PLAINTIFFS’ COMPLAINT FOR DAMAGES

Nature of This Action

1. This medical-malpractice action arises out of medical services negligently provided to 10-year-old Anorah Ignelzi at Marietta Eye Clinic (“MEC”), on September 30, 2019.

2. This action is brought by Anorah’s parents, Darell and Kathrin Ignelzi, on Anorah’s behalf.

3. Pursuant to OCGA § 9-11-9.1, the affidavit of Anesthesiologist Erick A. Harris, MD, is attached hereto as Exhibit 1. This Complaint incorporates the opinions and factual allegations set forth in Dr. Harris’s affidavit.

4. As used here, the phrase “standard of care” means: the degree of care and skill ordinarily employed by the medical profession generally under similar conditions and like circumstances as pertained to Defendants’ actions here.

5. This Complaint sets forth relevant medical principles and facts, most of which are uncontroversial.

6. With few exceptions, the medical facts are supported by citations to the medical record and by screenshots of the cited excerpts. Plaintiffs have taken the time and effort to provide such support, in order to make it as easy as possible for Defendants to answer the allegations, so that the parties—and the Court—may ascertain the disputed facts, on which this controversy may turn.

7. Negligence here is plain: During a routine outpatient procedure to remove a tiny benign lesion from the eyelid of a little girl, the anesthesiologist failed to reduce and clear the oxygen-rich air in the surgical field, so that a fire broke out over the girl’s face when the surgeon turned on an electric cautery. As a result, the little girl, Anorah Ignelzi, suffered serious burns, underwent skin-graft surgery, still receives therapy for PTSD, and expects to have additional surgeries.

Parties, Jurisdiction, and Venue1

8. Plaintiffs Darell Ignelzi and Kathrin Ignelzi are citizens of Georgia.

9. Defendant Sheel Todd, M.D., is a citizen of Georgia. Dr. Todd may be served with process at her residence: 3999 Matty Drive NE, Marietta, GA 30066-1113 (Cobb County).

10. Dr. Todd is subject to the personal jurisdiction of this Court.

11. Dr. Todd is subject to the subject-matter jurisdiction of this Court in this case.

12. Dr. Todd has been properly served with this Complaint.

13. Dr. Todd has no defense to this lawsuit based on undue delay in bringing suit, whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

1

OCGA §§ 14-2-510 and 14-3-510 provide identical venue provisions for regular business corporations and for nonprofit corporations:

“Each domestic corporation and each foreign corporation authorized to transact business in this state shall be deemed to reside and to be subject to venue as follows: (1) In civil proceedings generally, in the county of this state where the corporation maintains its registered office…. (3) In actions for damages because of torts, wrong, or injury done, in the county where the cause of action originated, if the corporation has an office and transacts business in that county; (4) In actions for damages because of torts, wrong, or injury done, in the county where the cause of action originated.”

These same venue provisions apply to Professional Corporations, because PCs are organized under the general “Business Corporation” provisions of the Georgia Code. See OCGA § 14-7-3. These venue provisions also apply to Limited Liability Companies, see OCGA § 14-11-1108, and to foreign limited liability partnerships, see OCGA § 14-8-46.

OCGA 9-10-31 provides that, “joint tort-feasors, obligors, or promisors, or joint contractors or copartners, residing in different counties, may be subject to an action as such in the same action in any county in which one or more of the defendants reside.”

14. Dr. Todd is subject to venue in this Court because she is a resident of Cobb County.

15. Pursuant to OCGA 9-10-31, Dr. Todd is also subject to venue in this Court because one of her co-defendants is subject to venue here.

16. At all times relevant to this Complaint, Dr. Todd acted as an employee or agent of one or more of her co-defendants, MAK Anesthesia, LLC; MAK Anesthesia Holdings, LLC; and MAK Anesthesia Wellstar, LLC.

17. Defendant MAK Anesthesia, LLC (“MAK Anesthesia”) is a Georgia company with a principal office at 1300 Ridenour Blvd NW, Suite 300, Kennesaw, GA, 30152 (Cobb County). Registered Agent Name: Pamela Weigandt, MD. Physical address: 1300 Ridenour Blvd NW, Suite 300, Kennesaw, GA, 30152 (Cobb County).

18. MAK Anesthesia is subject to the personal jurisdiction of this Court.

19. MAK Anesthesia is subject to the subject-matter jurisdiction of this Court in this case.

20. MAK Anesthesia has been properly served with this Complaint.

21. MAK Anesthesia has no defense to this lawsuit based on undue delay in

bringing suit, whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

22. MAK Anesthesia is subject to venue in this Court because MAK Anesthesia maintains its registered office in Cobb County, and also because MAK Anesthesia transacts business in Cobb County.

23. Pursuant to OCGA 9-10-31, MAK Anesthesia is also subject to venue in this Court because one of its co-defendants is subject to venue here.

24. At all times relevant to this Complaint, MAK Anesthesia was the employer or other principal of Defendant Sheel Todd, MD.

25. If another entity was the employer or principal of Dr. Todd during those times, that entity is hereby on notice that, but for a mistake concerning the identity of the proper party, this action would have been brought against that entity.

