Case Archive
 
Pulmonology
Ref. # 637401

In a premises liability case, a 78-year-old man was swimming at a health club for about 30 minutes and experienced difficulty breathing. He was transported to a hospital, where he complained of burning and pain in his lungs due to "fumes in the pool." Several other individuals noted the fumes at that time and experienced respiratory irritative symptoms. He gave a history of having smoked a half of a pack of cigarettes everyday for 40 years, and averaging 3-4 beers and one glass of wine consumed per day. He was tachypneic (respiratory rate of 38-40 per minute) and noted to have prolonged expiratory phase without audible wheezing. Blood gases on 4 liters of nasal oxygen showed a pH of 7.39, pCO2 of 38, and a pO2 of 119. Because of history of heavy alcohol intake he was treated with Librium, thiamine, and folic acid for possible alcohol withdrawal. He also received inhaled bronchodilators and parenteral corticosteroids for possible chemical bronchitis and/or pneumonitis. The following morning the patient was much improved: respiratory rate was 22 with no wheezing. Pulmonary function tests (PFT's) demonstrated moderate obstruction. Chest CT scan revealed extensive bullous emphysema along with a small nodule in the right lower lobe, consistent with a long history of smoking. Blood tests were normal. The next day he was discharged on a regimen of Serevent, Flovent, and a taper of prednisone, along with his previous prescription of PRN Albuterol. Four days later the patient was readmitted for chest tightness and worsening wheezing. He said he had cut down his cigarette usage to 2-3 per day. PFT's were repeated and his Vital Capacity (VC) had dropped to 3.3 liters; Forced Expiratory Volume in 1 Second (FEV1) to 1.28 liters; and FEV1/FVC (FVC stands for Forced Vital Capacity) ratio had dropped from 59% at the initial admission to 39%. He was again sent home on a tapering schedule of steroids along with inhaled bronchodilators and oral Vantin for possible bacterial infection and Diflucan for oral thrush. One month later the patient was admitted again by his physician due to "acutely worsening shortness of breath and dyspnea on exertion." Vital signs were normal, as were chest CT and tests for pulmonary emoblism. A medQuest pulmonologist reported the plaintiff suffered an exacerbation of his underlying Chronic Obstructive Pulmonary Disease (COPD)/emphysema due to apparent fume exposure and resulting in the first two hospitalizations. However, there is no evidence this long-term smoker suffered any long-term effects from this exposure. The initial CT scan documented substantial lung destruction of the type typically seen with COPD. His pulmonary functions, while transiently depressed at the time of the incident, subsequently improved to a predictable level. Assuming the odor and irritation were the result of chlorine (or other noxious fume), the episode was not prolonged and repetitive enough to result in long-term respiratory disability.

Pulmonology
Ref. # 86397

A 36 year old Maryland woman suffered from dysfunctional uterine bleeding which was unresponsive to hormone treatment. A hysterectomy was elected. Pre-op the anesthesiologist noted diagnoses of obesity, thyroiditis and sleep apnea. The physician gave the patient the names of two otolaryngologists to evaluate the sleep apnea after she recovered. The surgery was uneventful. Post-op the patient was given a PCA pump allowing a maximum dose of 12 mg/hr of IV morphine. She was transferred to a typical medical-surgical floor where, four hours later, the nurses found her without vital signs. Resuscitative efforts were unsuccessful. The principal findings at autopsy were non-caseating granulomatous inflammation affecting the lungs, liver and spleen, consistent with sarcoidosis. Moderate right ventricular hypertrophy and involution of the thyroid were also noted. The pathologist opined the cause of death was respiratory failure secondary to severe pulmonary sarcoidosis. A medQuest pulmonologist reported the cause of death was not sarcoidosis. There are only rare cases of patients expiring from this condition and those that do follow a downhill course for years, showing numerous symptoms, such as shortness of breath, which this woman never displayed. Given her medical history, it is probable she succumbed to hypoxemia secondary to narcotic-induced respiratory depression superimposed on sleep apnea. Since the patient was not monitored, her condition was not recognized until after she had suffered cardiac arrest.

Pulmonology
Ref. # 52928

A 31 year old West Virginian man with a prior medical history of deep vein thrombosis and phlebitis was seen in an urgent care center for hemoptysis, chest pain and low-grade fever. He was diagnosed with upper respiratory infection and discharged. Three days later he presented to a local ER, where he was diagnosed with pulmonary emboli. A Greenfield filter was placed and the patient was intubated. Subsequent to extubation the patient went into respiratory distress and cardiac arrest. CPR was unsuccessful; the patient died in the OR. A medQuest pulmonologist found negligence at the urgent care center for failure to diagnose the pulmonary emboli. Timely diagnosis and treatment would have improved the patient's chance for survival.

Pulmonology
Ref. # 25228

A 41 year old Pennsylvania man underwent a cervical spine discectomy and fusion for recurrent neck and arm pain. As the surgery was concluding, the CRNA left the OR to go to the restroom. Upon his return he discovered possible equipment malfunction and determined the patient's pulse rose from 80 to 104 and oxygen saturation had dropped to 65%. The patient's blood pressure dropped and the CRNA ventilated him by hand. Oxygen saturation returned to 100% 30 minutes later and the patient was moved to the recovery room, where he exhibited neurological posturing and seizures. A brain CT scan was negative. Neuroleptic malignant syndrome and pulmonary embolism were ruled out. The diagnosis was hypoxic encephalopathy due to the 15-30 minute period of hypoxemia in the OR. A medQuest pulmonologist opined the hypoxia was caused by malposition of the endotracheal tube into the right mainstem bronchus. The attending anesthesiologist and anesthetist negligently failed to prevent, recognize and correct the malposition. Further negligence included the failure to maintain proper monitoring equipment in the OR, for which the hospital is partly responsible. The patient's brain damage was preventable.




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