A 77-year-old woman with a history of breast ca and tobacco use presented to the hospital for a VATS to remove a right lung mass.
She met the anesthesiologist in pre op and signed a consent form.
The anesthesiologist was working with an SRNA rotating through cardiothoracic in this teaching hospital.
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The patient was induced.
After successful placement of the DLT the surgeon performed a bronchoscopy which per documentation is his usual practice.
The case was canceled and the patient extubated, monitored in the ICU, discharged, then returned at a future date to have her surgery.
She claimed damages from the intubation.
An ENT evaluated her.
An anesthesiology expert was hired by the plaintiff.
8. Placement of a DLT is more difficult than single lumen intubation, in part because the tube has a greater diameter than a single lumen tube; further, once the tip of the DLT has passed the larynx or vocal cords, the tube must be rotated 90 degrees in order to adequately position it into the mainstem bronchus.
9. On June 30, 2016, ██████████████, an SNRA, was at the end of a month-long rotation through cardiothoracic anesthesia at ███. DR. ███████ was the anesthesiologist responsible for supervising Mr. ████████ that day.
10. At the time, DR. ███████ did not know the number of DLT intubations Mr. ████████ had performed on his own and wasn’t certain whether it was more than five; he was aware that Mr. ████████ had performed at least one DLT by himself that morning under DR. ███████’s supervision (Exhibit F, 37:24-38:11).
11. DR. ███████ said that prior to the procedure, he spoke with the patient and informed her of the risks of DLT intubation, stating that due to the size of the tube, she might experience a sore throat; additionally, prolonged mechanical ventilation might preclude removal of the breathing tube at the end of the procedure (Exhibit F, 58:19-60:3, 60:4-14). He said he did not remember telling her about any other risks (Exhibit F, 60:4-14).
12. He did not inform the patient that the SRNA would be inserting the tube (Exhibit F, 60:18-25).
13. It is estimated that over 600,000 DLT intubations are performed annually in the United States. Of that number, tracheal tears are extraordinarily rare. Indeed, DR. ███████ did not even inform Mrs. ███████ of the risk of a tracheal tear from the DLT intubation. DR. ███████ said he had never injured a patient while placing a DLT (Exhibit F, 80:10-14). I personally have performed and supervised hundreds of DLT intubations and have never had a tracheal tear.
14. A tracheal tear can occur if the DLT intubation were performed too forcefully or if the tube were pushed against resistance. If a tear occurred as a result of the foregoing, it would be a departure from accepted medical practice.
15. DR. ███████ testified the DLT intubation was performed by Mr. ████████ under his supervision, and that this was a smooth induction without anything out of the ordinary (Exhibit F, 81:15-82:2). After direct visualization of the vocal cords, the student inserted the DLT. After the tube passed the cords, DR. ███████ said he helped Mr. ████████ turn the tube, stating that the turn was a “very critical step of the insertion” (Exhibit F, 83:15-85:2). DR. ███████ said that while the SRNA held the tube, DR. ███████ turned the tube (Exhibit F, 6-12).
16. After the insertion of the DLT, the thoracic surgeon ██████████████████ performed fiberoptic bronchoscopy to check the placement and saw the tracheal laceration (Exhibit E, page 100). Dr. █████ in his operative report states that the tear appeared to be almost through and through full-thickness and he made the decision to cancel the surgery to allow for assessment of the injury and damage (Exhibit E, page 100).
17. DR. ███████ testified that the location of the tear was mid trachea (Exhibit F, 89:3-7).
18. A chest x-ray was performed at 2:32 p.m. while the patient remained in the operating room. The report of 4:16 p.m. states that the tip of the endotracheal tube was seen in the left mainstem bronchus and that “subcutaneous emphysema in the lower cervical soft tissues” (Exhibit E, p. 104). Subcutaneous emphysema is the presence of air outside the airway and in this context indicates a traumatic intubation.
19. The records show that the patient suffered an injury, the tracheal tear, as a result of the intubation, and it is my opinion that the injury speaks for itself. Something occurred which should not have happened. A tracheal tear during a DLT placement is extremely rare, but can not happen without a mechanical precipitating event, such as forceful advancement of the DLT, thereby suggesting that the records may not accurately reflect what transpired during the intubation.
20. As a result of the tracheal tear during induction, Mrs. ███████ suffered injuries. She was transferred to the SICU for monitoring. The records reflect the patient had blood tinged sputum postoperatively and a cough. She complained of pain when swallowing, requiring pain medication. Her lobectomy was deferred to allow time for the tear to heal and she was treated with antibiotics, Vancomycin and Zosyn prophylactically, necessitated by the tear. On follow-up with her pulmonologist on July 6, 2016, the patient reported hoarseness and a sore throat.
21. In conclusion, my opinions with a reasonable degree of medical certainty are as set forth herein, and further, that the injuries and sequellae suffered by Mrs. ███████ were substantially caused by the tracheal tear.
Outcome
The patient died from her cancer several years into the lawsuit.
The estate did not wish to continue the lawsuit.
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MedMalReviewer/Anesthesiologist Opinion
This is the 2nd tracheal tear case that we have seen. The first can be found here and was caused by a bougie. Both tears were in the membranous portion of the trachea, both with instruments known to cause damage. Proper insertion technique of the DLT was a focus throughout this anesthesiologist’s deposition. I am surprised they were able to locate a membranous tear in the mid-trachea if the DLT was inserted and positioned in the carina prior to bronchoscopy. Similar to the bougie case I suspect the instruments weren’t used correctly, this case being more nuanced by the presence of a student as well.
Despite the tracheal injury visualized on bronchoscopy and being the reason for cancellation of the case, this isolated injury doesn’t seem to be the cause of her symptoms. The consulted ENT suspected vocal cord swelling and the tracheal injury secondarily leading to altered respiratory patterns. There seemed to be optimism that without physical deformity some improvement would be seen which is reassuring from an injury such as this one.
An executor of an estate may not wish to continue a lawsuit for numerous reasons. This may include their own physical/mental demands, location to the legal jurisdiction, their own opinion of merit, or when costs are relevant how likely they are to be successful. Here the injuries were not severe, and she died of her cancer shortly after. If she won at trial the jury would award monetary damages for pain and suffering for only a few years. There is a high cost that comes with financing a medical malpractice case and a payout should justify it.
Working with trainees can be a rewarding experience for many of us, but there is some inherent liability as well. Negligent supervision as well as lack of informed consent (SRNA would be doing the intubation) were themes in this case. The answers in this anesthesiologist’s deposition detailing his involvement were a positive look in defending both of these claims. He was clearly involved in the process and controlling the procedure, and he did a good job specifying that. I still suspect there was some element of improper technique as I am not sure what other mechanism could lead to a tracheal injury as this one.
