I sometimes run into a case that is anesthesia-adjacent and choose to include it - this is one such case.
A 71-year-old man presented to the hospital for a colectomy to remove a malignant neoplasm.
Post operatively he was hypotensive and anuric and brought to the SICU.
After obtaining consent via the son, the intensivist Dr. L inserted a Swan-Ganz catheter to measure hemodynamics.
Two days later the patient had improved, and the ICU team decided to remove the SGC.
A junior surgery resident was given this task.
Less than an hour after removal the patient went completely unresponsive.
A code was called when family was at bedside and the intensivist Dr. L stormed in.
The patient was resuscitated but died 1 month later in the hospital.
The removal of the SGC was blamed as the cause of the patient’s demise.
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A CT surgeon was hired by the plaintiff’s attorney to write an expert opinion.
6. It is my opinion, to a reasonable degree of medical certainty that the cardiac arrest and the ensuing complications and death suffered by ███████ were all caused by the negligent handling of the procedure to remove the central line inclusive of ensuring/failing to ensure an adequate occlusive dressing. It is my opinion to a reasonable degree of medical certainty that the effects of the entrainment of air occurred after the patient was moved from his bed to the chair. It is my opinion that the failure to apply and ensure a proper and effective occlusive dressing was a departure from good and accepted standards of medical practice and that this departure was a substantial factor in bringing about the air embolism that caused the cardiac arrest. It is my opinion within a reasonable degree of medical certainty there are two variables involved in this case with respect to the occurrence of the air embolism. One would be the size of the opening into the venous system created by the improper placement of the occlusive dressing and the second would be the rate/amount of entrainment of air. It is my opinion that the entrainment of air sufficient to cause the cardiac arrest would be based upon a combination of these two variables and thus could have occurred anytime from the placement of the ineffective occlusive dressing up to the time the physical and mental effects manifested themselves.
7. While Dr. █████████ was unable to locate any literature to support the proposition that a delayed effect from the introduction of air into the venous system has been documented attached herewith are several articles and excerpts from peer reviewed publications on the subjects of delayed effects of air emboli and slow entrainment of air. These published findings conclude that the delayed effects may not be seen for up to 50 minutes.
8. Dr. █████████ notes in paragraph “11” of his affirmation that “Mr. ████████ treatment providers documented their belief that his cardiac arrest was caused by a pulmonary embolism, which is a blood clot not an air embolus”. If Mr. ███████ cardiac arrest was caused by a pulmonary embolism caused by a blood clot as opposed to an air embolus, one would expect to see significant dysfunction/dilation of the right side of the heart and elevated right-side filling pressures. However, in this case an echocardiogram performed after the arrest was strikingly similar to one performed pre-operatively. There is nothing new or novel about pulmonary emboli causing these right-sided abnormalities of the heart. Using echocardiograms as an objective test to diagnose emboli and to differentiate their causes is one of the accepted methods within the medical community.
9. Dr. █████████'s affirmation completely ignores the fact that the objective echocardiogram test fails to reveal a change and significant dysfunction/dilation of the right heart.
10. Dr. █████████ does not address or even make reference to the objective echocardiogram test, nor does he opine any causation. He doesn't profess to have an opinion as to the cause of the cardiac arrest but claims that, whatever it was, it wasn't from an air embolism.
11. Dr. █████████'s only argument against air embolism is the time difference from the removal of the Swan-Ganz Catheter to the time of the arrest.
12. Dr. █████████ opines at paragraph “26” of his affirmation that “there is no medically or scientifically accepted theory that can establish a causal link between… Dr. ███████'s removal of the Swan-Ganz Catheter and his cardiac arrest. I disagree. It was not a coincidence that the patient became symptomatic shortly after the removal of the Swan Ganz catheter and related introducer and being moved from the bed to the chair.
13. Dr. █████████ relies on Dr. ███████'s recitation of the events even though Dr. ███████ readily admits that he has no memory of the procedure.
