Sample Case Evaluation Reports - Pulmonary Medicine Expert Witness


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Bronchoscopy For Diagnostic Purpose Under General Anesthesia, Mismanaged Resulting in Death in the Recovery Room.

At age 69, this patient with chronic psychiatric problems, was hospitalized on 8/1. Because of a recent cough and breathing problems not responsive to antibiotics, and a chest x-ray consistent with widespread pneumonia or broncho-alveolar carcinoma, she was seen by a Pulmonary Specialist who correctly recommended a fiberoptic (thin, flexible fiberoptic telescopic device) bronchoscopy examination of the inside of the passageways (trachea, major and minor bronchial tubes) of her lungs as well as sampling the lung secretions for germs and cancer cells, as well as a brush biopsy (like a Pap smear), and a trans-bronchial biopsy (piercing a bronchial tube to sample the deep lung substance),

Because of her severe anxiety and panic attacks, it was reasonable to suggest that this procedure be performed under general anesthesia. Before the anesthesia, arterial blood gas studies revealed impaired oxygen saturation in her blood (80-90%) even with nasal oxygen supplementation. On call she also received a tranquilizer tablet.

She was placed under general endotracheal anesthesia from 10:30 a.m. until 11:20. The CRNA (Certified Registered Nurse Anesthetist) was Kevin and the Anesthesiologist is Dr. Larry (was this doctor there all the time, and in the recovery room too?)

Dr. David performed the fiberoptic bronchoscopy and saw no lesions in her bronchial tubes. He also performed the bronchial lavage (washing), the brush biopsies, and the trans-bronchial biopsy. He had no difficulties, and his procedure was done through the endotracheal tube in a breathing but anesthetized patient. Generally there are only two safe times to remove the endotracheal tube: when the patient is breathing well but still asleep (still under anesthesia), or fully awake and demanding the endotracheal tube be removed. But in her case, because of her severe lung disease noted on her chest x-ray and by the impaired oxygen transport ability into her blood, the only safe time would be when she was fully awake. Not doing this is a departure from the accepted standards of care in my opinion. It put her in a zone of danger. This is the responsibility of the M.D. Anesthesiologist, the CRNA, their corporation, Dr. David (since he obviously was fully aware of the severity of her pulmonary condition), his Corporation and the Hospital.

According to the anesthesia record: “Breathing spontaneously, extubated (endotracheal tube removed), to PACU (Post Anesthesia Care Unit: Recovery room) with oxygen mask. According to the dictated operative report by Dr. David (dictated at 12:30 a.m. on 8/9): “After the patient was extubated in the recovery room, the patient had increased respiratory difficulties and ultimately had to be reintubated.” He had a duty to stay with his patient, especially if the M.D. Anesthesiologist was not present; this would put the “other M.D.” in charge and to some degree, in charge of the CRNA, even if he was a Surgeon, and especially as a Pulmonary Disease Expert.

Dr. David was present, according to the note on the Anesthesia Record, when she was reintubated with a 7.0-mm size tube.

According to the PACU page, she arrived there at 11:45, and from “0 to 2” had a “1” for “Respiration,” a “0” for “Consciousness” and a “1” for Oxygen Saturation. This was inadequate. At 11:45 the nurses notes (which are difficult to read) state respiratory problems and “jaw support attempt but not sufficient.” Pulling up on the jaw helps to pull the tongue away from the upper windpipe. Dr. Nick (apparently an Anesthesiologist) was present. But she was intubated by CRNA #1? Why was the less skilled person allowed to do this more difficult intubation, especially when Anesthesiologists should be available: they have the needed greater skill? The failure to have the most skilled person attempt to intubate is a departure from the standards of care.

That Nurse’s note says “Bilateral (both sided) breath sounds.” But was it from her spontaneous respiration sounds they (who listened???) heard or was it really from the endotracheal tube securely positioned in her windpipe??? How far was it inserted? Did they use the hand ventilator (“bag”) to force air into her lungs and listen at the same time to be sure that it was in the trachea (after they inflated the balloon that surrounds the lower inch and seals the space between the endotracheal tube and the trachea)?

