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Failure to recognize esophageal intubation

by Laura Hale Brockway, ELS, Vice President, Marketing, and
Roxanna Maiberger, Risk Management Representative



A 51-year-old man was scheduled for a right knee replacement revision on August 3 at a local hospital. The revision was required because of loosening hardware.

The patient’s medical history included morbid obesity, asthma, hypertension, high cholesterol, and diabetes. On the morning of the surgery, the patient reported shortness of breath and wheezing. A medical assistant gave the patient albuterol to address his wheezing.

Physician action

The patient was taken to the OR and Anesthesiologist A intubated the patient. Anesthesiologist A described the events in this case in two separate narrative progress notes. According to Anesthesiologist A, the hospital asked him to write a second note because his first note lacked detail. The first set of notes were brief, because OR staff were trying to get the patient ready for transfer and Anesthesiologist A wanted the records available for transfer. There were several discrepancies between the first and second set of notes.

The two sets of notes differ following the patient’s intubation. The first note stated the patient was taken to the OR at 7:50 a.m. He was intubated with a 7.0 endotracheal tube. The first note also stated that at 7:58 a.m., the patient’s end-tidal CO2 (EtCO2) was lost and dexamethasone, propofol, albuterol, and three doses of epinephrine were given. The second note stated that at 7:50 a.m. the EtCO2 decreased and airway pressures began to rise. The notes show an 8-minute discrepancy for when the EtCO2 started to decrease.

The first note implied that Anesthesiologist A thought the patient was in bronchospasm. The second note explicitly stated that Anesthesiologist A believed the patient was in bronchospasm. The second note documented that an anesthesia tech came into the OR and pushed the endotracheal tube in 2 cm and taped the tube. There is no mention of this in the first note. The patient’s O2 saturations decreased to the low- to mid-70s. His stats remained at that rate until 8:05 a.m. when they dropped into the high 50s and low 60s.

It was discovered that the endotracheal tube was in the esophagus. Anesthesiologist A used a glidescope to reposition it. The patient became bradycardic and shortly after was in cardiac arrest. He was defibrillated five times and received epinephrine and amiodarone. The patient went into sinus rhythm. An arterial line and central line were placed. He was given norepinephrine for five minutes, and his oxygen saturations improved. The patient was taken to the PACU.

The patient was later transferred to a regional medical center for a higher level of care and a neurology consult. Despite treatment at the regional medical center, the patient did not recover and was declared brain dead. Life support was withdrawn and the patient died.

The autopsy report listed the cause of death to be the result of a recent hypoxic/ischemic brain injury due to esophageal intubation during anesthesia induction. The patient’s morbid obesity was listed as a contributing factor.


A lawsuit was filed against Anesthesiologist A and the hospital. The allegations were:

  • failure to provide proper anesthesia causing anoxic brain injury and death (Anesthesiologist A);
  • failure to evaluate and monitor the patient (hospital);
  • failure to perform and document a complete medical examination (hospital); and
  • and failure to stabilize the patient for transfer (hospital).

Legal implications

The plaintiff’s anesthesiology consultant stated that the patient’s anoxic brain injury occurred because the endotracheal tube was placed in the esophagus instead of the trachea. The delayed recognition and correction of this issue led to the hypoxia, cardiac arrest, and brain injury.

The plaintiff’s consultant’s criticism mirrored that of defense consultants — that Anesthesiologist A should have considered esophageal intubation when treating the bronchospasm. This caused a delay in the discovery of a mispositioned endotracheal tube. However, one defense consultant stated that she understood how it might have been possible for Anesthesiologist A to pursue treatments for bronchospasm in this patient who had a history of asthma.

The plaintiff’s consultant made several concessions that benefited the defense of this case. He stated that an esophageal intubation is not a violation of the standard of care and can happen in any number of situations. He also stated that Anesthesiologist A used reasonable methods to confirm proper placement of the endotracheal tube by noting bilateral breath sounds, noting the presence of EtCO2 after intubation, and confirming the patient’s abdomen was not distended.

Documentation was a complicating factor in this case. The two versions of the anesthesia notes were inconsistent with each other and were also inconsistent with the notes from the other providers. It was difficult to establish a valid chronology of events.


This case was settled on behalf of Anesthesiologist A. The outcome of the case against the hospital is unknown.

Risk management considerations

The following risk management considerations should be reviewed in tandem with a physician’s state medical board rules or other laws that address medical record documentation. Texas’ state rules and regulations are cited below as an example. However, it is important and strongly recommended that physicians review the medical board rules for the state in which they practice.

Documentation was problematic in the defense of this case. Upon reviewing the medical records and reports for this claim, two key elements concerning documentation were found:

  1. Consistency: There were two versions of progress notes. Each version was different which left multiple events unclear. As a result, it could not be determined what actually happened versus what may have happened throughout the patient’s care.

    It is important to follow your state medical board rules for medical record documentation. For example, the Texas Medical Board outlines the standards for an “adequate” medical record. Note that an “adequate” medical record indicates minimum expectations for documentation. If there is additional information in which a provider believes is relevant to the patient’s care, it is recommended to include it. (1)
  2. Documentation of staff members present/chaperones/assistants. The presence of the anesthesia tech was not documented in one of the anesthesiologist’s notes. It is important to document the names of individuals who are part of the patient encounter. This may include staff members, chaperones, and people who may be accompanying the patient.

    The Texas Medical Board Rules state that “the date and legible identity of the observer” is part of the required documentation constituting an “adequate” medical record. This includes documenting the name, appropriate credentials, and role being performed in the patient’s chart. This documentation helps to promote an accurate account of the chronological events involved in the patient’s care. (1)

While it can be a challenge to ensure accurate documentation during critical portions of a case, consistency is key. In this case, conflicting versions of the same event were a challenge to the defense of the anesthesiologist.


1. Texas Administrative Code. Title 22. Examining boards. Part 9. Texas Medical Board. Chapter 165. Rule 165.1. Medical Records. Available at$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=165&rl=1. Accessed March 22, 2021.