26. Defendant MAK Anesthesia Holdings, LLC (“MAK Anesthesia Holdings”) is a Georgia company with a principal office at 1300 Ridenour Blvd NW, Suite 300, Kennesaw, GA, 30152 (Cobb County). Registered Agent Name: Pamela Weigandt, MD. Physical address: 1621 N. Roberts Road, Suite 110, Kennesaw, GA, 30144 (Cobb County).

27. MAK Anesthesia Holdings is subject to the personal jurisdiction of this Court.

28. MAK Anesthesia Holdings is subject to the subject-matter jurisdiction of this Court in this case.

29. MAK Anesthesia Holdings has been properly served with this Complaint.

30. MAK Anesthesia Holdings has no defense to this lawsuit based on undue delay in bringing suit, whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

31. MAK Anesthesia Holdings is subject to venue in this Court because MAK Anesthesia Holdings maintains its registered office in Cobb County, and also because MAK Anesthesia Holdings transacts business in Cobb County.

32. Pursuant to OCGA 9-10-31, MAK Anesthesia Holdings is also subject to venue in this Court because one of its co-defendants is subject to venue here.

33. At all times relevant to this Complaint, MAK Anesthesia Holdings was the employer or other principal of Defendant Sheel Todd, MD.

34. If another entity was the employer or principal of Dr. Todd during those times, that entity is hereby on notice that, but for a mistake concerning the identity of the proper party, this action would have been brought against that entity.

35. Defendant MAK Anesthesia Wellstar, LLC (“MAK Anesthesia Wellstar”) is a Georgia company with a principal office at 1300 Ridenour Blvd NW, Suite 300, Kennesaw, GA, 30152 (Cobb County). Registered Agent Name: Pamela Weigandt, MD. Physical address: 1300 Ridenour Blvd NW, Suite 300, Kennesaw, GA, 30152 (Cobb County).

36. MAK Anesthesia Wellstar is subject to the personal jurisdiction of this Court.

37. MAK Anesthesia Wellstar is subject to the subject-matter jurisdiction of this Court in this case.

38. MAK Anesthesia Wellstar has been properly served with this Complaint.

39. MAK Anesthesia Wellstar has no defense to this lawsuit based on undue delay in bringing suit, whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

40. MAK Anesthesia Wellstar is subject to venue in this Court because MAK Anesthesia Wellstar maintains its registered office in Cobb County, and also because MAK Anesthesia Wellstar transacts business in Cobb County.

41. Pursuant to OCGA 9-10-31, MAK Anesthesia Wellstar is also subject to venue in this Court because one of its co-defendants is subject to venue here.

42. At all times relevant to this Complaint, MAK Anesthesia Wellstar was the employer or other principal of Defendant Sheel Todd, M.D.

43. If another entity was the employer or principal of Dr. Todd during those times, that entity is hereby on notice that, but for a mistake concerning the identity of the proper party, this action would have been brought against that entity.

44. Defendants John/Jane Does 1-10 are those yet-unidentified natural persons and/or entities who may be liable, in whole or part, for the damages alleged herein. Once served with process, John/Jane Does 1-10 are subject to the jurisdiction and venue of this Court.

45. This Court has subject-matter jurisdiction over this case.

46. Venue in this Court is proper as to all Defendants.

General Medical Principles

Papilloma Lesions

47. Squamous papillomas are generally benign (noncancerous) growths on the skin and other tissues of the body.

48. Squamous papillomas often begin in the squamous cells (thin, flat cells) found in the tissue that forms the surface of the skin (the epidermis).

49. When found on the skin, squamous papillomas are more commonly referred to as warts or verrucas.

50. The Human Papilloma Virus (HPV) causes most papillomas.

51. Papillomas do not spread around the body and are not aggressive.

52. Squamous papillomas often occur on the eyelids, especially in children.

53. The standard treatment for most eyelid papillomas is surgical excision.

54. The excision is a routine outpatient procedure typically done only with local anesthesia and lasting only a few minutes.

Operating-Room Fires

55. Fire in the operating room (OR) is a relatively rare event.

56. When a fire in the OR occurs, the medical outcomes are often catastrophic for the injured patient, with severe legal and economic consequences for the surgical team and the facility.

57. Most OR fires are preventable with communication, appropriate education, and management of risks.

58. These preventive measures have little cost and are nearly 100 percent effective.

59. Most claims for harms caused by OR fires arise in an outpatient setting (76 percent), involve the upper body (85 percent), and are cases managed with monitored anesthetic care (81 percent).

60. Patient injuries from an OR fire are often severe—for example, painful and disfiguring burns to face and neck or severe airway injury with tracheostomy and permanent lung damage.

61. Typically, the patient must return to the OR many times to treat acute burn injuries and revise scar tissue, causing recurring anxiety, post-traumatic stress, and economic burden.

Cause of OR Fires: The Fire Triad

62. OR fires are usually caused by the convergence of three elements in a closed environment: an oxidizer, fuel, and an ignition source.