That Nurse’s note says that the heart rate (H.R.) decreased to 40 at 11:50. Instead of the obvious low oxygen (and did she have a continuous transcutaneous [skin] monitor on as she should have because of her much higher risk factors??); instead of confirming the proper secure position of that endotracheal tube, they gave her the drug atropine to attempt to chemically speed up her heart rate. Who ordered it and why? It had no effect per that note. So at 11:53 she was given epinephrine (adrenaline) “per ordered,” by whom? This, instead of rechecking on the patency and control of her airway, jumping to chemicals instead of confirming her airway, is negligent. This is negligence of the CRNA, the Anesthesiologist(s), Dr. Nick and Dr. David.

Dr. David ordered Lasix (a potent diuretic) instead of confirming the airway. Then she “arrested.”

The “Code Blue” (arrest) sheet said “ventilations started at 11:45 bag valve device” and that she was “intubated, time 11:47, by CRNA Kevin.” It said personnel responding: Dr. David, Dr. Harold, Dr. Paul, Dr. Nick (what time did each get there), as well as: Ann, R.N., Karen, R.N., Earnie, R.T. (Respiratory Therapist), Kevin, CRNA and Dr. Marie (? signature) signed it. Depose them.

After a chest x-ray was done at 12:05, a chest tube was placed between her ribs into the pleural space (between the lung and the rib space) to rule out air pressure squeezing her lung as a cause of the problem (tension pneumothorax) which was not found. It notes, “per M.D. ETT (endotracheal tube) repositioned.”

The Anesthesia / PACU note by what appears to be Dr. Nick says she was “in obvious respiratory failure – PO2 (oxygen blood pressure) 70s (very low), poor respiratory movement/supraclavicular retractions (as she tried to inhale, her flesh sucked into toward her lungs because of airway obstruction, not just inability to breathe because of “poor” effort), being assisted by CRNA.” If that is the case, they all are grossly negligent because if the tube was correctly positioned and she was “assisted,” there should and could not be retractions. If no tube was in place, watching her struggle with her severe lung disease and delaying inserting the tube is also negligent.

It is obvious that the balloon cuff was obstructing her airway that tube must be securely taped to prevent any slippage. Its length must be looked at to be sure enough is inside her windpipe, and that it did not move. The note goes on to say: “Very little air exchange on auscultation (finally “they” listened to her chest), determined reintubation necessary, 7.0 ET (endrotracheal tube) placed by o.k. and breath sounds but severe rhonchi (coarse breath sounds) on left. Discussed with Dr. David – suspect tension pneumothorax…” (he put in the chest tube). “CPR initiated during this time. After this, ventilations not appreciably improved. Abdominal distention noted (because the tube was put into her esophagus [food pipe] which is behind and parallel to the trachea and pumped her stomach full of air). Repeat laryngoscopy (looking into the back of her throat with a lighted instrument) by Kevin, CRNA reports tip of ETT is in the glottis (vocal cord space) with cuff herniated (slid up too high and not fully in trachea and can block the airway) reintubated (by whom?) with confirmation of improved breath sounds bilaterally now.”

He also passed a stomach suction tube down her esophagus to decompress her stomach which as distended pushes up on her diaphragm (breathing muscle) and further compress her lungs like a piston pushing up from below. “CXR (chest x-ray) taken during CPR showed ETT in esophagus prior to being repositioned” (that report is missing. Obtain it and good copies of all the x-rays). “Am concerned that patient suffered a period of anoxia (lack of oxygen) from combination of inability to ventilate prior to thoracostomy (chest tube insertion) with unknown period of ETT not adequately ventilating trachea. Suspect ETT became dislodged during chest compressions at about the same time that thoracostomy was performed.” Who was the doctor in charge?

However, the Nurse’s notes clearly show that she was reintubated the second time (the first intubation was prior to the bronchoscopy and then removed), before she arrested, and it was not timely and/or properly done or she would not have arrested from anoxia. The ETT was “repositioned” at 12:05. She was “reintubated” at 11:47 and “repositioned” at 12:05.

