Case Archive
Thoracic Surgery
Ref. # 173001

A 46 year-old Florida man with a 14-year history of hypertension developed the sudden onset of substernal crushing chest pain after walking his dog. He was dizzy and had to lie down to prevent passing out. The next evening he presented to the ER complaining of one hour of chest pain that radiated into his throat, shortness of breath, diaphoresis and palpitations. He was not hypertensive or tachycardic; his blood pressure was 107/53, heart rate was 73. Electrocardiograms showed no evidence of ischemia. A chest X-ray was read as showing a normal cardiac silhouette with the mediastinum appearing somewhat widened, which was thought to be secondary to tortuosity of the aorta. The diagnosis was "stereotypical cardiac related chest pain" and treatment included aspirin, sublingual nitroglycerin and morphine. The chest pain persisted and began radiating into the back. Early the next morning the pain was graded 5/10 and the IV nitroglycerin dose was increased. The "atypical" pain persisted and radiated into the jaw. The IV nitroglycerin and heparin were discontinued. A repeat ECG was normal; two sets of CKs were normal. Throughout the day the patient's blood pressure and pulse gradually increased to 136/74 and 95, respectively. Early that evening the patient became bradycardic and developed electromechanical dissociation. A full code was called. A supine chest X-ray after intubation showed a widened superior mediastinum. The possibility of an aortic dissection was raised. A pericardiocentesis was unsuccessful. The patient expired shortly thereafter. The autopsy revealed an acute type A aortic dissection. The intimal tear occurred in the proximal ascending aorta and the false channel extended all the way down to the iliac artery. Rupture occurred in the intrapericardial portion of he aorta leading to acute cardiac tamponade, electromechanical dissociation and death. A medQuest thoracic surgeon opined the hospital and treating physicians negligently failed to diagnose and treat the aortic dissection. The patient's acute onset of pain, unaccompanied by nausea and vomiting, is more consistent with an acute dissection than an ischemic syndrome. The chest X-ray in fact clearly showed a widened mediastinum which, in association with the patient's clinical presentation and the normal ECG, should have raised the suspicion of an acute aortic dissection. Further evaluation by a two-dimensional echocardiogram, a computed tomographic scan with contrast, or an aortogram would have led to the correct diagnosis. Emergency surgery could have been performed with an approximate 10% mortality. The patient's life would likely have been saved.

Thoracic Surgery
Ref. # 49748

In 1992 an Alabama woman developed acute myelogenous leukemia; it appeared to have been treated successfully. Two years later she was admitted with non-productive cough, shortness of breath, orthopnea, and erythematous papules on the upper and lower extremities bilaterally. A thoracentesis was performed on the left side; the patient arrested in the room sometime thereafter. The autopsy report noted 1600 cc's serosanguineous fluid and 400 cc's coagulated blood in the left pleural cavity. A medQuest thoracic surgeon reported that the thoracentesis was performed appropriately. Thirty minutes after the procedure the patient deteriorated. Abdominal and chest X-rays were taken to determine the cause of the patient's deterioration but bleeding was not considered, as it should have been because it is a known complication. The patient had a reasonable chance of survival with proper diagnosis and treatment.

Thoracic Surgery
Ref. # 65728

A 59 year old Pennsylvania woman with endstage emphysema was admitted for lung volume reduction surgery. During the skin incision the innominate artery and the aortic arch were dissected. Corrective surgery several hours later was unsuccessful and the patient expired. A medQuest thoracic surgery reported that injury to the innominate artery is not an accepted complication associated with a sternotomy. The patient's death was preventable.

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