Anesthesia for a Christmas-week overbite operation ends in teenager's death
News staff writer - Birmingham News
Seventeen-year-old Brandi R. Timmons was one of the last patients wheeled into surgery Dec. 23, 1998, at Baptist East Medical Center in Montgomery.
It was Wednesday and the last day of the work week for many doctors and nurses who anticipated a supersized holiday created by Christmas falling on a Friday.
An Sidney Lanier High School honor student and cheerleader undergoing elective surgery to correct an overbite, Brandi closed her eyes for the last time. She never awoke from anesthesia.
Last month, a Montgomery jury delivered a $14.5 million judgment against Brandi's anesthesia doctor and nurse. It was a stunningly large verdict, more than 50 times the cap of $250,000 being debated nationally for non-economic damages in medical negligence lawsuits.
A defense attorney described the amount as an outrageously unfair penalty for an incomprehensible series of events that led to the tragic death of a promising young woman. Nobody was to blame, he said.
But a plaintiff's attorney said the jury intended to send a strong message. The case revealed basic flaws in anesthesia training and procedures while demonstrating just how far some members of the medical profession will go to cover up serious errors, he said.
Host of distractions:
Joseph "Buddy" Brown, a Mobile attorney who represented Brandi's mother, Johnnie Timmons, in the lawsuit said the anesthesia team at Baptist East was working that Wednesday amid a host of holiday distractions, including the upcoming long weekend and a nearby open house in a surgeon's office.
And there was constant shifting of Brandi's anesthesia providers. Her original anesthesia doctor was called away to another case; another anesthesiologist took his place and then left.
Finally, a third anesthesiologist, Dr. William Ware, finished Brandi's case. In addition, a shift ended for Brandi's original nurse anesthetist, and a second anesthesia nurse, Lil Hayes, finished the case.
Brown said some change of doctors and nurses is understandable during a four-hour surgery, but this was too much.
"If it's my kid, I want continuity," he said.
Records indicate that a ventilator breathing tube was removed from Brandi's nose in the operating room after surgery. She was taken off a monitor and wheeled into a recovery room, Brown said. When she was put back on a monitor, her vital signs showed she was in trouble.
Brown said Brandi was still under the influence of strong narcotics given for pain, and she was unable to breath on her own. She wasn't monitored closely enough to pick up the problem, he said.
Then, a nurse who was watching Brandi in the recovery room didn't call a doctor quickly enough, Brown said. Finally, Brandi went into a full cardiac arrest and a Code Blue was declared, a signal for emergency resuscitation of a patient.
"Then, we've got mismanagement of the code," Brown said.
He said Ware and Hayes responded, but gave improper drugs, didn't even attempt to shock Brandi's heart back into rhythm and took 10 minutes to get a ventilator tube back in Brandi's lungs.
Doctors and nurses did get Brandi's heart beating again, but her brain was gone, deprived of oxygen for too long, Brown said. She was transferred to the University of Alabama at Birmingham on Christmas. She was taken off life support and died Jan. 2.
The case revolved around medical records and their accuracy. If the records were right, Brandi clearly had not received proper care. But defense attorneys said the records were wrong, and attempts to correct them just made things worse.
Brown said Ware's medical partner called the hospital's risk manager a sort of internal medical investigator at home on the Sunday after Christmas and asked her to attend a meeting the next day with doctors and nurses involved in Brandi's code.
The risk manager checked with the hospital's attorney, who told her such a meeting would be inappropriate, Brown said.
When the risk manager relayed the message to Ware and his partner, they told her that there were inaccuracies in the code sheet, a key document that recorded details of Brandi's emergency resuscitation. The risk manager checked with the nurse who kept the code sheet. The nurse stood by her records. Besides, Ware had also signed the code sheet on Dec. 23, Brown said.
"The code sheet is the truth," Brown said. ``It speaks the truth."
