Sample Case Evaluation Reports - Thoracic Surgery Expert Witness
 

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Misdiagnosis of dissecting thoracic aneurysm in 39 year old woman, causing death by pericardial tamponade.

The care given at the Hospital #1 ER did deviate from the standard of care in the evaluation of the patient and as a result, there was a delay in diagnosis resulting in death that more likely than not would not have occurred absent the negligence. Methods of diagnosis of dissecting thoracic aortic aneurysm (separation of the layers of the main artery from the heart to the body) are based on presentation - that is, the particular constellation of symptoms and findings and based on the index of suspicion created by the history and physical, various diagnostic tests including transesophageal echocardiogram (placing an echocardiogram probe in the esophagus close to the heart), CAT scan or MRI contrast or MRI angiogram.

The index of suspicion necessary to pursue the diagnosis of dissecting aneurysm would be created by persistent chest pain radiating into the neck (observed) and associated symptoms (described), a difference in the pulse pressure in the arms (not investigated or recorded). Rarely, an abnormal cardiac sillouette on x-ray. An abnormal EKG may be noted depending on the type of dissection.

There are numerous causes of chest pain including myocardial ischemia (angina); myocardial infarction (heart attack); esophagitis due to reflux (heartburn); pneumonia. The accepted standard of care would be to rule out the more dangerous and lethal etiologies of chest pain and then having done that, rely on a presumptive diagnosis of a non-lethal diagnosis. The diagnosis to be established by later testing. Except for a myocardial infarction (MI), the potentially lethal etiologies were not ruled out, were not even considered. Even the diagnosis of MI was not adequately investigated and ruled out.

The parties culpable include: Hospital #1, ER, Dr. #1, Dr. #2 and Dr. #3.

Chronology:

On 6/7 this 39 year old woman was brought to the Hospital #1 ER at about 7:30 PM by a friend complaining of severe chest pain radiating (extending) into the neck, back and stomach, shortness of breath, nausea, faintness and visual changes. She was not taking any medications. She underwent baseline evaluations by Dr. #2, including a chest x-ray and EKG. I could find no record of lab tests being ordered or obtained. She was treated with a "GI cocktail" and nitroglycerine (NTG - coronary and other smooth muscle dilator), toradol (analgesic), xanax (anti-anxiety) and phenergan (potentiates analgesic) with some relief.

The salutary effect of these treatments are nonspecific and cannot be relied upon as to a presumptive diagnosis. The presumptive diagnosis was "atypical chest pain" and despite persistence of symptoms she was discharged home. It is recorded in the record and stated by the husband that at the time of discharge, she was still feeling "bad" and Dr. #2 was aware.

Discharge instructions included medications (phenergan, prilosec and xanax) and were advised to return to normal activities and see her physician. What is "atypical chest pain"? The chest x-ray was essentially normal as read by the Radiologist, another Physician reviewer and I agree.

6/8 Symptoms were unabated, however because of medication patient was very drowsy. She contacted her doctor, #3, but only spoke to his nurse.

6/9 Symptoms persisted. Conference with Dr. #3 resulted in a prescription being called in, filled and taken and an appointment 6/10.

6/10 Evaluation by Dr. #3 at Hospital #1. He reviewed her recent history and examined her but did not record arm differential blood pressure nor was a repeat cardiogram or other test ordered. He recorded a tachycardia (rapid heart rate) of 104. Differential according to statement of husband included fibromyalgia, virus, anxiety; according to Dr. #3, anxiety, fibromyalgia, medication reaction. He advised discontinuing phenergan and xanax and (continue?) Valium, prilosec and amytriptyline and check in a few days.

6/11-12 No change

6/13 Returned to ER and saw a Resident Physician who was followed by Dr. #1 who felt she had an infection (according to husband) and a cortisone shot (celestone 12 mg IM) was administered. This medication is not generally indicated in the treatment of fibromyalgia on an acute basis. He recorded normal findings on exam except for a tachycardia of 114 without explanation. (no diagnosis was recorded by Dr. #1 but it appears that he thought it was fibromyalgia). She was discharged and after 8 hours, she was feeling better. No one checked arm differential blood pressure and did not record absence of carotid bruits (whistling sound made by blood lowing through a narrow pinched artery) and the tachycardia was unexplained.