63. These three elements have been called “the Fire Triad” and “the Fire Triangle.”

64. First, the most common oxidizers in an operating room are oxygen and nitrous oxide, which are used in anesthetizing the patient.

65. Most surgical fires occur in oxygen-enriched environments, when the

concentration of oxygen exceeds 30 percent. (For perspective: the normal concentration of oxygen in “room air” is 21 percent.)

66. When supplemental oxygen is delivered to a patient in an operating room, an oxygen-enriched environment can be created.

67. In an oxygen-enriched environment, materials that may not normally burn in room air can ignite and burn.

68. An open oxygen delivery system, such as nasal cannula or facemask, presents a greater risk of fire than a closed delivery system, such as a laryngeal mask or endotracheal tube.

69. Open delivery of oxygen from a direct source, through a device such as a facemask or nasal cannula, is the major factor contributing to most OR fires.

70. This is not surprising: At oxygen concentrations near 50 percent of higher, any spark or generated heat can ignite a fuel source.

71. Even at oxygen concentrations above 30 percent, the burning process is accelerated.

72. As oxygen concentration rises from 21 to 50 percent, the time required for surgical drapes to ignite decreases and burn-rate increases.

73. The fraction-of-inspired-oxygen (FiO2) level reflects the oxygen-concentration in the air being delivered to the patient.

74. An FiO2 level of 1.0 means that the concentration of oxygen is 100%—pure oxygen. Likewise, an FiO2 level of 0.3 means that the air is 30% oxygen.

75. Second, common fuels in ORs include surgical drapes, towels, gauzes, sponges, alcohol-based prep solutions, masks, and endotracheal tubes.

76. Surgical drapes, towels, sponges, and gauzes are made from cotton, paper, or plastics—all excellent fuels.

77. When oxygen-concentration exceeds 50 percent, oxygen becomes trapped within the fine fibers and naps of cotton towels or drapes. This oxygen can vigorously promote combustion—a phenomenon known as “fiber flame propagation.”

78. Third, common ignition sources include electrosurgery units (“ESUs”), surgical lasers, fiberoptic lights (such as headlamps and lighted instruments), and defibrillators.

79. Even a static spark may become an ignition source.

80. An ESU is the most commonly used ignition source in the operating room.

81. A monopolar ESU, often called by the brand-name “Bovie,” produces a hightemperature electrical arc.

82. Cautery or cauterization is a medical technique of burning a wound to limit bleeding, damage, or infection.

83. A Bovie is often used by physicians in the operating room to cauterize wounds.

84. A Bovie’s monopolar tip can ignite a fire, as can a loose or worn connector or cable on the device.

85. If the three elements of the Fire Triad converge in a closed environment, any spark may result in flames.

86. For that reason, strategies to prevent OR fires are based on separating the three elements of the Triad.

Prevention of OR Fires, Generally

87. The key elements to fire prevention in the operating room are:

● Risk assessment

● Communication among members of the surgical team

● Preventive measures based on level of risk

88. These elements generally reflect the Silverstein Fire Risk Assessment Tool and other formal fire-prevention tools, including those published by the Anesthesia Patient Safety Foundation and the American Society of Anesthesiologists.

89. Such tools assess the risk of a procedure as high if it (a) is above the level of the xiphoid, (b) uses an open oxygen source (e.g., delivery of oxygen via facemask or nasal cannula), and (c) involves the presence of an ESU or other ignition source. This image shows the xiphoid in red.

90. The most important fire-prevention measure is communication among surgicalteam members regarding potential fire risk and plans to manage risks.

91. A failure in communication is a factor in most OR fires.

92. Beyond the share responsibility to communicate, responsibilities for controlling the elements of the Fire Triad are allocated according roles.

93. Thus, because nurses are typically responsible for drapes, towels, and sponges (fuels), nurses are also responsible for related preventive measures such as keeping drapes and towels away from ignition sources.

94. Likewise, anesthesiologists are responsible for managing oxygen-concentration levels.

Prevention of OR Fires: Oxygen Concentration

95. The anesthesiologist’s monitoring and control of oxygen-concentration plays a crucial role in preventing OR fires.

96. The most effective fire-prevention measure is to eliminate open delivery of oxygen whenever possible.

97. For procedures above the xiphoid, open delivery of oxygen should be avoided whenever possible.

98. If treatment of the patient requires open delivery of oxygen, the most effective fire-prevention measure is to limit oxygen concentration to 30 percent or less, while avoiding nitrous oxide.

99. Before an ESU is turned on in the OR, an anesthesiologist administering oxygen through an open delivery system must ensure that the FiO2 level is 30% or less.

100. In addition, when the anesthesiologist lowers the FiO2 level to 30% from a higher setting, the anesthesiologist must preclude the use of an ESU for at least 3-5 minutes, to allow the oxygen-rich air to dissipate.

Prevention of OR Fires: Communication to Prevent Risk-Convergence

101. Because OR fires occur when the three elements of the Fire Triad come together, members of the surgical team must communicate about these elements to mitigate their convergence.

