Sued for post-op pain control with morphine

A 17-year old dies after a tonsillectomy:

Irene Triplett’s lawyer, Bruce Fagel, said that Lee ordered the nurses to give Versed, a sedative, to calm Gomez before surgery. At the post-anesthesia care unit, Gomez was given two injections of two milligrams of morphine. The injections were 10 minutes apart, Fagel said. The morphine was given because a nurse thought Gomez was in pain because he was “moaning.” Those drugs caused him to stop breathing, Fagel contends.

Defense attorneys are denying their clients were responsible. Experts testified about the effects of drugs and how they might have affected Gomez’s medical condition, obstructive sleep apnea. Also, the surgery was complicated because he had a large tongue, small airway and large tonsils, characteristics of Down syndrome. They also have pointed out to jurors that Gomez was 4 feet 10 inches tall and was overweight at 176 pounds.

2mg of morphine 10 minutes apart should not lead to respiratory failure.

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  • Anonymous

    In a better world, there would be a frank and sober discussion about what went wrong here and how it might be avoided in the future. In fact such discussions take place amongst doctors all the time. They’re not a reflection of how poorly we do our jobs, but rather of how we can’t intuit all possible outcomes in all situations.

    As it is, this case will devolve into a nit picking match over how much morphine can be given to “X” individual at “Y” time. No one is going to learn anything after this case is done. We can all imagine a much more candid and informative discussion about this matter in a Grand Rounds kind of forum. That’s never going to happen under our current med-mal system.

    I’m not going to say anything further about this case as I know that med-mal lawyers troll these sites all the time (including the ones trying this case). Suffice it to say the plaintiff’s attorneys are not very sharp.

  • Anonymous

    “In a better world, there would be a frank and sober discussion about what went wrong here and how it might be avoided in the future.”

    I second that 1000 percent. An excellent post.

    People with Down syndrome tend to be more vulnerable to airway and lung problems. I’m wondering if the health care team in this case was aware of this fact; possibly not, since physicians and nurses often are left to flounder around when it comes to caring for people with disabilities. Communication with Down syndrome patients can be a huge issue too.

    A sad case for everyone involved.

  • Anonymous

    Why can’t you physicians have a frank and sober discussion right now about it? You can request the medical records (they’ll likely be part of the trial transcript when it’s over), review the case, and reach a conclusion.

    Are you afraid that you might conclude there was negligence involved, and thus might be called to testify?

  • Anonymous

    NO. We’re afraid that a-hole med-mal lawyers will turn a tragedy into a three ring circus and try to suck as much money out of it independent of the facts (fro “justice,” of course). This is how John Edwards made his millions and bought his Senate seat- by “channelling” the souls of dead CP babies in front of mis-informed, gullible juries.

  • Anonymous

    Good answer. You really have a firm grasp on the issues.

  • Anonymous

    Does it say how long after the surgery he was discharged?

  • Gasman

    The kid made it home and was sitting up watching televisision. There was probably several hours between the recovery room dose of morphine and the subsequent steps of stage II recovery, discharge, transport and television time. Peak effect of these drugs would have ocurred minutes after administration, and the blood levels would have continued to drop continuously thereafter. It is quite a leap to conclude that whatever was not harmful in recovery was somehow lethal at a tenth or the dose later.

    Lawyers don’t need valid facts, just ones that they can twist to suit their own needs.

  • Commander Adama

    I hope this family wins tons of money. Money will help replace their son. Money taken from evil hospitals and evil doctors. I hope that someday we can live in a world without hospitals and doctors, so that these tragedies can be avoided.

    /sarcasm off

    It’s too bad this happened. I would like to see health courts (something less like the lottery system we currently have) that would help families determine what went wrong and ensure that the system is corrected. I don’t think families need to be compensated tons of money for losing loved ones. I can understand reimbursing for the economic value of the individual and REASONABLE attorney’s fees, but anything more than that is just silly (maybe punitive damages if someone really screwed up, but that money doesn’t need to go to the family).

    /end happy-fun post

  • Anonymous

    So once you go through your front door, the hospital is no longer responsible for whatever happened?

    It appears physicians don’t need any facts, or much more than the meager ones provided by this article, to decide a case. Wonder why I have to spend so much time in the waiting room if diagnosis is this easy?

  • Anonymous

    They suppressed respiration and didn’t protect the airway in a vulnerable patient. Sounds like negligence to me…although I WOULD like to see the actual medical records, including nurse notes, and hear from experts about the standard of care.

    The amount of morhpine may not normally be excessive. However, again, this was a vulnerable patient whose respiration needed monitoring.

    Care must be tailored to the patient, don’t you agree?