6/14 was found dead at 5:45 am. Coroner estimated time of death to be around midnight due to a dissecting aortic aneurysm causing a pericardial tamponade (squeezing of the heart by blood, like a vise).

Old charts of Hospital #1 from 1987 to 1999 indicate that she had borderline hypertension not requiring treatment. On several physical examinations differential arm blood pressure was recorded, and in fact it is listed on the clinic physical examination form.

The use of the steroid was not only inappropriate for the presumptive diagnosis, but more likely than not this aggravated her condition and caused the dissection to extend and break into the pericardium (heart sac) causing a pericardial tamponade that caused her death.

There is no doubt in my mind that there was a departure from acceptable standards of care on the part of the individual physicians involved in the care of the patient as well as Hospital #1. The issues raised in this case represent viable avenues of pursuit. Necessary to support the presence of negligence would be Expert testimony from a Vascular or Cardiothoracic Surgeon and an ER Physician.

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Operative removal of part of lung for cancer, with development of mucus plugs in bronchial tree causing blockage of bronchial tree requiring bronchoscopic cleansing, and question of being over medicated for pain.

This 53 year old woman with a long history of smoking had a chronic cough for one month, was treated with antibiotics, and had a chest x-ray consistent with a tumor mass in the upper half of her left lung.

A bronchoscopy (passage of a lighted telescopic device down her windpipe into her lungs) on 6/2 did not reveal evidence of cancer, however the mass was at the periphery of her lung. She was given good information and gave her informed consent for surgery which was performed by Dr. #1 on 6/7 at the Hospital #1.

Before surgery her lung function evaluation demonstrated that she was an acceptable candidate for removal of part or all of her left lung which is 40 percent of total lung function (since the heart is mostly on that side of the chest).

The operation to remove part of her left lung and anesthesia went uneventfully and was properly done. Chest drainage tubes were inserted, managed properly by the nurses, and removed at the correct times by the Surgeon.

The mass was squamous cell carcinoma, the most favorable type of lung cancer for cure, since it usually grows locally and spreads to the lymph nodes instead of the blood stream. The tumor measured 2.6 centimeters (one inch) across and the lymph node removed at the central top of her lung was negative for metastatic cancer spread.

Dr. #1 ordered the nurses to assist her deep breathing with a ventilation assisting device (Triflo) which they did do as documented in the nurses notes. They also encouraged her to cough to prevent the build up of thick mucus, which can block (plug up) the bronchial tube passages in her lung.

The Surgeon ordered "Chest x-ray one view daily," not "first thing in the morning" as she claimed. And a daily chest x-ray was taken, as confirmed by the nurses notes, on 6/8 at 0835, and the Surgeon arrived at 0900. He obviously would have to go to the x-ray department to view it or call and speak to the Radiologist. Such a report usually would not be typed and in her medical chart until the next day. That x-ray showed the usual post-operative findings including probable contusion of the left lung from operative manipulation.

The Surgeon ordered the narcotic Demerol to be given as 25 to 75 milligrams every 2-4 hours as needed (PRN). Phenergan, an anti-nausea medication, mild sedative and narcotic potentiator was ordered as 25 milligrams every 3 hours PRN. That is one-half of the usual dose.

She was not over-medicated. The nurses gave her the pain medication at her request and on 6/7 she received 50 mg. of Demerol at 1850 (6:50 PM), and the 75 mg at 2110, and on 6/8: 0035, 0410, 0805, 1005, 1215, 1535, 1740 and 2200. Phenergan was given on 6/7 at 2110 and on 6/8: 0075, 0410, 1530, and 2200.

