Failure to order chest x-ray

Presentation

A 68-year-old woman residing at an assisted living facility experienced syncopal episodes that resulted in falls with minor head trauma. The patient’s medical history included an implantable cardioverter defibrillator (ICD) with a pacemaker feature, myocardial infarction, hypertension, and gastrointestinal bleed requiring transfusion. She also had a history of smoking.

Physician action

A neurosurgical consult was obtained during an emergency department visit. A CT scan was ordered and revealed a right frontal meningioma with a mass effect that would require a craniotomy. Phenytoin and dexamethasone were prescribed, and the patient was discharged back to the assisted living facility. A craniotomy would be performed at a later date.

One month later, the patient was admitted to a large metropolitan hospital to undergo the craniotomy. The patient was noted to be more withdrawn and confused than during her initial visit.

The following morning, the patient was taken to the operating room for the craniotomy. The anesthesiologist attempted to place an internal jugular line on each side and was unsuccessful. After some difficulty, a central line in the right subclavian vein was successfully placed.

The craniotomy was performed by the neurosurgeon without complications with an oxygen saturation reading consistently greater than 95%. After the incision was closed, the neurosurgeon left the room to speak to the family. The patient remained intubated and was still under the effect of general anesthesia.

During transfer from the operating room table to the ICU bed the patient went into cardiac arrest. The patient’s pacemaker was noted to be firing but not capturing. CPR was immediately initiated, and a code was called.

The neurosurgeon returned to the operating room to assist. A chest x-ray was immediately ordered. While waiting for the x-ray to be taken, the neurosurgeon inserted a 16-gauge angiocatheter in an attempt to aspirate air from a pneumothorax, which was unsuccessful.

Approximately 10 minutes later, the chest x-ray was taken and revealed a large pneumothorax on the right side, and a small pneumothorax on the left side. A general surgeon placed bilateral chest tubes. After this was completed, the patient was successfully resuscitated and taken to the ICU. The patient’s cardiac enzymes were elevated and consistent with myocardial injury.

The patient’s pupils were mid-position and fixed, and other neurological signs suggested that a severe neurological injury had occurred. A CT scan showed no mass effect. The patient remained unconscious but was able to breathe spontaneously. Over the next several days, the patient’s neurological status did not improve and she never regained consciousness. At the family’s request to terminate life support, the endotracheal tube was removed. She suffered a cardiac arrest the following day and died.

Allegations

A lawsuit was filed against the anesthesiologist. The allegations included failure to order a chest x-ray after the difficult placement of a central line and failure to stop surgery after more than 30 attempts to place the central line.

Legal implications

The plaintiff’s attorney retained a well-credentialed expert to testify that the standard of care of an anesthesiologist after a difficult central line placement is to obtain a chest x-ray before beginning the operative procedure.

He further stated that the anesthesia record contained documented findings of the patient’s clinical deterioration up until the time of cardiopulmonary arrest. The record did not indicate any response of treatment from the anesthesiologist based on these clinical changes. He argued that there was documentation of detrimental sequential changes in pulmonary function during the procedure without evidence of required intervention on the part of the anesthesiologist. He also stated that there was no evidence that the signs of deterioration were discussed with the neurosurgeon at the time.

Anesthesiologists who reviewed this case for the defense had criticisms regarding not taking a chest x-ray after the placement of the central line. They were also critical of the fact that the anesthesiologist did not record ventilation pressures during the surgery. Attempts to find a supportive expert for the anesthesiologist were unsuccessful.

In the deposition, the anesthesiologist admitted to completing the anesthesiology chart before the surgery ended. There were also inconsistencies in reported facts by the anesthesiologist.

Disposition

The case was settled on behalf of the anesthesiologist.

Risk management considerations

We hear about late entries being documented into a medical record. In this particular case, the defendant completed the documentation before the surgery ended. Thus, the contemporaneous entry requirement of the record was compromised. The credibility of the entire anesthesia record then becomes questionable. Documentation of events should only be entered into the medical record as they occur and not ahead of time.1

Omissions of observations and assessments, such as ventilation pressures, during the surgery hindered the defense as well. Lack of documentation can negatively affect the perception of the care provided. A thorough chronological diary of a patient’s care is invaluable to a physician’s defense.