Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
Did Radiologist Misinterpret Scan, Leading to Unnecessary Surgery?
A 58-year-old woman with right upper quadrant pain was sent for an ultrasound to check for gallstones. Defendant Dr. C., a radiologist, interpreted the studies as positive for a gallbladder full of stones. The patient was referred to a surgeon, who confirmed the symptoms and performed surgery to remove the gallbladder. When the removed gallbladder was sent to the lab, no gallstones were found.
The plaintiff claimed that she underwent unnecessary surgery and that the defendant had misinterpreted stool within the bowel loop as gallstones. The plaintiff claimed that the defendant should have recommended further studies, such as CT.
Dr. C. claimed that the interpretation of the ultrasound was reasonable and that the surgeon had decided to operate based on clinical symptoms, not just the interpretation of films.
Outcome
According to a published account, a defense verdict was returned.
Comment
Gallbladder disease is often diagnosed based on symptoms alone. The finding of stones only confirms the suspected diagnosis. Alternatively, it is also well known that a finding of gallstones alone, without symptoms of disease, is reason enough to avoid removing the gallbladder.
In this case, symptoms were present, and there was apparently suspicion of stones on ultrasound. It may well be argued that the surgeon would have removed the gallbladder even if stones had not been found. The radiologist error, if it occurred, may well not have changed the outcome.
It would be interesting to know if the defendant’s pain resolved after the cholecystectomy. In any case, it appears that the jury got this one right with a defense verdict. —JP
Intubation Attempt Delayed After Thyroidectomy
Shortly after a 29-year-old Virginia woman underwent a partial thyroidectomy, a neck hematoma developed. Unnoticed for several hours, the hematoma led to massive internal and external neck swelling, which caused breathing difficulty and airway compromise.
When the defendant anesthesiologist was called to the patient’s bed, he determined that the swelling would make intubation difficult or impossible. He decided to wait for arrival of the surgeon who had been called before attempting to intubate.
During the wait for the surgeon, the patient went into respiratory arrest. The anesthesiologist then attempted to intubate the patient, but was hindered by the swelling. Hypoxic brain injury and death occurred.
Plaintiff for the decedent claimed that intubation should have been attempted immediately after the swelling was noted. The defendant claimed that he had acted reasonably and that the neck hematoma was a surgical complication requiring surgical treatment.
Outcome
According to a published account, a defense verdict was returned.
Comment
This case illustrates two points. First, the surgical team must respond swiftly to emergent postoperative complications. Second, if your job involves dealing with airways, your job also involves dealing with airway problems.
Surgical clinicians are popular people—they’re always wanted somewhere else in the hospital. Yet surgeons must respond swiftly to genuine emergent postoperative complications. Post-thyroidectomy hematoma is a potentially life-threatening complication, occurring in between 0.3% and 1% of cases, usually within 24 hours. Signs and symptoms may include neck swelling, neck pain, and evidence of compressive airway compromise (eg, dyspnea, stridor, hypoxia.)
When a hematoma causes airway compromise, the surgical incision must be opened at the bedside to evacuate the hematoma and save the patient’s life. Surgical personnel will likely know this; other bedside responders might not. Potentially life-threatening complications require the surgical clinician’s immediate response.
Clinicians responsible for airway management must have a “plan B,” a “plan C,” and a “plan D” to handle the difficult airway, even if their use is rare. Emergency airway management may be particularly problematic for the anesthesiologist. This clinician is accustomed to dealing with orderly intubations in a well-organized operating room, richly stocked with equipment and ancillary staff—but unaccustomed to being summoned to the bedside of a rapidly deteriorating patient on a ward floor with few support personnel and even fewer supplies.
Anyone in a facility where airway emergencies are possible must be prepared for catastrophe, be able to respond rapidly, have a plan and backup plans, and be intimately familiar with the accompanying airway kit. Ultimately, any clinician responsible for emergency airway management must have well-honed surgical airway skills (including cricothyroidotomy). The clinician is required to spend the necessary time to master, and periodically practice, a perishable skill that may never be used.
In this case, I suspect the plaintiff produced an expert witness willing to testify that the standard of care required bedside release of the hematoma and settled in the malpractice case against the surgical clinicians. In the case against the anesthesiologist, the defendant may have successfully argued that the hematoma prevented him from finding appropriate cricothyroidotomy landmarks, or convinced the jury that an expanding hematoma was itself a relative contraindication to a cricothyroidotomy, according to the standard of care applied to anesthesiologists. For the defense to have succeeded, however, the evidence must have shown that the anesthesiologist was capable of performing a surgical airway but had solid case-specific reasons for not doing so.
In sum, airway issues are a common source of litigation. Have a plan and several contingency plans. “Out of the OR” is not “out of the woods.” Surgical clinicians must be prepared to respond emergently to severe, life-threatening postoperative complications. —DML