If a patient is over-sedated, they may not cough and mucus can build up in their lungs. But if a patient is in pain, they will not cough because of the chest incision pain, and the same condition will result. On 6/9 and 6/10 some doses of Demerol were 50 mg. and most were 75 mg. For a 53-year-old person who weighed 150 pounds, that is very reasonable dose. She only received the Phenergan two times each on 6/10 and 6/11. This is not at all excessive dosing.

Usually for the first two to three days narcotic injections are given every two to four hours when a patient has pain, as it was given here.

On 6/11 (4 days post-operative) she received 12 to 35 mg. of Demerol which is barely effective.

On 6/7, 6/8 and 6/9 the nursing medication record notes that she was nauseated by the drug Toradol for pain and did not receive it. On 6/11, when the Demerol dose was drastically reduced she took the Toradol at 9:30 a.m. and they noted "not able to take" and she received no more.

Immediately post-operation many patients are nauseated and Demerol causes nausea. When the Demerol was reduced, it was a reasonable decision to try to use Toradol again, and caused her no harm. It was initially given with Darvocet and thereafter she only had the Darvocet orally, which is much weaker.

On 6/9 at 9 a.m. she was taken to the Radiology Department for a chest x-ray and Dr. #1 saw her at 10 a.m. At 1020 she received 75 mg. of Demerol and just had one chest tube removed, and was using the Triflo breathing device to help her take deep breaths. At 1445 she received 75 mg. of Demerol, was using the Triflo "with great effort" and had a "wet cough without production." She was not over-medicated. She was not heavily sedated.

On 6/9 the chest x-ray was unchanged. On 6/10 there was consolidation on the left lung and the Surgeon performed a bronchoscopy procedure to remove the mucus plugs that were so thick they would not suction up in the small opening of the bronchoscope. He used its suction to pull them out and reinserted the bronchoscope four times to clear them out. This was good care.

The chest x-ray on 6/10 was improved.

But because it had not cleared by 6/11, he re-bronchoscoped her on 6/12 and "the patient's respirations were tremendously improved after removal of numerous, probably 5, large mucous plugs." This was good care.

The chest x-ray on the afternoon of 6/12 was much improved, and better 6/13 and stable on 6/14 (after she was discharged from the hospital).

That temporary atelectasis (patchy collapse of lung ventilation capacity by mucous plugs) would not cause any permanent damage to her lungs.

Her blood oxygen levels were almost always over 90% with little extra nasal oxygen.

In my opinion the Surgical and Nursing care was good. The nurses' notes are very detailed and document exactly what should be done in such a post-operative patient.

Rudeness should not be allowed, but I can not assess any damage directly from her impression of what occurred. The hospital President said " …and we acknowledge that our staff could have done a much better job of caring for you." I doubt he read the medical records including every page of the nurses' notes as I have done. It seems more like a "political" generic "apology" than based on the hospital documentation of very competent care of a complex post-operative condition.

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Lung cancer with pneumonectomy (lung removal surgery), post-operative hemorrhage, re-operative, pneumonia in remaining lung and death.

According to the records, the patient coughed up blood and had a chest x-ray that showed a tumor mass and a CAT scan confirming this 3 x 4 centimeter irregular lesion that was consistent with lung cancer. This was in the right upper lobe. On the right side of the chest, the lung has three lobes, or segments, each supplied by a separate artery system and bronchial tube division.

He had pulmonary function studies that revealed adequate lung function for the operation, which would hopefully be curative. According to the records, the risks and complications of the procedure were reviewed with the patient by the surgeon, Dr. #1, and the patient consented to the operation.

The patient had a history of cigarette smoking but had stopped for about 5-6 years. However, there would be lung damage that, to some degree, was irreversible. Because of the cancer, operative intervention was the treatment of choice considering the absence of obvious metastatic cancer to any other part of the body.

Surgery took place on August 31. Dr. #1 describes the operation as being performed in the usual and standard manner, and the Operative Report was dictated by him on the same day of surgery, which would assure some accuracy. He initially hoped to remove the right upper lobe, or possibly the right upper and right middle lobes, and spare the right lower lobe. A sampling of the lymph nodes (the site to which lung cancer frequently spreads) was initially negative.