102. Specifically, each provider on the team must alert the others of the risk posed by the elements he or she controls.

103. For example, a nurse must warn of drapes that may turn into fuel, and the anesthesiologist of concentrated oxygen that may serve as an oxidizer.

104. In addition, each member of the surgical team must ask about and ascertain the risk posed by the other elements.

105. Thus, an anesthesiologist must inquire about the possibility that a potential ignition-source like a Bovie might be used, especially if the anesthesiologist plans to introduce concentrated oxygen into the surgical field.

106. Risk assessment and prevention of fire in the OR thus require effective communication, coordination, and teamwork.

Treatment of Anorah Ignelzi

Prologue: Anorah Is Born with Benign Lesion

107. Anorah Ignelzi was born with a tiny “mole like bump” on her lower left eyelid. MEC 2.

108. The lesion was purely a cosmetic issue—it did not “hurt, itch, or cause any discomfort.” MEC 2.

MEC 2.

109. As Anorah turned 10, she naturally started to become more self-conscious about her appearance, including the lesion.

110. The following photograph shows Anorah on September 20, 2019—ten days before the events at issue in this lawsuit. MEC 8.

MEC 8.

111. The lesion is barely discernible in the photograph. MEC 8.

September 10: MEC Diagnoses Lesion as Benign Papilloma

112. On September 10, 2019, Anorah and her father, Darell Ignelzi, visited the Marietta Eye Clinic (MEC) for a medical evaluation of the lesion. MEC 2.

113. Other than the lesion, Anorah had “no further complaints with her vision or eyes” at that time. MEC 2.

MEC 2.

114. Optometrist Michael-Vu Do examined Anorah. MEC 2-3.

115. Dr. Do diagnosed the lesion as benign Squamous Papilloma – a “benign neoplasm of the eyelid.” MEC 3.

MEC 3.

116. Dr. Do explained to Anorah and her father that “Squamous papillomas are common conditions with variable clinical appearance.” MEC 3.

117. Dr. Do further explained that papillomas “may be observed or surgically removed.” MEC 3.

MEC 3.

118. Dr. Do also recommended a follow-up visit with Ophthalmologist Byron A. Long. MEC 3.

September 20: Dr. Long Confirms Diagnosis and Orders Excision Surgery

119. On September 20, 2019, Dr. Long examined Anorah. MEC 5-8.

120. Dr. Long confirmed the diagnosis of a benign verrucous papilloma, noting that it was worsening. MEC 6.

MEC 6.

121. Dr. Long explained to Anorah that “Benign lesions of the eyelid can be monitored,” but that the “only way to confirm the diagnosis of a lesion is with a biopsy.” MEC 6.

122. Dr. Long further explained that surgical excision of a papilloma “in most cases is curative.” MEC 6.

123. After meeting with Anorah and her mother, Kathrin Ignelzi, Dr. Long entered an order for surgery to remove the lesion. MEC 6.

124. During the same visit with Dr. Long, Mrs. Ignelzi signed the consent forms for the “excision of lid lesion.” MEC 13-14, MEC 15-16.

MEC 13.

125. As the forms made clear, the surgery as a “routine” procedure, with a good likelihood of success in removing the lesion. MEC 15, MEC 13.

MEC 15.

MEC 13.

September 30: The Routine Procedure Goes Sideways

126. On September 30, 2019, Anorah underwent this routine procedure to remove the “eyelid lesion of lower left eyelid.” MEC 19.

MEC 19.

127. Dr. Long was the surgeon, and Dr. Todd the anesthesiologist.

128. Because of Anorah’s age and because of the location of the lesion near her eye, the procedure took place in “the main OR,” an ambulatory surgery center, as opposed to a doctor’s office. MEC 6.

MEC 19.

MEC 6.

129. Prior to the procedure, Anorah “was seen in the preoperative holding area where the procedure was discussed with her,” with her mother present. MEC 19.

MEC 19.

130. This is Anorah minutes before the procedure.

131. At 07:08, Dr. Todd and RN Meredith Rountree brought Anorah back to the OR. Anorah was watching an iPad and talking with the staff. MEC 32.

132. At 07:08, Dr. Todd started to administer gas and propofol intravenously, and Anorah “was asleep.” MEC 32, MEC 19, MEC 23-24.

MEC 32.

MEC 19.

MEC 23.

133. Glynnis Jones injected local anesthetic to the lesion and surrounding areas—2% lidocaine, epinephrine, and 0.5% Marcaine. MEC 32, MEC 19.

134. Anorah was then “prepped with betadine scrub and draped in the usual aseptic fashion.” MEC 19, MEC 32.

MEC 32.

MEC 19 135. The drapes were placed over the mask. MEC 24.

MEC 24.

136. At 07:16, Dr. Long entered the operating room. MEC 32.

MEC 32.

137. At 07:17, the surgical team took a one-minute timeout. MEC 31, MEC 32.

MEC 31.

138. During the timeout, the team confirmed that all members had “introduced themselves by name and role;” that the surgeon, anesthesiologist, and nurse had verbally identified the patient, site of surgery, and procedure; and that they had reviewed “anticipated critical events.” MEC 30.

MEC 30.

