DENVER (KDVR) – A woman who awakened during hernia surgery but remained unable to move or communicate with her doctors while the incisions were being made is now suing her anesthesiologist, the nurse anesthetist, and the company that employed them.

“I would say it’s just living through a medical nightmare – like an absolute horror story that will have an impact on the rest of my life,” said the patient Stacey Gustafson.

Gustafson is suing Katherine Palomino, a certified registered nurse anesthetist, Gregory James Goldenhersh, an anesthesiologist, and U.S. Anesthesia Partners of Colorado, alleging the awareness she experienced during her 2019 surgery was the result of negligence. 

The suit claims an IV that was supposed to administer the drug propofol to Gustafson was disconnected during the procedure.

“It’s a colossal mistake. It’s inexcusable. Literally, the records say the medication is running out onto the pillow, and the pillow is wet. We don’t medicate pillows. We medicate patients. I don’t know how you could argue that’s not a mistake,” said Jennifer Keel, the attorney who filed the suit on Gustafson’s behalf.

U.S. Anesthesia Partners of Colorado issued a written response on behalf of the defendants named in the lawsuit.

“(U.S. Anesthesia Partners of Colorado) provides excellent anesthesia care for approximately 225,000 patients in Colorado each year,” said Tony Good, vice president of communications.

“Our over 500 clinicians in Colorado are focused on one thing — patient safety. This is demonstrated by the high-quality outcomes we have across the many thousands of surgeries and procedures in which we provide anesthesia care each year. As this case is a legal matter, it is inappropriate to comment or litigate the matter publicly other than to say that USAP will be defending this case vigorously,” he said.

Sharp pain, unable to speak

Gustafson said she awakened to a sharp pain when the surgeon was making an incision into her abdomen. “I had this intense pain but couldn’t move. I couldn’t talk,” she said.

Gustafson, whose eyes were taped shut during the procedure, said she was unable to speak, move, or breathe on her own because as part of the surgery, she had been given a separate drug that paralyzed her muscles. She also had been given a breathing tube.

“I remember thinking, ‘Oh my gosh. I need to tell (the medical professionals), and maybe I’ll just try to move something.’ And so, for whatever reason, I decided I would try to move my feet. I couldn’t move my feet. … ’OK, I can’t move my feet. Can I move my legs? Can’t move my legs. Can I move my hands?’ And nothing. Nothing was moving,” she said.

She said she could hear the surgeon talking and giving instructions to other medical professionals in the operating room while she was trying to distract herself from the excruciating pain.

“It felt like my insides were being ripped out. Like a combination of pulling and tearing, and then, at some points, just burning,” she said.

According to Gustafson’s medical records, propofol was initially “thought to be infusing,” but after several minutes, the nurse anesthetist noticed Gustafson’s pillow was wet and the IV was not connected.

Gustafson said she was frantically trying to will her body to move, so she could alert someone in the operating room that she was in pain.

“Eventually, I was able to move my head, and to me, it felt like I was just shaking my head like crazy, but we’re told that it was very small movements,” Gustafson said.

Medical records show Gustafson received an “inhalation agent” after the medical team noted “purposeful movement” with her head. However, no one noticed the disconnected IV until approximately 13 minutes after that. 

The records say, “Propofol infusion discovered not connected,” followed by, “Propofol infusion connected, inhalation agent increased.”

Gustafson said she now suffers from frequent nightmares and has post-traumatic stress disorder.

“From the lawsuit, I think part of it is, I need closure. I have to, at some point, heal, and I think that’s part of my healing journey is to feel like something has been done,” she said.

Gustafson signed an anesthesia consent form ahead of the surgery in which she acknowledged that “awareness while under anesthesia” was an “extremely rare” risk factor.

However, Gustafson’s attorney said the type of awareness Gustafson experienced was the result of a medical mistake rather than a physical phenomenon.

“They never actually plugged in the IV of the propofol bolus,” Keel said. “That’s what we’ve alleged, and Stacey was actually told that by the anesthesiologist when he came to talk to her later which is why we alleged it in the complaint. What he told her was – they had unplugged that IV to give her something for nausea before surgery, and they never plugged it back in, so it was just running out onto the pillow.”

Awareness during surgery not common

“Overt errors such as disconnected IV tubing or forgetting to reconnect an IV tubing are extremely uncommon,” said Dr. Dan Cole, a past president of the American Society of Anesthesiologists and the current president of the Anesthesia Patient Safety Foundation. “More often with the failure of the anesthetic system, it would be kind of a loose connection that may have gotten disconnected inadvertently with the repositioning of the patient during the procedure,” he said.

Cole, an anesthesiology professor at the University of California, Los Angeles, has no connection to the Colorado case but spoke generally with about anesthesia.

Intraoperative awareness, he said, is reported to occur around one in 1,000 cases. While the experience is “not common,” he said, “in my judgment, it is way too common. We would like it to occur zero percent of the time.”

Cole said the impact on patients can either be “very, very minimal” or “tragic.”

“Patients can suffer from longstanding PTSD from it,” Cole said.

The Anesthesia Patient Safety Foundation recently issued recommendations to help reduce intraoperative awareness during surgery. These recommendations, Cole said, were meant to supplement previous guidelines issued more than a decade ago by the ASA.

“An EEG-based monitor of unconsciousness (depth of an anesthesia monitor) is required to reduce the likelihood of awareness whenever total intravenous anesthesia is combined with the administration of neuromuscular blocking agents,” the APSF recommended.

According to Keel, Gustafson’s surgery did not include a brain-monitoring system like an EEG.

The ASA’s Task Force on Intraoperative Awareness — a task force on which Cole served — published guidelines in 2006 that included an advisory about using a checklist protocol ahead of surgery.

“Because intraoperative awareness may be caused by equipment malfunction or misuse, the Task Force believes that there should be adherence to a checklist protocol for anesthesia machines and equipment to assure that the desired anesthetic drugs and doses will be delivered,” the guidelines said.

Cole said “it hurts in the heart” to know some patients suffer from intraoperative awareness.

“We learn from these things, and the more that we can learn about what happened and getting to the root causes of why these things happen, we can create a better future and do some things that will help prevent these things from happening,” he said.