling an ambulance.
She's not improving.
Her oxygen levels are terrible.
She's not awake.
The anesthesiologist can't wake her.
Finally, an ambulance is called.
She's taken emergently to the closest emergency room.
She's in a coma.
She can't feel anything.
She'll never awaken.
She remains in a coma over the next two days.
She suffered terrible brain damage.
All from a lack of oxygen.
All of her organs are now shutting down.
She can't survive.
All from a lack of oxygen.
How did she get such a lack of oxygen?
It all started when the GI doctor tried to push his way through the kink in the colon.
That triggered her to vomit into her mouth.
The anesthesia doctor failed to recognize the problem and tell the GI doctor who was doing the colonoscopy.
The GI doctor failed to tell the anesthesiologist he encountered a problem and would now end the procedure.
The anesthesiologist failed to recognize she had aspirated.
He failed to suction past her vocal cords to try and remove fluid contents from her lungs.
Each of the medical experts I consulted to evaluate this case were appalled.
They were furious.
They didn't understand how each of these doctors violated the basic standards of medical care.
Their miscommunications and their misunderstanding of what was going on, cumulatively and individually led them to believe she was fine.
She died because of miscommunication between her GI doctor and the anesthesiologist.
She didn't have to die.
This was preventable.