14. Dr. █████████ also takes the liberty of interpreting “when” certain events occurred in order to lengthen the time of when the arrest occurred. For instance, he states “that at approximately 4:55 pm, Mr. ███████ began to complain of being short of breath and his children called for assistance”. That is not the testimony. A review of the “code-flow sheet” reveals that at 4:54pm, Mr. ███████ was already “unresponsive” so the arrest had clearly occurred sometime prior to that, the air entrainment prior to that, and Mr. ███████ had obviously complained to his children sometime prior to 4:54 pm and sometime prior to his being unresponsive.
15. The patient's son testified that shortly after his father was transferred from the bed to the chair; “it felt like seconds after they had left the room, he was sitting in his chair… his entire body shook, just like jerked” and that after that he started talking to his father telling him, he's just anxious and then his father just collapsed. Then the son and the daughter went into the hallway and started yelling for help whereupon █████████████ responded. According to her testimony she called for help and someone else called the code.
16. Dr. █████████ states at paragraph “20” that he conducted a “thorough search of the medical literature” and could not find any articles supporting a theory that air introduced as a result of an improperly placed dressing could cause a cardiac arrest 55 or 25 minutes later. Putting aside the fact that the time period between Mr. ███████ being moved from the bed to the chair and the arrest occurring is clearly less than 25 minutes, as stated above there are in fact a number of articles and references in medical texts that discuss delayed effects from air embolism. In Volume 101 Number 3 of the Annals of Internal Medicine in September of 1984 – p. 401 of “Letters and Corrections”, three physicians from the Mayo clinic report an incident with a delay of approximately 15 minutes. In another article from 1973, “A New Complication of Subclavian Vein Catheterization” physicians from the Department of Surgery and Radiology at the Pennsylvania Hospital report a delay of 30 minutes involving a 15-year-old boy. In the textbook Complications in Anesthesiology edited by Emilio Lobato and others (a text book that was favorably reviewed in the New England Journal of Medicine) considers the various methods by which air may enter the venous system and the resultant effects. The conclusion of their analysis reflects that the effects are determined by the amount and speed by which the entrainment takes place and that a healthy heart is more likely to survive a slow entrainment of air than one less so and that the effects are individual but not defined simply by the timing of events.
17. In sum, while no “exact time” period can be identified between the entrapment of air and Mr. ███████' arrest, it was clearly less than 25 minutes and the above referenced literature supports that this could occur. In my opinion, the only way air could have been introduced is if Dr. ███████ failed to place an “effective” air occlusive dressing; the timing of these events is of no consequence.
18. Finally, even ██████████████████████ admitted at his deposition that his agitated response to the code in yelling, “Who removed the f**** Swan Ganz catheter from this patient?” was in response to a similar event at another hospital where a patient suffered an air embolism after an improper removal of a Swan Ganz catheter.
The surgery resident failed to write a procedure note documenting his technique and the removal of the SGC.
The plaintiff’s attorney was also convinced a consent needed to be done for removal.
Here is an excerpt from the defense’s cardiology expert.
8. ███████████ was a second-year General Surgery resident working in the SICU on August 17, 2013, and he was responsible for removing Mr. ███████' Swan-Ganz catheter and the introducer that was in the patient's right internal jugular vein. At approximately 4:00 p.m., after explaining the removal process to the patient, ███████████ placed Mr. ███████ in the Trendelenburg position (the bed was inclined to approximately 45° so that the patient's feet were above his head). After positioning the patient, ███████████ made sure the catheter was disconnected from all equipment and removed any adhesive dressing or suture that was keeping the catheter in place. He then made sure the catheter balloon was deflated so as not to damage a heart valve when pulling the catheter back through Mr. ███████' heart. ███████████ pulled the Swan-Ganz catheter out until the tip of it was within the introducer/sheath, and then he told the patient to take a deep breath and then hold his breath. With Mr. ███████ holding his breath, ███████████ removed the Swan-Ganz catheter and the introducer/sheath in one smooth, controlled, swift motion and immediately placed an air-occlusive, Tegaderm dressing over a piece of gauze placed on the insertion site. He then held that dressing in place for 5-10 minutes until he was confident that the patient was stable and there was no evidence of bleeding. ███████████ does not recall how long Mr. ███████ was in Trendelenburg position but testified that he could be moved back into a normal position at any time after the air-occlusive dressing was in place. There were no complications experienced during removal of the Swan-Ganz catheter and the introducer. Mr. ███████ made no complaints whatsoever and there was no evidence of any bleeding from the catheter insertion site.