At the start of the operation, he had removed the right upper lobe. He said, "the anterior arterial branch was divided between heavy silk ties and 4-0 Prolene (nylon) ligatures and the upper lobe pulmonary vein was likewise divided." This lobe was separated from the right middle lobe, and it appears that he removed the right middle lobe to gain further access to the remaining pulmonary arteries.

At this point in the operation, a lymph node that was just on top of the pulmonary artery going to the upper lobe segment was sent to the pathologist for a frozen section (instant examination by microscopic evaluation) and was returned as positive for cancer. He then said, "at this point, because of the lymph node being fairly close to the line of resection (the site of the surgical excision), and having negative lymph nodes elsewhere in the mediastinum (central portion of the chest) we decided to perform a pneumonectomy (removal of the entire right lung) to get a cleaner margin (to have a higher cure rate)." The remainder of the operation clearly describes removal of the rest of the lung, with tying off of the branches of the pulmonary artery and vein and the bronchial tube. The chest was then sutured closed and the patient taken to the recovery room.

Unfortunately, after the endotracheal tube was removed (extubated), the patient developed shock (low blood pressure and rapid heart rate). The drop in blood pressure responded to rapid intravenous fluid administration, and when the chest x-ray revealed haziness in the right chest consistent with bleeding, the patient was taken back to the operating room. An endotracheal tube was re-inserted, and the chest was opened. The rest of this Operative Report of August 31, for this procedure, which was also dictated on August 31, is a little bit confusing and contradictory.

He first says, "finger control was done of the hilum (the central portion where the lung is attached to the blood vessels) and it was evident that a tie had come off the anterior branch of the upper lobe." He then sutured this over. A few sentences down, he says, "all the other suture lines had already had running layers of Prolene and this particular anterior branch had been treated with heavy tie and 4-0 Prolene stick tie. It was not apparent why this site was bleeding. Both a tie and a stick tie (a suture ligature) appeared to be in place." Thus, in one part of the report he said it had come off, and in the other part of the report he says it was in place. In any event, the patient was bleeding from that chest site and required immediate attention which was given by Dr. #1.

Postoperative bleeding from a ligature coming loose in a pulsating area adjacent to the heart is an unfortunate mal-occurrence, in my opinion. I do not believe it would be from a departure from the accepted standards of care that could be supported by an independent expert.

The patient was timely treated with appropriate fluid, including blood; the shock was corrected rapidly; and thereafter the patient appeared to be stable.

The chest x-ray report of August 31, said, "the left lung appears to be clear and well-aerated." This is postoperatively. Two hours later, some congestion was noted. However, on September 1, the report showed "the left lung remains clear. . ." Later that day, there was some increased congestive-like changes within the lung. This remained unchanged on September 2, and unchanged on September 3. However, on September 4, there were more changes within the left lung that could be consistent with excessive fluid.

On September 5, they said, "stable left pneumonia." Later on September 5, they said it was stable but there was "extensive left lung pneumonia."

By September 6, there was some slight improvement. This was basically unchanged on September 7, but got worse on September 8. It was unchanged on September 9, but more extensive by September 10. The next chest x-ray report was on September 11, and there was no significant change.

The Physicians progress notes are quite detailed. After the pneumonectomy, the patient bled; was taken back to the operating room; the artery was oversewn; and the patient received four units of packed red blood cells. He was stable on September 1 and September 2, however he started complaining of shortness of breath. The patient received oxygen supplementation, including a re-breather mask with 100% oxygen supplementation. A pulmonary specialist, Dr. #2, was called in attendance and noted that the patient might get worse before getting better, and recommended the insertion of an endotracheal tube which was placed by the Anesthesiologist on call. All this meets the standard of care. At that time, the patient's oxygen saturation had improved somewhat while on the ventilator. This was properly managed throughout his course of care by Dr. #2. The patient also received additional blood to increase the oxygen-carrying capacity.

