Case Archive
Pulmonology, Critical Care
Ref. # 741101

A 59-year-old woman had a prior history of spinal fusion with iliac graft at L4-5, hepatitis, gastric cancer, and partial gastrectomy. She underwent an elective bilateral total knee replacement for severe degenerative osteoarthritis. The patient's surgery and post-operative course were routine until the following morning, when she became febrile to 100.7. Her fever spiked to 102.2 that evening and rose to 103.6 the next day. The fevers were in the setting of receiving blood. A pulmonologist described the patient as febrile and nauseous with dyspnea and rales. Assessment was respiratory insufficiency with pulmonary edema. Vancomycin was started and there was a 1000-cc diuresis after Bumex. An echocardiogram showed normal left ventricle function with pulmonary hypertension. For two more days the symptoms persisted. An exam described basilar rales. The pulmonologist noted ultrasound results were positive for a deep vein thrombosis (DVT). That evening an orthopedist noted cyanosis without describing its location. One hour later the woman was taken to the OR for Greenfield and venous bypass. The OP note mentioned Phlegmasia cerulea dolens, a severe form of DVT, usually of the vein of the upper leg. The surgeons performed a left iliac-femoral venous thrombectomy with intraoperative thrombolysis and a left-to-right fem-fem venous bypass using PTFEE and a left 4-compartment fasciotomy. Surgical dictation described chronic iliac occlusion with large collateral filling. Post-op the woman became agitated and began "bucking the vent." Subsequent vent parameters suggested relatively good lung compliance not consistent with ARDS. Later that night the patient suffered an asystolic cardiac arrest and died. She had pushed the endotracheal tube out of her mouth with her tongue. A medQuest pulmonologist reported the woman's treatment did not conform to the standard of care. She did not receive adequate anticoagulation after the initial surgery, which resulted in DVT. The diagnostic work-up for the patient's acute dyspnea and hypoxemia was delayed and inadequate. Once DVT was noted, the therapy did not include Heparin and was inadequate and dangerous. Finally, the patient was not given adequate sedation or pain relief, which resulted in her self-extubation.

Pulmonology, Critical Care
Ref. # 58148

A West Virginia man was misdiagnosed with congestive heart failure and chronic obstructive pulmonary disease. After four subsequent hospital admissions over four years he was ultimately diagnosed with sleep apnea and Pickwickian syndrome with chronic nasal obstruction, and successfully treated. A medQuest pulmonologist/critical care expert reported that during one of the admissions an ENT expert diagnosed apparent sleep apnea, which was not addressed. The subsequent two-year delay in the correct diagnosis was unwarranted and the pain and suffering was preventable.

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