139. The team also reviewed whether there was “anticipated blood loss.” MEC 30.

140. At 07:18, the procedure started. MEC 32, MEC 31.

MEC 32.

141. At that time, Dr. Long elevated the lesion and used medical scissors to “excise the lesion in its entirety.” MEC 19.

142. Dr. Long then “handed off” the lesion to the surgical assistant. MEC 19.

MEC 19.

143. That’s when a routine procedure became eventful—and tragic. See, e.g., MEC 32, MEC 18-20, MEC 23-24.

September 30: Dr. Todd Fails to Lower FiO2 Level, Triggering Fire Over Anorah’s Face

144. Seeing “some brisk bleeding,” Dr. Long asked for a handheld cautery and swabs. MEC 19, MEC 32.

145. After receiving the cautery and swabs, Dr. Long had an exchange with Dr. Todd. MEC 32.

146. Dr. Todd stated: “You have a handheld cautery.” MEC 32.

147. Dr. Long responded, “yes.” MEC 32.

148. Dr. Long then “used a handheld cautery to cauterize” the wound. MEC 19.

149. “Then fire broke out.” MEC 32.

MEC 19.

MEC 32.

150. There “was an O2 leak around the mask that they did not detect and a bovie was used which caught fire to the O2.” WCH 00032.

WCH 00032.

151. “A spark from the cautery ignited a fire that extended to the nasolabial” area of Anorah’s face. MEC 18.

MEC 18.

September 30: The Team Scrambles

152. The surgical team scrambled to put out the fire and triage Anorah’s burns.

153. The facemask was “burning.” It was “removed” and Anorah’s face was “doused with saline & water.” MEC 24.

MEC 24.

154. RN Rountree “saw a towel on fire on the left side of the bed.” She “grabbed it and stepped on it.” MEC 32.

MEC 32.

155. Anorah’s hat was removed because it too was on fire. MEC 32.

MEC 32.

156. Mimi Samatar, the surgical scrub, “immediately got sterile water and poured it all over the affected area” in order “to make sure that the flame was no longer present.” MEC 32, MEC 19.

MEC 32.

MEC 19.

157. After a few minutes, Anorah had a laryngospasm, which was “broken” when Dr. Todd administered another dose of propofol, and positive air pressure. MEC 24.

MEC 24.

158. Marie Hernandez came in and began wiping burned areas of Anorah’s head and neck with BSS (a sterile cleaning solution) and gauze. MEC 32.

159. Dr. Todd, Marie, and Nurse Rountree “began checking all of the head, neck and face” for burns. MEC 32.

160. Nurse Rountree “ran out and got florisene stripes and BSS to make sure there were no burns to the corneas.” MEC 32, MEC 31.

MEC 32.

161. The team “proceeded to clean the patient and continued placing cold slush on gauze with pressure” to the burned areas. MEC 32.

MEC 32.

September 30: Anorah Awakes to Pain on Her Burned Face

162. Anorah awoke to discover her face had been burned.

163. She was “combative while emerging.” MEC 24.

MEC 24.

164. Anorah was “crying” and “stating her eyes were burning and her face and right ear were burning.” MEC 32.

165. At 07:50, “Lidocaine jelly was placed on affected area on right side of face and bridge of nose.” MEC 32, MEC 31.

166. At 07:55, Dr. Long returned to the room with Akten ointment and instructed others to apply it to both of Anorah’s eyes. MEC 32, MEC 31.

167. Meanwhile, Marie “continued placing cool gauze and pressure to the affected areas.” MEC 32, MEC 33.

MEC 32.

MEC 33.

168. At 08:02, Dr. Todd gave Anorah intravenous pain medication and an oral elixir of oxycodone. MEC 32, MEC 33.

169. As she “began calming down,” Anorah “began asking questions about why her eyes and ear were burning.” MEC 32.

MEC 32.

MEC 33.

170. At 8:57, Anorah’s pain was an 8, on a scale of 1-10. MEC 34.

MEC 34.

September 30: Anorah Is Referred to Joseph Still Burn Center at Cobb Hospital

171. At 08:20, Dr. Todd and Dr. Long spoke with Anorah’s parents. MEC 33, MEC 24, MEC 43.

MEC 33.

MEC 24.

172. Dr. Todd and Dr. Long apologized to Anorah’s parents about “what happened with her.” MEC 43.

MEC 43.

173. Dr. Todd and Dr. Long also told Anorah’s parents that her burns were not bad, that they were first-degree burns, and that there was no need to take Anorah to the emergency room.

174. Distraught, Mr. Ignelzi asked Dr. Todd and Dr. Long to leave, and asked to speak with MEC’s director. MEC 24.

MEC 24.

175. At 09:15, Dr. Pamela Weigandt met with Anorah’s parents. 2 MEC 34.

176. Dr. Weigandt informed them that MEC was referring Anorah to the Joseph Still Burn Center at Cobb Hospital, where burn-specialist Claus Brandigi was expecting them. MEC 34, MEC 20.

MEC 34.

MEC 20.