  • Anonymous

    “So once you go through your front door, the hospital is no longer responsible for whatever happened?”

    Typical lawyer response.
    Let me re-phrase your statement or question.
    “So once you go through your front door, I (plaintiff lawyer) am no longer a player in the med-mal lottery?”

  • Gasman

    for Anon 2:41.

    Yes, at some point in this child’s care he recieved drugs that suppresed his respiratory drive and a surgery that altered his airway function. Yet he likely went through a series of recovery stages and had serial assessments of his discharge readiness.

    Will some patient, dispite my efforts, go home and die; possibly as a result of my actions, or possibly just one of those coincidences (almost 10,000 americans die every day!) Most certainly they will. The reality is I cannot keep every one for an extra day or two because the hospital system won’t have the beds if everyone assumes the same practice, payers won’t pay for it, and patients will balk being kept when they feel just fine and can sence that we’re costing them $1000 a day just to cover our ass.

    So, will I err in letting someone go home? Yes. However, if no one wants to pay the cost of my having perfect practice (keep them all until it’s way past reasonable for discharge) then those who share in the cost savings from my effecting a reasonable practice must share in the rare cost to the individual patient. Physicians must use individual judgement to save the system from financial ruin, the system needs to compensate the occasional patient injured as a result.

  • Anonymous

    This youth was a high-risk patient because of his DS.

    Kids with DS often have a flattened midface, poor muscle tone in the airways, large tongues, more vulnerability to respiratory problems, etc. They are quite prone to obstructive sleep apnea.

    Various studies have found that patients with DS who undergo tonsillectomy have poorer oxygenation and a slower time to recovery. For this reason, some experts recommend that tonsillectomy/adenoidectomy *not* be done on an outpatient basis.

    The article does not say whether the surgery team identified this youth as high risk and managed his care accordingly. In this case it might not have made a difference, but we can’t rewind time so no one can say conclusively.

    I hope the take-home point here – that people with DS, or any other disability, for that matter, are often medically more vulnerable than the rest of the population – will not be lost among the quibbling. There’s often a real gap in quality of care for these people. We need to do better.

  • Anonymous

    The lesson here should be: “Do not use morphine for any pain”.

    The pain after tonsilectomy, while unpleasant, is not unbearable. It definitely does not require an opiate. Risks versus benefits… What’s so difficult to understand?

    This is the “wonderful” system based on “protocols”, where people (especially nurses) become robots and stop thinking and tailoring the different steps to the patient’s needs.

  • Anonymous

    Actually, Gasman’s point is that doctors have role in controlling costs and divvy’ing up limited resources. We constantly play the odds. What the public can’t or won’t accept is that there aren’t sufficient resources to insure that every single patient gets care which virtually asssures that no problems will ensue after intervention.

    Commander Adama- you forgot to add “So say we all!”

  • Anonymous

    “What the public can’t or won’t accept is that there aren’t sufficient resources to insure that every single patient gets care which virtually asssures that no problems will ensue after intervention.”

    To an extent – can you blame them? Healthcare marketing promises a lifetime free of pain and suffering if you will just take this drug, use this hospital rated #1 because it has these surgeons, etc.

  • Anonymous

    After birth, you should never leave the hospital because something unforseen might happen.

  • Anonymous

    8:33….A child dying qualifies as a bit more than “something unforeseen”. You are very arrogant. I hope you aren’t a dr.

  • diora

    The pain after tonsilectomy, while unpleasant, is not unbearable.
    I was wondering about it. I don’t know enough to form an opinion on this particular case.
    But when I was 12 I had tonsillectomy/adenoidectomy. This was in Eastern Europe (in the 70s). All I had during surgery was local anesthesia and I’d imagine it was probably not the type they use here now (when they use local). Because I wasn’t numb, not by a long stretch.

    The only “pain killer” I got after the surgery was ice cream. I guess that was local idea of pain control. I didn’t get post-op antibiotics either, but that is beside the point. Obviously, the “standard of care” over there was different.

    Now this would probably not be the standard of care here, but the pain after the surgery wasn’t that terrible. Maybe I just don’t remember it, but I think I would if it had been truly terrible. And I didn’t get anything, not even tylenol.

  • Cathy

    Diora, I had my tonsils out when I was 13. I know I was asleep during the surgery but I don’t remember any pain meds at all following. I did stay in the hosp. until the next day and then discharged but I also only remember ice cream. I know when I went home I was only using ice cream to soothe my throat. I wouldn’t want my kids being given morphine following having their tonsils removed. Thankfully, they are all grown and none of them had that surgery. Neither have any of my grandkids.

