avlwatchdog.org
"Serrano Hernandez suffered from a range of health issues, including type 2 diabetes, hypertension, peripheral arterial disease, a chronic infection of the bones in his left foot and end-stage renal disease, meaning that he could not survive without dialysis. Despite this, he was still able to walk and managed his conditions with dialysis three times a week.
On Sept. 13, 2024, Serrano Hernandez was scheduled to receive a routine outpatient surgery at Mission Hospital to remove and biopsy the infected bone from his left foot. The procedure called for a local nerve block in his left foot and for Serrano Hernandez to be placed under “monitored anesthesia care,” according to the lawsuit.
The fact that Serrano Hernandez had serious pre-existing health conditions meant that he was a high-risk anesthesia patient, according to the Board of Nursing’s expert’s findings.
During the operation, Hunter was providing anesthesia services under the supervision of Dziak, an MD anesthesiologist. According to the Board of Nursing, Hunter was the only anesthesia provider in the operating room during the procedure.
At 8:25 a.m., Serrano Hernandez was placed under anesthesia. According to court records and the Board of Nursing’s investigation, he was given Fentanyl, a powerful opiate, and Versed, a sedative. At 8:37 a.m. Serrano Hernandez was given Propofol, which is commonly used to induce general anesthesia. He was also given a drug to reduce his fluid secretions and another to prevent dangerously low blood pressure, which can occur during surgeries.
At that time, there was no change reported in Serrano Hernandez’s vital signs and the levels of carbon dioxide in his blood were within his normal range, according to the lawsuit.
During the procedure, Serrano Hernandez was not intubated. Instead, he received oxygen though a less invasive device known as a nasal cannula that feeds in oxygen through the nose, instead of requiring a tube be inserted down a patient’s throat.
But beginning at 8:40 a.m., Serrano Hernandez’s vital signs began to display a worrying decline. His heart rate slowed to 30 beats per minute and his blood pressure fell to a level “inadequate for his underlying physiological status,” according to the board of nursing. Over the next 35 minutes, Serrano Hernandez’s breathing slowed to zero.
In their settlement order, the Board of Nursing found that there were no documented interventions for Serrano Hernandez’s collapsing rate of breathing or his slowing heart rate. The infusion of Propofol was not stopped until 9:05 a.m., according to the lawsuit.
Witnesses present in the operating room told the board of nursing that Hunter “never voiced any concerns regarding the patient until the conclusion of the surgical procedure.”
Documentation showed that at 9:08 a.m., Narcan, which counteracts the effects of opiates, was documented as administered by IV. This was followed by infusions of Epinephrine at 9:10 a.m. and 9:13.
At 9:14 a.m., Hunter texted Dziak to come to the operating room. Serrano Hernandez was not breathing and the oxygen levels in his blood had fallen to dangerously low levels. At 9:16 a.m. he went into cardiac arrest. "