Before she was reintubated at 11:47, too much time elapsed from their negligence’s and the first “vital signs” on the Code Blue sheet start at 11:58 with a heart rate of 30 and no respirations (she was “assisted” by the “ambu” – hand bag). It takes a few minutes of anoxia to cause the heart to slow and then went to “0” at 12:01.

All of this was preventable by not removing the ETT in the Operating Room, properly monitoring her breathing and blood oxygen levels, by timely and correctly reintubating her and securing the position of ETT.

There was no other cause of her severe brain damage. She had good care afterward including tests which confirmed that the only cause of her brain damage was from anoxia. She died on 8/19.

I cannot find the lung biopsy pathology report. The Physician’s “progress note” claims it shows cancer: Broncho-alveolar carcinoma. I did see the report from the bronchial washings that showed “clusters of cytologically malignant cells, consistent with origin of adenocarcinoma.” The brush biopsy was inconclusive. And based on the diffuse findings on the chest x-rays, she most likely had broncho-alveolar carcinoma which is a less common form of lung cancer. It also is the most virulent and does not respond to chemotherapy or radiation therapy, in my opinion. It cannot be removed by surgery since it involved both lungs.

I believe her longevity would have been weeks to a few months based on the extent of the x-ray report changes and her impaired oxygenation. She would have died as a lung cripple and with severe emotional distress based on her psychiatric history of severe depression and fears of death.

That was the ironic effect of their negligence: It eliminated what would have been an extremely traumatic slow death she would have experienced, day by day. There was no excuse for all their negligence, but the Defense will obviously raise these issues.

I would recommend that you authorize that the Medical Review Foundation, Inc. has all these records (and the missing documents) reviewed by Board Certified Medical Experts in Anesthesiology, Oncology (Cancer Therapy) and Pulmonary Disease.

We look forward to continue assisting you with this interesting and important case.

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Patient With Pneumonia on a Ventilator Removes Endotraheal Tube; Negligent Reinsertion causes Lack of Oxygen and Death

At age 53, he was hospitalized on 6/28 with acute left lobar pneumonia that was determined to be caused by the germ Legionella, and he received proper therapy through consultations with specialists in Infectious Disease and Pulmonary Disease.

Because of his use of steroids to treat his rheumatoid arthritis, and a 35- or 50-pack-year history of smoking, he was more susceptible to this infection, and was more resistant to treatment. It was a judgment call, because of his worsening respiratory failure, to intubate him (insert an endotracheal tube via his mouth into his trachea: windpipe). This was done on 6/30 with a size 8.5 tube, which is for an adult male size.

The endotracheal tube has a balloon cuff surrounding the lower inch, which, when inflated, seals off the space between the tube and the inside of the trachea. This permits positive pressure from the ventilator to be directed into the lungs and not leak (dissipate) around that tube. It also prevents gastric fluid or feeding aspiration into the lungs. Through the tube, the nurses frequently suction secretions, and a bronchoscopy (use of a flexible fiberoptic tube) can be passed for diagnosis and suctioning mucous plugs that obstruct the bronchial tubes (branches of the trachea).

Some Hospitals may still recycle endotracheal tubes by sterilizing them. That process can damage the balloon cuffs and increase the risk of leakage. New endotracheal tubes must meet good manufacturing practices and be constructed not to leak. You need to find out what brand and model tube was used, whether or not it was changed, or removed and reused with each of the two bronchoscopies, and through the Freedom of Information Act obtain all the information on leakage problems from the Bureau of Medical Devices of the F.D.A. (on Fishers Lane in Bethesda or Rockville, MD)

Neurologically he was intact until the cardiac arrest caused by lack of oxygen (anoxia) and low oxygen (hypoxia), which occurred on 7/13 when at 1320 the Nursing Staff notified Dr. #1, that the endotracheal tube (ETT) was leaking. “Dr. #2 was notified and re-intubations with a new tube was planned.” With the leak, the PO 2 (pressure of oxygen in the arterial blood) was 80 and the percent saturation of the hemoglobin pigment in the red blood cells, which carry the oxygen like a sponge, was excellent at 97%. If the PO 2 drops below 70, the percent saturation will rapidly diminish. That did not happen with the leak, and although there was some urgency to replace the tube, it was not an emergency.

