Internal medicine specialist delayed intubating patient and calling intensivist, ruling finds
The Superior Court of Justice of Ontario has ruled that an internal medicine specialist breached the standard of care in her treatment of a patient who experienced an acute asthma attack and suffered a brain injury.
The case was Gumbley v. Vasiliou, 2024 ONSC 4858. In October 2014, the patient suffering from an asthma attack arrived at Toronto East General Hospital at 4:30 p.m. An emergency physician saw her and administered treatments.
The defendant in this case was the internist on duty at the time. She had experience in treating respiratory conditions, including asthma. However, she was not regularly involved in intubating patients with severe asthma.
The internist assessed the patient sometime after 6:00 p.m. and decided to admit her to the intensive care unit at around 7:00 p.m. The internist ordered additional treatments, including epinephrine, sometime after 9:00 p.m. The patient was transferred to the ICU at around 9:40 p.m.
At some point, the patient’s symptoms worsened. The internist decided to prepare to intubate her sometime after 11:00 p.m. At 12 midnight, a respiratory therapist performed the intubation on the third attempt. Post-intubation, the patient was difficult to ventilate.
The internist paged the on-call intensivist at 1:10 a.m., who took over the patient’s care at 1:50 a.m. Her ventilation improved after the intensivist administered isoflurane. Later that month, an MRI showed significant brain damage.
The plaintiffs in this case, who were the patient and her family members, brought this case. They alleged that the internist was negligent and that this negligence caused the patient’s brain damage.
The Ontario Superior Court of Justice ruled in favour of the plaintiffs and granted a judgment against the defendant, subject to approval of the agreed amount of damages under Ontario’s Family Law Act, 1990. The court deemed the internist negligent.
The court found multiple instances where the defendant’s actions fell below the standard of care expected of an internist.
First, the court discussed the internist's inadequate record-keeping. Her sparse records contained troubling omissions on aspects such as arterial blood gas tests and the timing of an arterial line insertion, the court found. The hospital's IT issues potentially arising from a scheduled routine system maintenance did not excuse these shortcomings, the court noted.
Second, the court found that the internist only consulted the on-call intensivist at 1:10 a.m. despite the severity of the patient’s condition. This unreasonable delay deprived the patient of the chance to timely benefit from the intensivist’s expertise, the court said. A reasonable internist would have called the intensivist by 10:00 p.m., the court added.
Third, the court determined that the internist also unreasonably delayed the decision to intubate the patient until 11:00 p.m. The internist could have executed the decision just before or after the patient’s transfer to the ICU, the court noted. Once the internist did make the decision to intubate, she was responsible for ensuring that this decision would be executed quickly, the court added.
Lastly, regarding causation, the court found that the internist’s negligent acts – including her failure to call the intensivist earlier, her delay in making the decision to intubate, and her failure to ensure intubation by the most experienced clinician available – were cumulatively the most likely cause of the patient’s brain injury.
The numerous breaches in the standard of care led to the loss of multiple opportunities for a better outcome, the court concluded.