  • Anonymous

    Oh- my-God! Not……MOR-phine!! MS is routinely given IV in small doses (as in this case, I might add) to control the immediate post-op pain in the recovery room. Please give us a rational reason why patients shouldn’t have it Cathy. This particular case neither makes the case for or against it’s use- thought the silly trial lawyers would have you believe that a patient’s life hinged on it.

    And BTW the fact that your kids are grown up in no way means they might not still be “at risk” to be tonsillectomized.

  • Cathy

    LOL…Well goodness, calm yourself down. To attacked me like a Bible Story.

    First, I was responding to Diora on what I remember about a surgery that I had 40 years ago. I don’t know what I had while I was being operated on, only that I recall no pain meds following this surgery.

    I’m aware that my grown kids could get all sorts of illnesses. I was merely saying that they didn’t have this surgery while they were children.

    As for morphine…Personally, I don’t like it. Makes me itch and keeps me wide awake…Also, it’s a strong narcotic, that people having severe pain, such as terminal cancer receive. What is wrong with starting out small with pain and then going to the strong narcotics if the other stuff doesn’t work?

  • Anonymous

    “it’s a strong narcotic, that people having severe pain, such as terminal cancer receive.”

    Strong is a relative word cathy. Shall we talk about demerol or dilaudid?

  • Anonymous

    Cathy, The point I’m trying to make is that the trial lawyers have gotten you exactly where they want you: scared of both morphine (in ANY dosage) and tonsillectomies in general. You think they care about the fear they spread, as long as they win oodles of money??

    What isn’t made clear in the article, and which I’m sure the plaintiff’s lawyer will make no effort to immuminate is the fact that you’re limited in what you can give an recently anesthetized patient in the recovery room. It’s either demerol (not most doctors’ favorite) or fentanyl (talk about a strong drug!) to control the pain if you have any stenuous objections to morphine-which has an excellent and predictable safety profile, ESPECIALLY in the doses cited.

  • Anonymous

    You’re all dinging away about the morphine as if it were the only relevant fact about this case. It’s not. Most likely it’s one of several factors that, taken together, produced a fatal outcome.

  • NeoNurseChic

    Cathy,

    While not about the article, I wanted to comment on the morphine. It’s not just for chronic terminal pain. It can also be used in extended release for chronic, severe, non-cancer pain. I’d share more insight on that topic, but I can’t. Suffice it to say that for some people, it can be a lifesaver… :)

    And the other thing is that many patients won’t ever remember the pain meds they receive in the immediate post-op period in recovery. You’d know if you received morphine once you were back in your own hospital room or ambulatory care center, and at that point, you’re right, it probably wouldn’t be offered in most cases for tonsillectomy. However, in the OR recovery period, they often still give IV pain meds to treat pain at that phase. The patient isn’t even awake enough to take a med by mouth or have any water, etc at this point. I don’t think morphine for the immediate post-op pain is out of the question. There are lots more stronger pain meds out there… :)

    Take care,
    Carrie :)

  • Cathy

    It’s not that I’m afraid of morphine, I just don’t like taking it. I had a big surgery last year and was on a morphine pump. BTW, I’m a grown woman and this was major surgery. My pump was set at 1mg every 10 minutes is what I could get. I couldn’t stand the itching and asked for it to be taken off the next day and to give me oral darvocet.

    As for dilaudid, I have received it once, in the ER after an accident. Holy cow, she was still putting it in my IV and it felt like I was being put under for surgery. My GI doc uses fentanyl for EGDs that I have every 6 months. He used to use demerol but now he uses that, I have no idea why. When he used the demerol with the versed I had no after effects. I would come home and feel good. Wasn’t sleepy at all. With the fentanyl I’m a zombie for the entire day. Just come home and sit and sleep. I hate it also.

    Admittedly there are many things about medications I don’t know. I’m not a Dr. But,I wonder about an adult woman receiving 1mg morphine every 10 minutes for a very painful surgery recovery vs a child being given 2mg at 10 minute intervals for having his tonsils removed. I’m not placing any blame any where just making an observation.

    Carrie, Thanks for your explanations…:)

  • WilliamManginoMD

    Since I am one of the most hated commentator’s on Kevin-MD – you might as well pile on after these comments.

    Fixed agents are a ‘no-no’ with patients who have a propensity towards developing airway obstruction. Versed and valium were probably not good choices-but lets put that aside.

    Morphine is not a fixed agent. 2mg. times two doesn’t equal a ‘narcotic death.’

    Having said this-when a patient is thrashing about it usually raises the possibility [ duh! ] that the patient is anoxic and scared to death that he can’t move air across the glottic aperture. You know-like, I can’t breathe!!