What is the expertise of Dr. #2 in urgent bedside intubations? He was consulted on 7/13 by Dr. #3 concerning the potential need for a tracheostomy (to be performed by Dr. #4). Did he do both attempts? Who inserted it at the arrest?

Why did they not arrange for an Anesthesiologist to remove the leaking tube and insert a new one? What became of the evidence: the leaking tube?

At the time of re-intubation, the patient’s muscles were “paralyzed” with the drug succinylcholine. That prevents all spontaneous breathing and he could not move. All his muscles, including his jaw and throat would be flaccid. He could not resist their efforts. But he could feel their probing his throat, and also experience the oxygen deprivation and any associated fears of dying, until he passed into permanent unconsciousness during the second attempt at intubation. He was sedated with Versed.

After the first failed attempt, “they” ventilated him with the venti-mask bag ventilator (by hand). The second attempt failed and during that prolonged failure, his oxygen level dropped to a life threatening level of 23% saturation. His heart was directly affected by too little oxygen and it slowed to 30 b.p.m. (beats per minute). He needed immediate oxygen and was negligently denied it. Instead, “they” gave him the drug atropine to speed up the heart rate. That was a serious error, since it was not slowing from a drug treatable condition. Muscles cannot pump without oxygen. The heart is a muscle. And after three to five minutes of too little oxygen, the brain will sustain irreversible damage.

We are taught to hold our own breath during intubation attempts so that we know when to desist and reventilate with the mask bag unit. In fact, the patient can be continuously ventilated until a more skilled Doctor arrives to intubate. Also, he could have been continuously ventilated until the planned tracheostomy operation could have been rescheduled to be done at that time.

All those failures were negligent by Dr. #2, Dr. #1, and any other involved staff. To persist in attempting intubation for 10 minutes while the patient cannot breathe from the paralyzing drugs and was on an oxygen monitor showing severe oxygen deprivation is clear negligence.

That directly caused his irreversible brain damage, documented at the autopsy on 7/28 (he died on 7/26 after his “advanced directive” was honored).

Dr. #5 explained the tracheostomy at (?) 1300. A Nurse called Dr. #2. Versed (a potent Valium-like sedative) was given as 5 mg each dose at 1345, 1347 and 1350 followed by succinylcholine intravenously at 1352. The “Code Sheet” noted Dr. #2 and Dr. #1 were present. The arrest occurred at 1400 and CPR began at 1400.

At autopsy, the severe left lung pneumonia was documented, as well as the diffuse damage caused by prolonged ventilator use. He was “dependent” on the ventilator, until his pneumonia would have begun to resolve. A patient cannot effectively cough on a ventilator, so suctioning, pulmonary physical therapy, and periodic bronchoscopies were used and would have been needed, until the lung condition improved.

Of the three coronary (heart) arteries, the least significant, the right coronary artery had an 80% (narrowing) stenosis, the left anterior descending had only 50% (not hemodynamically (blood flow) significant) and the circumflex artery was normal. Therefore, he had no significant coronary artery disease to otherwise shorten his longevity.

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The Defense will argue that his Legionnaires’ disease pneumonia would be fatal after two weeks of antibiotics and ventilator use. I do not believe that to be true. Infectious Disease and Pulmonary Disease Experts could review the chest CT scan and x-rays (copies) and all these records to give you their opinion to the “so what” defense.

Based on the above, the Hospital and Drs.#1 and 2 departed from the accepted standards of care and caused his preventable brain damage and death.

As you follow up on my questions and suggestions, I suggest you authorize the Medical Review Foundation, Inc. to obtain Board Certified Medical Expert reviews in Infectious Disease, Pulmonary Disease, Anesthesiology, and Intensive Care Nursing.

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AIDS Patient with Pneumonia Receives Steroids and No Ventilator Which Causes Premature Death.

When a patient is HIV positive and has AIDS (Acquired Immuno-Deficiency Syndrome), his immune system is very impaired. This patient is very susceptible to infections, including pneumonia. 