Throughout his care, he was seen by the respiratory therapy department for chest physical therapy, for nebulization therapy to loosen the mucus within the lungs, and for suctioning. Their notes are quite extensive, and their care appears to be proper.

Unfortunately, when patients are placed on a ventilator, they cannot effectively cough. To cough, you have to close your vocal cords and build pressure up within the chest cavity, and then open the vocal cords suddenly for a rapid exhalation which brings up mucus. When the endotracheal tube is in place, the vocal cords are maintained in an open position and the airway through the endotracheal tube is always open. Thus, a patient cannot usually effectively cough. Frequent suctioning is required, and this was done frequently by the nurses and the respiratory therapists.

Though the use of the ventilator increases oxygenation within the lungs, as I mentioned, it does impair the ability to cough and, thus, it is a double-edged sword. It does increase the risk of pneumonia, while keeping the patient alive.

During the course of care, an infectious disease consultant was called in attendance on September 5, and followed the patient throughout the hospital stay. Appropriate recommendations were made for antibiotic therapy.

By September 7, the pulmonologist noted that the pulmonary status was worsening. Because of a concern for infection within the left chest cavity, a thoracentesis (needle sampling of the fluid) was performed. Initially, the culture was negative. However, eventually, the culture showed some germs (Streptococcus), as did the mucus within the lungs during the bronchoscopy procedure (passage of a lighted telescopic tube down into the lungs for examination and removal of fluid for analysis). They also ruled out the possibility of tuberculosis and monitored the antibiotic levels within the blood.

Despite the flexible bronchoscopy procedure performed on September 10, and the use of the ventilator, the patient's condition continued to deteriorate. By September 10, they noted the prognosis was very grim, and this was clearly discussed with the wife and brother. Despite manipulations with the ventilator by Dr. #2, which were appropriate, his condition worsened and the patient died at 2:55 a.m. on September 12.

The pathology report on the lung surgery specimens revealed the presence of the 3 x 4 centimeter (1 inch = 2.54 centimeters) lung cancer and the positive lymph node that was removed during the surgery noted above.

An autopsy was performed, and the only significant findings involved the left lung which showed "organizing pneumonia/lobar consolidation."

Throughout the course of care, there was concern about the amount of fluid the patient was receiving and the amount he was urinating. Appropriate diuretics were used to try to keep the blood volume and body fluid volume in a stable situation. The patient was prone to fluid retention with a delicate balance required not to remove too much fluid because of the propensity to go into shock (labile blood pressure). The records show that appropriate diuretics were used and fluid given to the patient to maintain a normal state as possible. The marked congestion within the lung at autopsy was consistent with the severe pneumonia that developed despite proper respiratory therapy, pulmonary intervention, and antibiotic therapy.

Because of the long past history of smoking, both lungs were not normal. Chronic changes occur to the bronchial tube linings that impair the ability of the lung to clear mucus and secretions, even when the patient is not on the ventilator. The use of the ventilator was required in order to maintain adequate oxygenation of the remaining lung. I want to point out that the left lung is approximately 40% of the total lung volume, because the heart sits mostly on the left side of the chest. The entire right lung had to be removed, and it was a reasonable judgement call by Dr. #1 to remove the right lung at surgery to increase the cure rate.

Based upon my review of all the records, it appears the patient required the operation, had an unfortunate complication of hemorrhage that was immediately noted and corrected, and the patient was stable and improving for two days postoperatively, at which time he developed increasing shortness of breath. He required intubation and the use of a ventilator to maintain oxygenation, and he had appropriate consultations by a pulmonologist and infectious disease consultant with proper medical care given. Unfortunately, the patient developed a progressive congestion within the lung, overwhelming pneumonia, that resulted in the inability to adequately receive oxygen despite proper attention, and that caused the death of the patient.

Based upon my review of all these records, I do not find departures from the accepted standards of care. Different facts would make a signifcant difference in the opinion.

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