177. Dr. Weigandt also promised Anorah’s parents that MEC would pay all costs associated with Anorah’s burns.

178. At 09:30, MEC discharged Anorah. MEC 34.

179. As they departed with Anorah, MEC gave Anorah’s parents gauze and an opened bottle of saline solution “to keep the gauze wet.”

September 30: Anorah’s Burns

180. Dr. Long and Dr. Todd downplayed Anorah’s burns as only first-degree burns. MEC 43.

2

As noted above, Dr. Weigandt is the registered agent for each of the three corporate defendants here.

MEC 43.

181. But, as the Still Burn Center soon confirmed, they were second-degree burns. WCH 00002.

182. The fire, moreover, covered significant surface areas on Anorah’s head, face, and neck. The flames:

● travelled “down into the nasolabial areas on both sides and then out towards the patient’s ear on the right side.” MEC 19.

● burned “the right temporal side of [Anorah’s] face as well as the right ear.”

MEC 32.

● burned the area “over the bridge of the nose bilateral where the mask had been placed.” MEC 32.

● singed Anorah’s eyelashes, eyebrows, and hair. MEC 19, MEC 32.

MEC 19.

MEC 32.

September 30: Dr. Todd Changes FiO2 Entries on Anesthesia Record

183. Dr. Todd’s anesthesia record for Anorah’s surgery at MEC contains handwritten entries for FiO2 levels in 15-minute blocks. MEC 23.

184. The entry for the block leading up to the surgery (07:00-07:15) reflects an Fi02 level of 1.0, or 100% oxygen-concentration. MEC 23.

185. The entry for the next block (07:15-07:30), when the excision and the fire occurred, reflects an oxygen level of 0.3, or 30% oxygen-concentration, precisely the maximum limit. MEC 23.

186. If they are to be believed, these two entries mean that Dr. Todd dropped the FiO2 level from 100% to 30% within minutes of the fire’s eruption. MEC 23.

187. But the 07:15-07:30 entry has been overwritten, blotting out the original entry. MEC 23. The same is true for other entries in the anesthesia record. MEC 23.

MEC 23.

188. The original entries, moreover, have not been crossed out with a line so that they remain readable next to the new entries. MEC 23.

189. Instead, the original entries have been made unreadable by reshaping them into new numbers. MEC 23.

190. In addition, the person making these changes did not scribble her or his initials or otherwise annotate the record, to call out and verify the changes. MEC 23.

September 30: Cobb Diagnoses 2nd-Degree Burns on Head, Face, and Neck

191. At 10:21, Anorah was admitted to WellStar Cobb Hospital with second-degree burns on “multiple sites of head, face, and neck.” WCH 00002.

WCH 00002.

WCH 00002.

192. At 11:21, Dr. Brandigi and Nurse Practitioner Kimberly Smith examined Anorah. WCH 00029.

WCH 00029.

193. Dr. Brandigi informed Anorah’s parents that her burns were much worse than MEC had indicated to him.

194. Anorah had “epidermal loss to the face and right ear.” WCH 00029-30.

WCH 00030.

195. Dr. Brangidi decided to admit Anorah to Cobb with second-degree burns, in order to “monitor for worsening of the wound given burn injury is less than 24 hours in age.” WCH 00032.

196. In addition, with Anorah’s parents’ consent, Dr. Brangidi decided to perform graft surgery to the head the following day. WCH 00032.

WCH 00032.

197. At 12:16, Pediatric Nurse Practitioner Lisa Samples examined Anorah. WCH 00033.

WCH 00033.

198. Anorah had burns “to left lower eyelid with edema to the upper lid, right cheek just adjacent to nares, right face along hair line and right ear.” WCH 00035.

WCH 00035.

199. After this examination, the plan was still to “watch burn for any worsening and go to OR in the am.” WCH 00036.

WHC 00036.

October 1: Anorah Has Epiburn Grafting Surgery at Cobb

200. On October 1, 2019, starting at about 08:50, Anorah underwent grafting surgery with Epiburn grafts. WCH 00039, WHC 00047-48.

WCH 00039.

WCH 00047-48.

201. This was Anorah shortly before this surgery.

202. During the procedure, Dr. Brangidi found seven significant second-degree and deep second-degree burns on Anorah’s head, face, and neck, covering surface areas as large as 8 x 5 centimeters. WCH 00048.

WCH 00048.

203. On October 2, 2019, at 13:30, Anorah was discharged from Cobb. WCH 00027.

204. After the surgery Anorah had to wear head-bandages for about two weeks.

Subsequent Weeks: Follow-up at Cobb

205. Anorah returned to Cobb for a follow-up appointment on October 4, 2019. WCH 00199-202.

WCH 00201, WCH 00202.

206. She then returned to Cobb for another follow-up appointment on October 9, 2019. WCH 00228-32.

207. Anorah returned for a third follow-up on October 17, 2019. CH 00260-64.

208. She returned once again for a follow-up on November 21, 2019. WCH 00286.

209. This is Anorah about four months after her graft surgery.

October 2019 to Present: Anorah Receives Ongoing Therapy for PTSD

210. Since October 3, 2019, Anorah has received psychological counseling from the same therapist, Melanie Kissell. THC 0002-03.

