CAALaw

The Right to Know Who Puts You Under

A Case Analysis of Informed Consent Failure, Supervision Ratio Negligence, and the Anesthesia Care Team Model

Case Law Index  ·  Informed Consent  ·  ACT Model  ·  Supervision Ratio

TL;DR

32 y/o male presents for routine orthopedic surgery under general anesthesia. He is told a CRNA will administer his anesthetic but is never informed that a physician anesthesiologist is available or that he has the right to choose between provider types. One supervising anesthesiologist is simultaneously directing four CRNAs across four separate operating rooms. The CRNA leaves the OR for 12 minutes mid-procedure, fails to monitor brain activity as required by hospital protocol, and the electronic blood pressure record is deleted. The patient sustains permanent anoxic brain injury and remains in a vegetative state. A Dallas County jury returns a verdict of $21,000,000.

Context

The Patient

Carlos David Castro Rojas, 32 y/o male. No documented significant medical history. No anesthesia risk factors identified on pre-operative assessment. ASA status I–II — a healthy young adult presenting for elective orthopedic surgery.

In October 2017, Rojas fell from a ladder while hanging Christmas lights, sustaining a tibial shaft fracture and knee injury. He presented to Baylor University Medical Center in Dallas, Texas the following day for surgical repair.

Pre-operative assessment: no anesthesia risk factors identified  ·  No significant comorbidities  ·  Elective ortho procedure

The Procedure

Open reduction and internal fixation (ORIF) of a tibial shaft fracture — a routine orthopedic procedure requiring general anesthesia. By every objective measure, this was a low-risk case in a low-risk patient.

The Anesthesia Team

Anesthesia was provided by CRNA Casey Martin, employed by US Anesthesia Partners of Texas (USAP). The supervising physician anesthesiologist was Dr. Mallorie Cline, M.D., also employed by USAP. At the time of Rojas’ surgery, Dr. Cline was simultaneously supervising three other CRNAs in three separate operating rooms — a 4:1 supervision ratio.

During the informed consent process, Rojas was told a CRNA would administer his anesthetic. He was not told that a physician anesthesiologist was available as an alternative. He was not told he had the right to choose between provider types. USAP’s own internal written policies stated patients should be informed of that right — but that disclosure was never made.

Timeline

October 2017

  • Pre-Op

    Rojas signs consent forms. Informed a CRNA will provide anesthesia. Not informed that a physician anesthesiologist is available, that provider qualifications differ, or that he has the right to choose. General anesthesia induced by CRNA Martin. Dr. Cline simultaneously supervising three other CRNAs in separate ORs.

  • Intraoperative

    CRNA Martin leaves the OR for 12 minutes during the procedure. Brain activity monitoring — required by Baylor’s own anesthesia department protocols — is not performed. Blood pressure begins to drop; multiple doses of vasopressors are administered, but the electronic hemodynamic record is not printed and is subsequently deleted from the monitoring system.

  • Post-Op

    Rojas is unresponsive following surgery. Diagnosis: anoxic brain injury secondary to intraoperative cerebral hypoperfusion. The only surviving blood pressure record is a handwritten log that shows no significant hypotension — contradicted by the multiple vasopressor doses documented in the anesthetic record.

  • Ongoing

    Rojas remains in a permanent vegetative state — unable to walk, talk, or perform basic functions. He is incontinent and requires 24-hour nursing care. His mother relocated to Dallas to assist in his care. He was 32 years old.

  • October 31, 2022

    Dallas County jury returns a verdict of $21,000,000 against CRNA Casey Martin, Dr. Mallorie Cline, and US Anesthesia Partners of Texas. Baylor University Medical Center had settled for an undisclosed amount prior to trial.