9. At approximately 4:30 p.m., approximately 30 minutes after the Swan-Ganz catheter was removed, Mr. ███████ was transferred from his bed to a chair in the SICU. Plaintiff █████████████, the decedent's son, and plaintiff's sister ██████████████ both testified that Mr. ███████ had a food tray placed in front of him once he was in the chair and he proceeded to look out the window of his room. Plaintiff testified that he and his father had “a whole conversation” after his father was seated in the chair.
10. At approximately 4:55 p.m., Mr. ███████ began to complain of being short of breath and his children called for assistance. His nurse, ██████████████████████, noted that Mr. ███████ was diaphoretic and she assisted Mr. ███████ back into bed but recognized that his mental status was changing and his blood pressure was dropping, and she called a Code Blue. The ███ code team responded to Mr. ███████' bedside and they performed chest compressions, re-intubated Mr. ███████ to secure his airway, and administered epinephrine, which successfully resuscitated the patient.
11. Following the code, an ultrasound by █████████ identified a small, mobile blood clot in the right internal jugular vein. A venous duplex scan of Mr. ███████' lower extremities on August 17, 2013 showed blood clots in the intramuscular veins of his calves bilaterally, and a venous duplex scan of his upper extremities on August 18, 2013 showed blood clots in the right internal jugular vein, right cephalic vein at the distal upper arm, left subclavian and axillary veins, left cephalic vein from the proximal upper arm to the distal forearm, and left basilic vein at the mid/proximal upper arm. Mr. ███████' treatment providers documented their belief that his cardiac arrest was caused by a pulmonary embolism, which is a blood clot, not an air embolus. Mr. ███████' treatment providers did not document any problems with the air-occlusive dressing placed by ███████████ nor did they document any suggestion or belief that Mr. ███████ had suffered an air embolism approximately 55 minutes after removal of his Swan Ganz line.
Outcome
The defense submitted a motion for summary judgment - the primary argument was that based on the timeline of events it could not have been an air embolism.
The plaintiff’s responded that there are triable issues of fact at hand and a dismissal is not appropriate.
The surgeon was dismissed from the lawsuit.
The intensivist, surgery resident, and hospital remained on the caption.
The case proceeded to a jury trial.
The jury ruled in favor of the defendants.
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MedMalReviewer/Anesthesiologist Opinion
It is typical for trainees to get dropped as a lawsuit progresses. They are working under an attending in part of a larger hospital system and not exercising independent medical decision making. However, this junior resident stayed on the caption through trial. He performed a procedure by himself, with questions around his technique, that intensivist Dr. L was visibly upset over (although he came up with the plan). I suspect that is why there was no reprieve for him here.
Removing a line can seem a banal uninteresting task, and I have no doubt a junior surgery resident has many tasks to accomplish in a day. Still, documentation would have been helpful in this case. In his deposition the resident said how he typically removes a line and it was a perfect textbook answer. There are 3 relevant forms of evidence: independent recollection, documentation in the record, and usual and customary practice. With minimal recollection years after the incident, and no documentation, the case is based on usual and customary practice of a junior surgery resident. He faced an uphill battle with Dr. L blaming him, and a CT surgery expert saying the line removal was done improperly. It is an unnecessary situation to be in when a few lines of documentation would have strongly supported his defense. He was fortunate to have a favorable outcome.
When emotions run high and there is yelling, cursing, and drama among hospital staff it gets remembered by family. It adds to the feeling that some wrongdoing must have happened. Anesthesiologists as a group are not the type for this, but we work among those who are. It is important to keep professional composure, and a vital skill to defuse these situations. Keep it all away from patient and family interactions.
I could not find an autopsy. A TTE was similar to pre-arrest and I did not see a CTA chest. A venous duplex had demonstrated lower extremity and upper extremity clots. This patient was clearly hypercoagulable with cancer and a recent surgery. Was this a PE? Something else? Do you buy the theory of delayed venous air embolism?