211. In the days after the fire, “Anorah presented with symptoms consistent to PTSD including depression, elevated fear, trouble concentrating, and excessive worry.” THC 0002.

THC 0002.

212. During therapy sessions, Anorah reported feeling “more angry and sad than she did before the operation.” THC 0002.

213. She also demonstrated “confusion and frustration about [people’s] reactions to her facial burns.” THC 0002.

THC 0002.

214. At home, Anorah began “isolating herself and going to her room for extended periods of time” and experiencing “anger outbursts daily.” THC 0002.

215. Anorah also demonstrated “symptoms typical to sustaining traumatic stress including a lack of interest in school, increased appetite, engaging in hypervigilant behaviors and exaggerated negative beliefs about the world being a dangerous place.” THC 0002.

216. Anorah’s family was also “impacted by Anorah's burn injury as evidenced by, increased arguing between members, tearfulness, avoidance, anxiety related to Anorah’s future, and an increased financial burden on household resources.” THC 0002.

THC 0002.

217. In sessions, Anorah engaged in “expressive art and play activities displaying themes of safety, regression, fear, and loss of power and control.” THC 0003.

218. She often represented herself in drawings wearing masks, indicating that that represented “her mixed feelings of anger, sadness, and happiness.” THC 0003.

THC 0003.

219. On December 3, 2019, Anorah’s therapist “recommended for Anorah to continue in family and individual counseling services until symptomology reduces to 80% or treatment goals are met at a rate of 80%.” THC 0003.

220. Therapy goals included “developing a healthy understanding about her experience,” “learning healthy coping strategies to use in moments of distress,” and “processing her thoughts and feelings about her experience.” THC 0002.

THC 0002.

221. Over the year and half that have followed, Anorah has remained in therapy with the same professional, working diligently to move past the trauma of the fire by meeting those goals and others. She remains in therapy today.

Epilogue: Future Surgeries

222. Since her graft surgery, Anorah has remained under the care of Dr. Brandigi at the Still Burn Center, with periodic appointments to check on her progress.

223. As she grows older, the focus is on ensuring that her skin heals properly.

224. As of the time of the filing of this Complaint, tentative plans are in place for one or more laser surgeries to address skin discoloration due to the burns.

225. In addition, Anorah’s doctors are considering whether she may need other forms of surgery to address scars surfacing and resurfacing as she grows older.

Injury from Professional Negligence

Count 1: Failure to Limit O2 Concentration Against All Defendants

226. Plaintiffs incorporate by reference all paragraphs of this Complaint as though fully set forth herein.

227. Fires in operating rooms occur when the three elements of the Fire Triad come together: an oxidizer like oxygen, fuel, and an ignition source.

228. As the anesthesiologist on the surgical team, Dr. Todd was responsible for monitoring and controlling the concentration of oxygen during the surgery.

229. Dr. Todd violated the standard of care by failing to limit the concentration of oxygen in the surgical field around Anorah’s head.

230. First, assuming that oxygen supplementation was indicated at that time, Dr. Todd failed to keep FiO2 levels within the maximum 30% limit required by the standard of care, precisely during the 15-minute window when the excision took place and the fire erupted.

231. Dr. Todd then changed the original handwritten entry for the FiO2 level actually delivered, by overwriting and reshaping the entry to read 0.3, or 30%, precisely the uppermost limit allowed by the standard of care.

232. Dr. Todd, moreover, overwrote the original entry without scribbling her initials or otherwise annotating the record to call out and verify the change—conduct that itself violates the standard of care.

233. Dr. Todd’s attempt to cover up the actual FiO2 level evidences her breach.

234. Second, even assuming that Dr. Todd did lower the FiO2 level from its prior setting of 100% to 30%, Dr. Todd failed to prevent the use of the Bovie for at least 3-5 minutes, to allow the oxygen to dissipate from the surgical field.

235. Dr. Todd’s failure to meet the standard of care was all the more egregious because this procedure, though routine, was a high-risk for fire.

236. As a result of Dr. Todd’s failure to meet the standard of care, the air in the surgical field around Anorah’s face was rich in oxygen—an oxidizer.

237. When that oxidizer came into contact with an ignition source (the Bovie) and fuel (towel, cap, even Anorah’s hair), fire erupted and spread over Anorah’s face.

238. Had Dr. Todd made sure that the FiO2 remained within the 30% limit around the surgical field, the heat generated by the Bovie would not have sparked the flames that burned Anorah’s head, face, and neck.

239. But-for Dr. Todd’s failure, therefore, the fire would not have occurred.

240. Dr. Todd’s failure to meet the standard of care thus caused Anorah pain and suffering, physical injury, and enduring psychological trauma.

241. As Dr. Todd’s employer or other principal at the time of the surgery, MAC Anesthesia, MAC Anesthesia Holdings, and/or MAC Anesthesia Wellstar is or are vicariously liable for her negligence, because she was acting within the scope of her employment or agency with one or more of those entities at that time.