Mechanism of Injury

Pathophysiology

The plaintiff’s experts argued that Rojas sustained anoxic brain injury secondary to sustained intraoperative hypotension that went unrecognized and inadequately treated. The proposed mechanism:

  • General anesthesia produces dose-dependent cardiovascular depression — reduced systemic vascular resistance, decreased cardiac output, and blunted baroreceptor reflexes. In combination with surgical blood loss and positioning effects, mean arterial pressure can fall substantially below the cerebral autoregulatory threshold.
  • Cerebral autoregulation maintains constant cerebral blood flow across a MAP range of approximately 50–150 mmHg. Below the lower limit, CBF becomes pressure-passive — if MAP falls uncorrected, cerebral perfusion pressure drops proportionally, leading to ischemia and ultimately infarction.
  • The vasopressor record — multiple documented doses of blood pressure-elevating medications — was the prosecution’s key evidence. The repeated need for vasopressors implied that MAP was falling repeatedly during the procedure. The deletion of the electronic hemodynamic record made it impossible to reconstruct the severity or duration of the hypotensive episodes.

Had cerebral function monitoring (processed EEG, such as BIS) been in use as required by hospital protocol, progressive cortical suppression preceding ischemic injury would have been detectable in real time — providing an opportunity for intervention before irreversible damage occurred.

The Law

The Breach

Plaintiff alleged three distinct, compounding breaches of the standard of care:

  • Informed consent failure. Rojas was not informed that a physician anesthesiologist was available, that a material difference in training and qualifications existed between provider types, or that he had the right to choose. Under Texas law, obtaining informed consent is a non-delegable duty of a physician — and USAP’s own written policies acknowledged patients should receive this disclosure. It was never given.
  • Inadequate supervision ratio. Dr. Cline was simultaneously directing four CRNAs across four separate operating rooms. The plaintiff’s attorneys argued — and the jury apparently agreed — that meaningful supervision of a patient under general anesthesia is functionally impossible at a 4:1 ratio. When an emergency requiring the supervising physician’s physical presence arises in one room, the other three patients are effectively unsupervised.
  • Intraoperative monitoring failures and spoliation of evidence. Brain activity monitoring was not performed despite a specific hospital protocol requiring it. The electronic blood pressure record was not printed and was deleted. The handwritten backup record — showing no significant hypotension — was contradicted by the documented vasopressor administration pattern, which plaintiff’s experts argued was direct evidence of repeated hypotensive episodes that the record had been altered to conceal.

The Outcome

On October 31, 2022, a Dallas County jury found in favor of the plaintiff and returned the following verdict:

  • Total Verdict: $21,000,000 against CRNA Casey Martin, Dr. Mallorie Cline, and US Anesthesia Partners of Texas, P.A.
  • Economic damages: $8,000,000 allocated specifically for lifetime care costs.
  • Prior settlement: Baylor University Medical Center settled for an undisclosed sum before trial, meaning the full $21M was borne by the USAP providers and their insurers.

Case: Wilda Jenniffer Rojas Graterol v. Casey Martin, CRNA, Mallorie Cline, M.D., US Anesthesia Partners of Texas, P.A. et al.  ·  Cause No. CC-19-05509-E  ·  Dallas County Court at Law No. 5, Texas

Reflection

This case is not primarily about clinical negligence — it is about institutional design and the informed consent obligations that the ACT model creates. The ASA’s own Statement on the Anesthesia Care Team is unambiguous: when anesthetic duties are delegated to a non-physician provider, the supervising anesthesiologist is responsible for informing the patient that such delegation will occur. Rojas goes further, establishing that the patient’s right to choose between provider types is itself a material fact requiring disclosure — not an optional courtesy.

For CAAs, this doctrine applies directly. A patient who consents to anesthesia administered by a CAA under physician direction has implicitly consented to the ACT model — but only if they were actually told that model would be used, what it means, and that alternatives exist. The absence of that conversation is not a technicality. As the plaintiff’s attorney put it: unless you know you have the choice, you don’t ask.

The supervision ratio finding is equally significant. The 4:1 medical direction model is CMS-permitted and industry-standard in ACT practice. But Rojas demonstrates that permissibility is not the same as adequacy — and that when a patient suffers a catastrophic outcome while their supervisor is physically unavailable, a jury will hold the system, not just the individual provider, accountable.

References

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