Free Opening Brief in Support - District Court of Delaware - Delaware

·· · · Case 1 :04-cv-01306-GIVIS Document 63-3 Filed 11/21 /2005 Page 1 of 2
University at Buffalo
The State University 0fNew York _ y _ _
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Lynn J. Hernan. M.D. • Christopher M.B. Heard, M.B.Ch.B., F.R.C.A.
- . ,_ -‘ " __ _Prashant‘.lbshi,·M;D. ·e . Budiwiryawan, M.D. _, i° 1 . ·‘ :_‘
August 18, 2005 re: Catherine Laag v A.l. duPont Hospital for Children
_ Paul A. Bradley
McCarter & English, LLP
919 N. Market Street `
Wilmington, Delaware 19899
Dear Mr. Bradley: - ‘
‘ I am a Pediatric Intensive Care specialist, licensed to practice medicine in New York. I
am board certified in Pediatrics and Pediatric Critical Care, as well as Neonatology and
Pediatric Cardiology. My practice is confined to Pediatric Critical Care. I have been
Chief of Pediatric Critical Care at the Children’s Hospital of Buffalo since 1991. Before
that, I was Associate Director of the Pediatric ICU at the Children’s Hospital of
Pittsburgh (1985-1991) and Chief of Pediatric Critical Care at the University of »
Minnesota (1979-1985). My career in Pediatric Critical Care has spanned 26 years. I am
Q currently Professor of Pediatrics at the State University of New York at Buffalo. _
My review included hospital records of Catherine Laag through 9/11/2003; chest x-rays
from her hospitalization 9/6-9/2003; depositions of Edward Cullen, Jr., M.D., Caroline
Boyd, M.D., Cheryl Martinenza, RN, and Steven Cook, M.D.; respiratory therapy flow
sheets through 9/10/2003, resuscitation flow sheet 9/9/2003, and nursing notes. I have
also reviewed the 7/6/2005 report of Stephen Lieberman, M.D.
Catherine Laag was admitted at 10 years of age to A. I. DuPont Hospital for Children
with pneumonia and respiratory failure (8/27/03). She had an underlying diagnosis of
Down?s Syndrome. Catherine was-initially treated with azithromycin, IV fluids and
oxygen. As her oxygenation deteriorated, she was advanced to BiPAP, and ultimately
was intubated on 8/29 by Dr. Cullen. Her respiratory course included a brief period of
high frequency ventilation, with return to conventional ventilation 3 days before
extubation on 9/9/2003. The morning of extubation, Catherine was active and agitated,
biting her endotracheal tube. A decision was reached to try to extubate her rather than re-
sedate her and prolong her course of mechanical ventilation. After- extubation, Catherine
unexpectedly developed severe airway swelling, necessitating re-intubation.
Unfortunately her re-intubation was difficult and Catherine arrested during the process of
placing a new endotracheal tube. Numerous well-qualified physicians attempted to re-
intubate Catherine and failed. The specialist who did ultimately succeed at intubation also
failed on his initial attempt.
Department of Pediatrics
Division of Pediatric Critical Care, School of Medicine and Biomedical Sciences
Women and Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222
rei- may 878-7442 rar; (716) sramoi

* ·· · Case 1 :04-cv-01306-GIVIS Document 63-3 Filed 11/21 /2005 Page 2 of 2
,. It is my opinion that Catherine Laag received aggressive and excellent critical care and
( respiratory therapy in the days preceding her arrest, including the use of high frequency
oscillatory ventilation, which is a new mode of mechanical ventilation.
The decision to extubate Catherine on the 9°h of September was well within the standard
of care. Her gas exchange was adequate, her respiratory effort`was deemed adequate and
she met Dr. Cullen’s criteria for extubation. That is not to say there was no risk that she
might require re-intubation; some patients do require re-intubation. Dr. Cullen had reason
to believe he would be able to re-intubate her if necessary, as he had, himself, previously
intubated her airway. He had no reason to suspect she would develop airway swelling.
And he had reason to believe that Catherine would be successfully extubated. q
The development of acute airway edema in a patient like Catherine Laag can be quite
sudden. It is not so common an occurrence that special precautions would routinely be
taken, yet not so rare as to be unanticipated:In'Catherine’s case, the swelling was so g
.severe that it apparently compromised her gas exchange and necessitated re—intubation
using an unusually small endotracheal tube. The swelling apparently effaced the
landmarks usually used as a guide to placement of a new endotracheal tube. As a
consequence, several experienced physicians who frequently performed intubations
found the intubation to be difficult or impossible. It is not clear from my review that the
area of greatest narrowing was even visible during the intubation attempts, making tube
size difficult to assess. I believe it is the abrupt, unexpected and severe nature of this
q narrowing that led to Catherine’s arrest.
I believe the means used to resuscitate Catherine were those commonly applied, and that
the resuscitation adhered to common standards of practice.
It is most regrettable that Catherine Laag arrested and suffered sequellae of that event.
The events leading up to that arrest were not, however, predictable, nor do they represent
substandard medical care. More likely than not, had her extubation been postponed, the _
same sequence of events would have occurred at that later date.
Yours truly,
Bradley P. Fuhrman, M.D.
Chief Pediatric Critical Care
Children’s Hospital of Buffalo
Professor of Pediatrics _ I
State University of New York at Buffalo