Count 2: Failure to Communicate Against All Defendants

242. Plaintiffs incorporate by reference all paragraphs of this Complaint as though fully set forth herein.

243. Fires occur in operating rooms when three elements converge: an oxidizer like oxygen, an ignition source like a Bovie, and fuel.

244. The standard of care requires the surgical team to communicate about these elements to mitigate their convergence in the operating room. This requirement applies with special force where the procedure is high-risk for fire.

245. Specifically, the standard of care requires providers to alert the surgical team of the risk posed by the elements they control.

246. Thus, the standard of care requires the nurse to warn of drapes that may turn into fuel, and the anesthesiologist to warn of concentrated oxygen that may serve as an oxidizer.

247. In addition, the standard of care requires each member of the surgical team to ask about and ascertain the risk posed by the other elements.

248. Thus, an anesthesiologist must inquire about the possibility that a potential ignition-source like a Bovie might be used, especially if the anesthesiologist plans to introduce concentrated oxygen into surgical field.

249. Here, Dr. Todd failed to meet these requirements.

250. First, Dr. Todd failed to warn the surgical team that she planned to introduce and had introduced oxygen-rich air into the surgical field.

251. There is no record that Dr. Todd voiced the warning during any pre-operative communications or even during the timeout just before the procedure started.

252. When the surgeon asked for the Bovie aloud, Dr. Todd again failed to sound the warning, during the time it took to bring, set up, and activate the instrument.

253. Instead, Dr. Todd merely observed flatly: “You have a handheld cautery.”

254. Even after the surgeon said “yes,” Dr. Todd again failed to sound a warning.

255. Had Dr. Todd issued the warning, even at that eleventh hour, the Bovie would have remained off, and no fire would have erupted.

256. Second, Dr. Todd failed to inquire whether a Bovie might be used.

257. When the team discussed “anticipated critical events” including “anticipated blood loss,” Dr. Todd failed to inquire about the potential use of a Bovie, even though she herself planned to introduce oxygen-rich air into the room.

258. Only after the surgeon asked for the Bovie did Dr. Todd reflect, vacantly: “You have a handheld cautery.”

259. Had Dr. Todd inquired about the possible use of a Bovie, she could have taken deliberate action to delay or prevent its use.

260. In addition, the surgeon and others would have realized that she was planning to introduce or had introduced concentrated oxygen, so that the whole team would have worked together to avoid the convergence of oxygen and Bovie.

261. Dr. Todd’s failure to warn and inquire thus permitted the convergence of concentrated oxygen with the Bovie, leading to the fire.

262. But-for these failures by Dr. Todd, therefore, the fire would not have occurred.

263. Dr. Todd’s failure to meet the standard of care thus caused Anorah pain and suffering, physical injury, and enduring psychological trauma.

264. Dr. Todd’s failures to meet the standard of care were all the more egregious because this procedure, though routine, was a high-risk for fire.

265. As Dr. Todd’s employer or other principal at the time of the surgery, MAC Anesthesia, MAC Anesthesia Holdings, and/or MAC Anesthesia Wellstar is or are vicariously liable for her negligence, because she was acting within the scope of her employment or agency with one or more of those entities at that time.

OCGA § 13-6-11 Claims Against All Defendants

266. Plaintiffs incorporate by reference all paragraphs of this Complaint as though fully set forth herein.

267. Plaintiffs show that Defendants have acted in bad faith, have been stubbornly litigious, and have caused Plaintiffs unnecessary trouble and expense.

268. Plaintiffs are thus entitled to their expenses of litigation pursuant to OCGA § 13-16-11, including reasonable attorneys’ fees.

______________________

269. Pursuant to OCGA Title 51, Chapter 4, Plaintiffs are entitled to recover from all Defendants for all damages caused by the Defendants’ professional negligence.

___________________

270. As a direct and proximate result of the Defendants’ conduct, Plaintiffs, on behalf of Anorah Ignelzi, are entitled to recover from Defendants reasonable compensatory damages in an amount exceeding $10,000.00 to be determined by a fair and impartial jury, for all damages Anorah suffered, including physical, emotional, and economic injuries.

271. WHEREFORE, Plaintiffs demand a trial by jury and judgment against the Defendants as follows:

a. Compensatory damages in an amount exceeding $10,000.00 to be determined by a fair and impartial jury;

b. All costs of this action;

c. Expenses of litigation pursuant to OCGA § 13-6-11, including reasonable attorneys’ fees;

d. Punitive damages; and

e. Such other and further relief as the Court deems just and proper.

Respectfully submitted,

/s/ Lloyd N. Bell Lloyd N. Bell Georgia Bar No. 048800 Daniel E. Holloway Georgia Bar No. 658026

BELL LAW FIRM 1201 Peachtree St. N.E., Suite 2000 Atlanta, GA 30361 (404) 249-6767 (tel) bell@BellLawFirm.com dan@BellLawFirm.com

/s/ Lawrence B Schlachter, MD, JD Lawrence B Schlacjter, MD, JD Georgia Bar No. 001353

SCHLACHTER LAW FIRM 88 West Paces Ferry Rd Atlanta GA 30305 Telephone: (770) 552-8362 larry@schlachterlaw.com

Attorneys for Plaintiffs