If a patient has asthma (a spasm of the brachial tubes), then in addition to bronchial dilator medications and antibiotics (if he has an infection), the use of steroid medications may be necessary to help overcome the allergic nature of the cause of the bronchial tube spasm. The lungs will have high-pitched wheezes, not rhonchi (wet, congested) breath sounds. 

This patient, at age 62, was HIV positive and developed shortness of breath and pneumonia. He had “rhonchi” and no wheezing. There are no x-ray reports in the medical records, and they should be obtained. 

In the Emergency Room, he was evaluated and they noted he had been to other Hospital Emergency Rooms recently and received antibiotics. Their records should be obtained. 

He received antibiotic therapy for his pneumonia. The usual standard of care is to obtain a sputum (deep cough) specimen for laboratory testing (culture and sensitivity) to determine which germs are present, and the best antibiotics to kill them. I do not find that in the records, and if it was not done, is a departure from the proper standards of care. 

Upon arrival and for the entire stay (6/24-7/1), he received potent steroid medication by intravenous injection (30-60 milligrams of Solu-Medrol every 6-12 hours). He had no wheezing or evidence of bronchial spasm. In my opinion, this worsened his already damaged system’s ability to combat any infection. 

On admission, his arterial blood oxygen level was very poor and required an oxygen mask. I will discuss this issue in some detail. The red blood cell pigment is called hemoglobin. It holds oxygen like a sponge holds water. However, its grip is not linear. It follows an “S” shaped curve. Room air is 21% oxygen. With normal lungs, the pressure of oxygen in the blood is 95-99 (PO2 ,also called TORR). The saturation of the hemoglobin is normally close to 100%. With lung disease (including pneumonia), less oxygen enters the blood, but the hemoglobin still is highly saturated. With an oxygen pressure of 50-60, the hemoglobin is usually 85% saturated. But that is at the beginning of the sharp downslope of the “S” shape curve. With a little further drop off of the arterial blood oxygen pressure (PO2), the saturation falls dramatically, the patient turns blue and will die. 

In his case, on 6/23 at 3:28 p.m., his PO2 was 74.2 and his oxygen (O2) saturation was 86.5%. On 6/30, with an oxygen mask giving him 50% oxygen to breathe (versus 21% on room air), his PO2 (oxygen pressure in his aterial blood) was only 50.8 and his oxygen saturation was 90%. His condition worsened late that night. He was not intubated (tube put into his windpipe (trachea) and a ventilator was not used to force oxygen into his lungs to increase the oxygen in his blood). The oxygen mask would not work with his lungs failing from pneumonia. 

His blood count also worsened, consistent with severe infection. The white blood count (WBC) ws normal on 6/23 at 5100 and had risen to 12,000 on 6/30. But the differential smear changed (shift to the left), consistent with severe infection. 

He became very anemic (less red blood cells and hemoglobin to carry any oxygen to his body’s cells), the platelet count (clotting particles made in his bone marrow) dropped severely (thrombocytopenia) and he would bleed. All this hospital stay he received high doses of the steroid drug Solu-Medrol, as I noted. 

He required this ventilation mask, but then on 6/30, he required the intubation and ventilator. However, on 6/30, at 8 p.m., when he was still alert and conscious, he signed a Consent Form for “no intubation.” The Hospital Personnel considered this the same as a Do Not Resuscitate (DNR) order, but it is not quite the same. As few hours later, they watched him die. 

In my opinion, the abuse of steroids allowed the lung infection (pneumonia) to progress, which ended his damaged life. Without the steroids and with the correct antibiotics and pulmonary care, he had a better chance to live. 

I suggest that you obtain the missing records (x-ray reports and any culture and sensitivity bacterial reports). I also suggest that you obtain good copies of the chest x-rays and the previous emergency room records, plus all documentation as to his HIV and AIDS status. Then authorize us to have all these records evaluated by Board Certified Experts in Pulmonary Medicine, Emergency Medicine and Infectious Disease for their opinions as to the care at this Hospital and those Physicians, as well as try to determine his AIDS status and potential longevity. 

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