A 69-year-old man underwent an attempted TEE with the cardiology service under moderate sedation, but was unable to tolerate the procedure.

He was rescheduled with anesthesiology.

He received propofol and the patient underwent a seemingly uneventful TEE and cardioversion.

Several hours passed and the patient did not appear well. A code stroke was called.

An EGD was performed and a covered stent placed by the GI service.

His condition deteriorated rapidly.

He died the following day.

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The hospital, cardiologist, and anesthesiologist were sued among numerous other physicians involved in his care.

After his death the anesthesiology department physician for quality improvement suggested the attending anesthesiologist clarify some of his documentation, so he wrote the following note.

Outcome

The case settled with the hospital paying the settlement and all involved physicians were dropped.

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MedMalReviewer/Anesthesiologist Opinion

1. The risk of an esophageal perforation during a TEE is less than 0.1%, whereas the mortality from this perforation is around 30%. Some of the risk factors include advanced age, hiatal hernia, and esophageal pathology such as diverticulum, achalasia, spasm. It appears the patient was well sedated for the procedure based on the documentation. The anesthesia documentation I found referenced a propofol bolus followed by an infusion rate at 200mcg/kg/min with no other sedatives given. There was no evidence here the patient fought or bit the probe or did anything that suggested an inadequate depth of anesthesia was achieved when anesthesiology was involved.

2. Retroactive documentation after a bad outcome is a minefield. I’ve seen it absolutely destroy a physician, especially if it was done in a way that tries to make it look like it was done in real time. Surprisingly, the note addition here written by the attending anesthesiologist was at least neutral. It can be a difficult decision to supplement documentation after a bad outcome. There could have been more of an issue if the anesthesiologist attempted to change the LDA portion of the EMR documentation themselves to “fix it” from when RT misdocumented. This would look like the anesthesiologist was attempting to cover something up and could easily be misconstrued. Instead, he stated the reason for his additional documentation, listed the facts where there were errors, and was able to explain so in his deposition when asked about it. If documenting after a complication this is going to be the best way of doing so. My advice would be to always check with your hospital’s legal department or your insurance company before doing this. With all due respect to the physician who is the head of “quality improvement”, they do not have the legal training to provide good advice on this.

3. I can’t really say cardiology holds a lot of blame here for anything wrong. They reasonably attempted themselves and when it became clear moderate sedation would not cut it, they aborted and rescheduled with anesthesia. The procedure then went forward seemingly uneventful. The patient was appropriately monitored and the complication discovered post operatively. None of it seems like an unreasonable timeline to me that would rise to medical malpractice. It was just a low incidence unfortunate outcome, and in this country sometimes that is enough for settlements. As no payments were made on behalf of any physician there is no reporting to the National Practitioner Data Bank. The hospital pays, no physician bears the brunt of this, and the plaintiff gets compensation.