Brown said there were indications that key entries in other medical records had been changed. One time entry was altered to show Brandi was off a monitor for only two minutes instead of seven minutes, and some entries had been made with a different color ink.
In addition, Brown discovered that Ware and Hayes were not required to remain up to date on their certification for advanced cardiac life support, commonly known as ACLS.
The ACLS system spells out the methods, materials and sequences of action needed for emergency resuscitation. Medical professionals who work in emergency areas must be tested and recertified in ACLS every two years.
But there is an exception for anesthesia doctors and nurses, even through they often end up supervising emergency resuscitations.
Authorities say anesthesiologists and nurse anesthetists work routinely with the drugs used in resuscitation, and there's a belief that they need to be trained once but not recertified every two years in ACLS.
So Hayes had not been recertified in ACLS for at least 10 years, and Ware for at least five years, Brown said.
There's a world of difference between bringing somebody out of anesthesia and an emergency resuscitation, Brown said.
"It is certainly an area that is ripe for re-examination," he said.
In the end, Brown asked the jury for $20 million and got $14.5 million. It was a strong message from a jury in Montgomery, where big-money verdicts are few, particularly for medical malpractice, he said.
"This is not Barbour County or one the areas reputed to be tort hell," Brown said.
And if the $250,000 cap that is being discussed nationally was instituted, the lawsuit would never have been filed, Brown said. The expenses for years of legal work would have exceeded the judgment, he said.
"It would have gone uncompensated, unaddressed," Brown said.
Randal H. Sellers, a Birmingham attorney representing Ware and Hayes, said there was no good reason for such a "shockingly large verdict."
"We're not talking about some evil intent here," Sellers said.
The verdict was the product of a natural tendency to assign blame for the inexplicable, tragic death of a healthy teenager, he said.
"Rare things do happen," Sellers said.
And that was a problem doctors just couldn't explain exactly what killed Brandi, although Sellers said he suspects her heart failed.
He said the code sheet was riddled with errors, filled in by a nurse who didn't have experience in keeping such records. No matter what the code sheet stated, it didn't take 10 minutes to get a breathing tube back in Brandi, Sellers said.
"There were other things on the code sheet that were inaccurate," he said.
Sellers said Ware signed the code sheet without looking at it, and later the inaccuracies were brought to his attention. Then Sellers and his partner simply tried to set up a meeting with risk management to discuss the problem.
"It's a kind of darned-if-you-do and darned-if-you-don't decision," Sellers said.
Sellers said allegations about other medical records being altered were based on faulty premises about different colored ink and numbers that just appeared to be written over.
The coming holiday and the shifting around of anesthesia providers had nothing to do with Brandi's death; nor were these big issues in the trial, Sellers said.
The only lesson the case provides is that doctors and nurses can deliver good care and still pay the price for the death of a healthy person.
Sellers said he will fight to have the award reduced.
"The case is not over," he said.
Dr. Frederick W. Ernst, a Dothan anesthesiologist and patient advocate, said the lawsuit award is very large, but facts of the case raise some red flags.
It's not unusual for anesthesiologists to shift around in an operating room, but not to the extent they did in Brandi's operation, Ernst said.
"Three changes that's a little much," he said.
And the attempt to correct medical records was just plain stupid, Ernst said. There's a procedure for making corrections just file an addendum to the record. That's all a doctor can do after the fact, he said.
And Ernst decided in 1998 to keep his ACLS certification up to date, even though it's not required. "We are beginning to see a move toward that," he said.
Hospitals can require current ACLS certification for anesthesia providers, but not all of them do, he said. Ernst estimated that he's handled about 25 emergency resuscitations in his 30 years as an anesthesiologist. So it doesn't happen every day.
"When you don't do this that often, it becomes hazy," he said.
Brown said Brandi's mother hopes her daughter's death leads to improvements in anesthesia care better monitoring of patients and up-to-date emergency training for anesthesia doctors and nurses.
"If it saves a single life, Brandi will not have died in vain," Brown said.