    Extubating this patient was probably not the best idea-but I wasn’t there, so who am I to criticize.

    Gee!! Let me say it one more time—extubating this patient was not a good idea–apparently. Was there some rush to get him home? !!!

    Is this some mystery case?!!!

  • Cathy

    Dr. Mangino, off topic..Do you have a BLOG of your own? I tried to find you on one but no luck yet. Was just wondering.

  • WilliamManginoMD

    Well, thank you for asking, Cathy. You must be the only person in America who wants to read my blogs-comments! Even my mother has never asked!!

    No I don’t- I read Kevin once in awhile. I have written extensively on the subjects to which I limit my comments; pain management, anesthesia and some civil rights and constitutional issues-like the governments’ war on pain specialists who prescribe opioids. I happen to be one of them.

    While my comments may seem overly critical of others-the fact remains that my rhetorical questions are meant for everyone-me included.

    This case [ above ] in question, is sad for the child and family-and for the doctors. While I believe in what I say, the fact is, we don’t know how these situations develop if we are not there.

    If you are interested in this particular case then read a standard pediatric anesthesia text on airway management for a child that has to return to the OR with re-bleeding.[ full stomach or not ].Also on the management of epiglottitis-which gives similar types of info.

    Obese kids with airway obstruction are tough to manage. As a former ENT resident and anesthesiologist I faced similar situations.

    Just because there may be malpractice in this world-doesn’t mean that a lawsuit will resolve it.

    If the lawyers want us to be ‘Marcus Welby’ then lets have them start acting like ‘Atticus Finch.’

    Best wishes to you – and to other readers. I’m the last guy in the world that needs a blogsite.

  • williammanginomd

    Cathy,

    No there is no blogsite for me; much to the delite of most readers.

    Take care.

  • Cathy

    I don’t know why you believe you are the last person who should have a blog? There are no qualifications too meet. Anyone can (and does) have one. I think you have alot to say and that people could learn from reading what you write. I find you interesting.

    Who cares whether people agrees with you or not. A blog is about saying and writing what you believe in. It’s also a great stress reliever and a way to get rid of frustrations. Many come and read and never return, (most in my case), but some stick around and you can have some pretty good back and forths. You already know that.

    Being chronically pissed off on a BLOG, keeps me from being that way with my family and friends.

    Anyway, I just wanted to tell you that I think you could have a really good BLOG if you tried it.

  • NeoNurseChic

    Dr. Maningo,

    I’ve read several of your comments on this site, and I have agreed with a lot of what you said! Plus, I think we have place of employment in common – one of your formers is my current, if I remember correctly!

    Don’t be so hard on yourself – your writing is very thought-provoking.

    Take care!
    Carrie :)

  • WilliamManginoMd

    Dear Cathy and NeoNurse Chic-appreciate your kind comments.

    I hope your current place of employment is not that small hospital in Illinois – where they escorted me to the door when I criticized the surgeon for instructing the nurse anesthetist to “Keep the patient light,” [referring to the level of anesthesia ] which resulted in an aspiration pneumonitis that could have been avoided had my instructions been followed [ by both the surgeon and his “buddy” the CRNA.

    I suggest to anyone who works in an OR, where I’ve been, to not mention my name- if you value your political longevity.

    By the way-I was never sued-they were-they lost – and now, when I drive through Illinois I get a very good feeling.

    Hell has no fury like that of a doctor scorned.

  • NeoNurseChic

    I live just outside Philadelphia…so no, it’s not Illinois. :)

    And I’m not an OR nurse by any means…I’m a neonatal nurse. :)

    Take care,
    Carrie :)

  • Anonymous

    It would appear that Dr. Mangino now HAS his own weblog (and fans, to boot) right here.

  • WilliamManginoMd

    I don’t want fans or a website- believe me.

  • Anonymous

    All of this is for naught in that the jury returned a verdict in favor of the defendants.

  • Anonymous

    “Hell has no fury like that of a doctor scorned.”

    I don’t know about that one. I’ve seen some pretty angry patients, especially those who are given inadequate pain management after surgery. Maybe the doctors just get more opportunity to express it. However, I think physicians are more likely to get their way, especially in a hospital setting (patient vs. doctor-who do you think is going to win? It would be nice if all such pairs could work together).

    Also, pain is a subjective thing. Whether or not narcotics or whatever are appropriate after a surgical procedure depends on the severity of said procedure AND the patient’s reported pain. When we start to assign an amount of pain that someone “should” be feeling, we leave ourselves open to the distinct possibility of undermanaging pain. And such a possibility is a horrible reality to many, many patients today.