Case Archive
Hospital Administration, Anesthesiology, Otolaryngology
Ref. # 599201

A 61-year-old man was admitted to the hospital with a reported history of left-sided chest pain. A diabetic, he had a CVA ten years prior. He was diagnosed with pneumonia and transferred to the CCU. A thoracentesis was performed and the patient was then intubated and placed on a ventilator for respiratory distress. Five days later the endotracheal tube (ETT) required replacement due to an audible air leak. This was accomplished with difficulty. The next day the patient underwent a thoracotomy with decortication for a post-pneumonia left empymena. The next day another air leak developed. The patient requested that the anesthesiologist replace the ETT. The anesthesiologist responded two hours later, extubated the patient, then was unable to reintubate him despite several attempts. The anesthesiologist then paged the in-house general surgical resident with a plan for a tracheostomy. The resident arrived and requested a tracheostomy tray/cart. None was present. The resident unsuccessfully performed a percutaneous cricothyroidectomy with a No. 18 angiocatheter. From a different unit the nurses brought a tray/cart, which did not contain any cuffed tracheostomy tubes. During an emergency tracheostomy the resident used a No. 4 metal trach tube without a cuff, but it did not contain a coupling permitting a connection to the needed ventilator equipment. According to notes, a temporary connection was "rigged" to the ventilator. An ENT resident was paged from an affiliated hospital several miles away. After reviewing the call schedule, he consulted with an attending ENT who was incorrectly listed as on-call for the initial hospital. When the ENT resident arrived he tried to insert the ETT as the anesthesiologist withdrew the No. 4 metal trach tube. The airway was lost. The ENT resident decided to perform an emergency revision of the tracheostomy. Neither the tracheostomy tray nor the bronchoscopy cart contained a scalpel, so the he attached a No. 11 blade to a hemostat to form a makeshift scalpel. The patient lost a large amount of blood, became anoxic and ultimately expired. A medQuest hospital administrator, anesthesiologist and otolaryngologist independently found numerous deviations from accepted standards and procedures. The medical records did not truthfully document the clinical care rendered. A tracheostomy set-- with a scalpel--should have been in the CCU. ICU settings must have cuffed tracheostomy tubes immediately available. The hospital failed to maintain accurate call schedules and contact numbers. The resident physicians were not adequately experienced to manage this airway emergency and no attending physician was available. The anesthesiology resident acted appropriately by calling for help when he encountered difficulty but the ENT resident negligently failed to take the patient into the operating room emergently. Neither the ENT nor anesthesiology resident had ever performed an unsupervised tracheostomy. The deviations were proximate causes for the patient's death and damages. Had accepted standards been met, he would be alive and well.

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