Sample Case Evaluation Reports - Internal Medicine Expert Witness

Excessive diuretic use causing dizziness and fall with fracture of hip and elbow, anesthesia for surgery with esophageal perforation, infection, and death.

There are two issues of negligence in this case. First is the preventable cause of her dizziness that resulted in her fall, which caused her hip and elbow fractures. The second is the cause of her perforated esophagus during the anesthesia for her fracture surgery.

The patient was 89 years old, and had past symptomatic coronary artery disease which was successfully treated by an angioplasty (balloon catheter stretching open) procedure in 1992. In 1993 the repeat catheterization (x-ray dye contrast injection) showed that the arteries remained open. In 1998 she had an echocardiogram (sound x-ray like study) which revealed an ejection fraction (pumping efficiency) of her heart to be 70%. That is excellent, normal. Therefore, if she would not have died from her perforated esophagus (food pipe from the throat to the stomach), even at age 89 she had some reasonable longevity.

She had a recent history of becoming dizzy when standing, and fell and fractured her right hip and elbow. Her care in the emergency room, and prior to surgery was excellent.

She was on a potent diuretic drug, Lasix, which had caused her to become dizzy a number of times. She was not taking this drug for "congestive heart failure", because with an ejection fraction of 70%, it would not be needed. The consulting Cardiologist, Dr. #1, who saw her before her hip and elbow fracture surgery, noted that she had chronic venous stasis edema (swollen legs from varicose vein like problems) and was taking 40 milligrams of Lasix twice a day (b.i.d.), "… but a few months ago her dose was increased to 80 mg. b.i.d. by Dr. #2 because of problems with continued edema (swelling). Since then, the patient has had dizziness on standing frequently and believes her dizziness last night was related to this". I agree.

Dr. #1 said under his "Suggestions: 1). Would discontinue Lasix for now until her pre-renal azotemia (kidney failure caused by low blood pressure decreasing the blood flow to her kidneys, causing a reversible type of kidney failure, caused by too much Lasix decreasing her blood volume of plasma, a medically induced and negligent form of dehydration) is resolved and orthostatic dizziness is resolved;" which means her decreased blood volume would, by gravity, pool in the lower half of her body upon standing, decreasing the total blood volume passing through her heart (pump), temporarily reducing her blood pressure and therefore less oxygenated blood to her brain, causing her to become dizzy and fall.

Obtain the office records of Dr. #2 and statements from family members who can document if the patient advised him of her dizziness after he doubled her dose of Lasix. Was she advised of that potential side effect? She should have been told, and seen again as soon as she had those symptoms, as well as being told to discontinue that drug for one day, and resume the previous lower dose.

The failure to do so would be a departure from the standards of care and significantly increase her risk of falling, fracturing her hip (she fractured the other hip a few years before), and any complications from the required orthopedic surgery, whether that care was negligent or not, would never have occurred, and she would not have died at this time, after prolonged suffering.

The Orthopedic Surgery the night (1935 to 2145, 7:35 p.m. to 9:45 p.m.) of 7/25/99 was properly done by Dr. #3

The Anesthesiologist was Dr. #4, and the Anesthetist was Nurse #1 according to the operating room nurse's notes and what appears to be their names on the anesthesia record. The endotracheal tube (breathing tube inserted into the windpipe) looks like the initials are Nurse #1.. and its proper placement was checked by Dr. #4. The Nurse's notes say each arrived at 1930 and left at 2200. Obtain copies of their Contracts with the Hospital.

One of them inserted an esophageal temperature probe. In my opinion it was forced too hard and at that point, where it did easily slide down until that location, it was pushed through the esophagus (which is about 1/4 inch thick), on the right side of the esophagus, causing the through and through perforation into the inner edge of her right chest area. Air escaped into her mediastinum (central area of the chest containing her heart and central parts of her lungs). There was air under the skin (subcutaneous emphysema) noted by Dr. #5 on 7/27. He also stated that: "she states she has not eaten in two days". During her previous hip surgery rehabilitation a few years before she developed a food impaction at the junction between her esophagus and her stomach, but this time she would not be fed before general anesthesia. She did not eat afterward. Therefore, stuck solid food did not perforate her esophagus.

The Thoracic (chest) Surgeon, Dr. #6 said in his consultation notes: "I suspect that the patient developed an esophageal perforation probably at the time of her hip repair. Reviewing her operative record it appears that an esophageal temperature probe was placed at the time of surgery and this could conceivably have contributed to the etiology (cause) of esophageal injury". In my opinion it was the cause. There was no stomach suction (NG) tube and even if it was used, it would not cause a perforation. It is very flexible and somewhat soft.

If a patient violently vomits, they can tear the esophagus at its junction with the stomach (Boerhave Syndrome). In this case there was a 1/2 to 1 centimeter hole (1 inch = 2.54 centimeters). This is 1/5 to 2/5 inch hole, which was through the mucosa (the skin like lining), and "the edges were puckered at worst". The muscle wall of the esophagus covered the perforation as Dr. #6 saw it at surgery. He properly sutured it closed in two layers, and then removed her fifth rib at the chest incision site, and used that intercostal (chest/rib) muscle to cover the operative repair. This was good care. He inserted two chest tubes for drainage, again the standard of care. Dr. #7 operated through her abdomen to insert a suction tube into her stomach (gastrostomy) and a feeding tube into her small intestine (jejunostomy). Again, proper care, and helped isolate the repair site from stomach acid.

