Carol Keefer was admitted to the University of Michigan Hospital with a preoperative diagnosis of sqamous cell CA in situ of the floor of the mouth and retromolar trigone. Carol’s post operative diagnosis was confirmed to be invasive squanmous cell carcinoma of the floor of the mouth and retromolar trigone. Carol was eventually discharged from the post anesthesia care unit and transferred to a regular room.

Shortly after arriving in her regular room, Carol complained of blood oozing from her mouth, shortness of breath, and difficulty in breathing. A doctor was called to evaluate Carol. Dr. Edwards noted her complaints, reassured her that this was normal and ordered Afrin, a face tent and breathing treatments.

Carol’s condition continued to worsen. Code was called. Attempts were made for oral airway. Hospital personnel were unable to bag her. Carol underwent several attempts of a direct laryngoscopy that were unsuccessful due to the large amount of blood and swelling. A decision was made to perform an emergency cricothyroidotomy with percutaneous cannulation of the trachea. Carol underwent emergency defibrillation with three attempts.

After Carol was resuscitated, she was transferred to SICU. Both Neurology and Cardiology consultations were obtained for post operative care and follow-up. The Department of Neurology stated on this assessment that Carol experienced a complicated post-operative hypoxic episode with evidence of severe diffuse brain injury. Her prognosis for a meaning filled recovery was poor. At the request of Carol’s family, she was transferred to a hospital in Canton, Ohio. One month and one day after undergoing a routine surgical procedure, Carol Keefer died.