Mrs. Taylor had a 3-day history of progressive fevers, nausea, and vomiting. She presented to
the emergency department at 2:30 a.m., where she appeared to be moderately ill and
dyspneic. Her initial temperature was 38.3 C, her blood pressure was 112/70 mm Hg, her
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heart rate was 118 beats/min, and her respiratory rate was 26 breaths/min. Her oxygen
saturation was 92% on room air. The examination was remarkable for crackles at her right
lung base. The examination of her cardiac, abdominal, and neurologic systems was
unremarkable. Laboratory studies showed a leukocyte count of 1410 9 cells/L with a left shift, a
creatinine level of 1.3 mg/dL (114.9mol/L), and a sodium level of 129 mmol/L. A chest
radiograph showed a dense right lower lobe infiltrate. Bacterial pneumonia was diagnosed.
The patient began receiving levofloxacin, metronidazole, and oxygen and was admitted to the
medical ward of the hospital. A pulmonologist was consulted by telephone about the initial
At 7:45 a.m., a nurse found Mrs. Taylor profoundly dyspneic and diaphoretic. Her oxygen
saturation had fallen to 69% on 2 L. The patient was immediately placed on a nonrebreather
mask at 15 L/min, which increased the oxygen saturation to 91%. Dr. Harris, who had
assumed Mrs. Taylor’s care that morning, was paged and arrived within minutes.
Dr. Harris found the patient in marked respiratory distress. She had a temperature of 37.6 C,
a blood pressure of 140/88 mm Hg, a heart rate of 140 beats/min, and a respiratory rate of 50
breaths/min. On examination, she had diffuse rhonchi, as well as crackles, throughout the
right lung field. The rest of the examination was unremarkable. An arterial blood gas showed
a pH of 7.41, a PCO 2 of 29, and a PO 2 of 63 (on the nonrebreather mask). Portable chest
radiography showed a worsening of the right lung infiltrate.
Dr. Harris diagnosed progressing pneumonia and impending respiratory failure. She
considered intubating the patient herself on the floor but opted to immediately transfer Mrs.
Taylor to the care of a pulmonologist and intensivist who was standing by in the ICU, for
probable intubation and mechanical ventilation.
Dr. Harris: In my mind, it was a matter of what would be safest. I really don’t have a lot of
experience with awake intubation, and I knew that a pulmonologist was already involved in the
case, so it was a really easy decision from my standpoint to get the patient transferred to the ICU
Dr. Harris first saw the patient at 7:57 a.m. and completed her evaluation by 8:20 a.m. It took
a few minutes for the logistics to be organized and for Mrs. Taylor to be physically
transported. She arrived in the ICU at 8:37 a.m. By this time, her respiratory distress was
more pronounced and she had become delirious. Her blood pressure was 142/65 mm Hg, her
heart rate was 145 beats/min, her respiratory rate was 38 breaths/min, and oxygen
saturation on the nonrebreather mask was 64%.
The pulmonologist preoxygenated Mrs. Taylor with a bag-valve-mask apparatus,
administered a dose of midazolam, and attempted intubation at 8:45 a.m. Unfortunately, the
attempt was complicated by ventricular fibrillation and a cardiac arrest. The physicians and
nurses resumed bag-valve-mask oxygenation, and the oxygenation saturation, which had
fallen to the mid-30s, rose to the 80s. Standard cardiopulmonary resuscitation was
performed, including 2 to 3 minutes of chest compression, accompanied by boluses of atropine
and epinephrine. The patient was defibrillated with 200 J and intubated successfully on the
second attempt at 8:49 a.m. Arterial blood gas values after intubation were a pH of 7.09, a
PCo 2 of 72, and a Po 2 of 39 on 100% Fio 2 .
The patient’s oxygenation ultimately improved and her cardiopulmonary status stabilized, but
she suffered profound and presumably irreversible brain damage. At the time of discharge, she
could not recognize family members or independently perform any activities of daily living.
Although the case was informally discussed among the providers involved, it was not
forwarded to or reviewed by the hospital’s risk management committee. The patient was
discharged to a long-term care facility for total custodial care. Several months after discharge,
the patient’s family sought legal counsel and decided to pursue a malpractice claim. About 20
months later, Dr. Harris received notice that she had been named in Mrs. Taylor’s malpractice
Dr. Harris: I was sitting in the ICU and my partner calls me up and says, You’re getting sued,
and that’s why I’m leaving medicine.