Dr. #6 found a small abscess cavity at the perforation site, consistent with the "36 hour delay" he noted. Again pointing back to the insertion of the esophageal temperature probe during the beginning of the anesthesia, for the orthopedic surgery, needed because of her fall, caused by her dizzy spell, when getting up.

On 7/26 at 1210 after her orthopedic surgery, the patient complained of left sided chest pain. Dr. #2 was called and ordered oxygen and an urgent EKG (electro-cardiogram), proper care. At 1300 her blood pressure dropped to 70/50 and was treated. She was also transferred to the CCU (Coronary Care Unit). A lung scan was done to rule out a pulmonary embolus (traveling blood clot into the heart lung circuit), and she had a CT Scan at 1930. That scan showed gas in the chest consistent with an esophageal perforation which was confirmed by a gastrograffin esophagram (water-soluble contrast x-ray dye study). It noted a perforation 3 centimeters below the carina (division of her trachea, windpipe) into the right and left main bronchial tubes. This is consistent with the area noted at surgery. It is too far down to be caused by a negligent insertion of the endotracheal tube for anesthesia.

All of her care from the onset of her chest pain, through a timely evaluation, operation, re-evaluation for a recurrent leak at the operative repair site and to her transfer to the second hospital, was very good.

The patient refused to have surgery when it was discussed at 0320 on 7/27. She was told the perforation was 100% fatal without surgery and 10-15% fatal with surgery and she refused again and again. Finally, she consented at 0850 and was moved from her room at 1110 to go to the operating room, where anesthesia began at 1135.

Early hours make a critical difference in the ability to repair the esophagus, where it has a chance to heal versus leak. Because of the delay after the diagnosis was made and surgery offered to her at 0320, until she consented at 0850, the 5 1/2 hours is significant; but what is much more significant is the time from the perforation at 2000 on 7/25 until 0320 on 7/27, which is 31 hours and 20 minutes versus the exact total time from perforation until surgery began on 7/27 at 1135 which is 39 hours (not 36 as noted by the surgeon) and 35 minutes.

The abscess found at the perforation clearly would be established during those first 31 hours and her refusal, in my opinion made only a minor contribution to the leak and re-operation, respiratory failure and her death.

On 8/2 she was transferred from Hospital #1 to Hospital #2 where she underwent repeat chest surgery on 8/2 by Dr. #8. He found there was a very small leak at the previous esophageal repair site. He inserted a "T" shaped tube with the long perpendicular part exiting her chest, to serve as and to create a natural "controlled fistula" which could spontaneously seal off after months. He re-used the previous muscle flap again for a more secure closure over the tube as it entered her esophagus. However, as days passed, this also did leak, as they too commonly do. But both operations on her esophagus met the standards of care.

On 8/9 she had a tracheotomy (hole cut into the windpipe through which the ventilation tube is inserted). All this is proper care

She become dependent on the ventilator and her condition did not improve. Her will stated that she did not want to remain on life support and they honored her wishes. The ventilator was disconnected on 9/14 and she ceased to breathe on he own shortly, thereafter.

In my opinion, Dr. #2 was negligent for his abuse of the drug Lasix in not reducing the dosage when she was having dizzy spells from her drug-induced dehydration. He and any Corporation of his should be a Defendant for all the reasons stated above.

Also, the Anesthesiologist Dr. #4 and the Nurse #1 and anyone else who was involved with the insertion of the esophageal probe, as well as any Corporation of theirs and the Hospital #1 who supplied them, should be Defendants. It would not be the practice of an Orthopedic Surgeon to be involved with that probe, and when all their work is taking place, he would usually be scrubbing his hands outside of that room.

I do not feel that her refusal to have the surgery which caused a late and relatively short delay was significant contributory negligence for the reasons stated. Furthermore, because of her pain medication (narcotic and sedative) used because of her hip and elbow surgery, it would significantly reduce her chest pain for hours until her infection symptoms caused the nurses and physicians to immediately begin the proper and rapid series of diagnostic tests that confirmed her diagnosis.

Determine what specialty Dr. #2 has and if he is Board Certified in that specialty. You should authorize us to have his care evaluated by an Expert in a similar field.

And the anesthesia care should be evaluated by an Anesthesiologist, which we can arrange for you.

Then a Thoracic Surgeon should discuss the nature of this problem if her treating surgeons become uncooperative. An Infectious Disease Expert may also be helpful in explaining why the perforation was deadly.

It also may be helpful to have a Cardiologist Expert discuss his opinion on what her longevity would otherwise have been, if not for those negligent acts. All these Experts are available on our independent consulting staff.

She suffered tremendously, and her pain and suffering can be assessed by a local Psychologist who can also interview her family members who were witnesses.

Please obtain the office records of Dr. #2 and statements concerning how long she had those dizzy spells, and whether she was warned of the side effects of increasing her Lasix, and whether or not the doctor was told of her dizzy spells.

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