January 1, 2010 Journal Watch summarizes a remarkable article entitled “Investigation of incidental findings on cardiac CT.” The article was based on a study conducted at a Canadian institution where the investigators evaluated the incidence, clinical importance, and costs of these incidental findings.
It’s first important to note that these researchers used the word incidental as equivalent to the word, occult. In medical imaging, an occult finding is an unexpected finding that has clinical consequence. Such findings are made with great frequency and have dramatically improved the lives of many. For example, a chest x-ray searching for a rib fracture reveals a lung cancer mass which was otherwise completely unexpected. A CT scan of the abdomen performed because of a complaint abdominal pain reveals a dissection of the thoracic aorta.
The Canadian researchers are strangely troubled by the discovery of unexpected conditions. The test they are evaluating is cardiac CT. Imaging data obtained during a cardiac CT includes imaging information of structures or tissues outside the heart. in an examination of 966 consecutive patients who underwent cardiac CT during 12 months at a single Canadian institution, incidental findings were noted in 401 patients. 12 of the patients were found to have clinically significant conditions, many of them, life-threatening without treatment.
Even if one accepts the very conservative assessment that only 12 of the patients were found to have clinically significant conditions, that means that 3% of everyone who had a cardiac CT performed had a condition that might have seriously harmed or killed them if it had not been accidentally seen in this study.
The researchers do not see the benefit derived by the 3% as a bonus. They don’t question that all the patients benefited from having a cardiac CT. In fact, no one questions that this method of scanning provides an important and noninvasive method of evaluating patients suffering coronary calcification and arterial disease. However, 68 patients exhibited incidental findings such as nodules or cysts in the lungs or liver. There’s the rub.
Confronted with 68 patients of the 401 who had abnormalities deemed to be indeterminate (undetermined significance) researchers worry that the abnormalities found might lead some to conduct further testing or evaluation. The solution, as they see it, is to not format the data concerning non-cardiac tissue and structures. They want to ask patients to consent to keeping the non-cardiac information invisible. If they see no “evil”, they need speak no “evil.”
The mother heard speaking in the above ad was present when a teenage driver recklessly careened down a quiet street striking her young son. The teen pulled into the nearby driveway of his home not even having realized he had hit and dragged the child. Miraculously, the child had only suffered severe scrapes and bruises.
The child was promptly taken to an emergency department of a large teaching hospital where a thorough survey confirmed the child had suffered no head injury or internal injury and the family was relieved. During the course of the various studies that were performed an endotracheal tube was inserted through the child’s mouth and into his airway to assure control over the child’s breathing should an, as yet, undetected injury to the lung or the space surrounding the lung be present. Because the child naturally resisted having a tube in his throat and respirator breathing for him, the child was chemically paralyzed so that he could not interfere with the respirator breathing for him. Though by end of day the tests were all negative the tube and respirator were left in place.
The child was transferred out of the emergency department to a monitored unit with the plan being that the tube and ventilator be removed the next morning.
That night, while a physician was teaching a less experienced resident physician to perform a procedure on the child the tubing connecting the respirator to the endotracheal tube in the child was unintentionally bumped by the doctors and the endotracheal tube was displaced such that the respirator was no longer ventilating the child. This event went unrecognized because alarms on the ventilator designed to warn immediately and loudly of the occurrence of such an event had been turned off. The disconnect was not therefore discovered until the child was virtually in cardiac arrest. Though the child survived following resuscitation, brain injury which resulted from the tube displacement and ensuing respiratory failure left him initially comatose.
The child’s mom and dad though present in the hospital were not in their child’s room when this catastrophe occurred. When they saw their son the next day they weren’t alarmed that he wasn’t moving because they knew he was chemically paralyzed. Excuses were given for why the child wasn’t removed from the ventilator that day and required continuation of the paralytic drugs for another day or so. Then the paralytic drugs were removed and the child was successfully able to be removed from the ventilator and have his endotracheal tube removed and he breathed on his own. He did not however wake up until much later.
Doctors provided the family with no explanation for why their child who had been admitted for bumps and bruises was now in coma. The delayed resuscitation of their child and the physicians’ role in unintentionally displacing the endotracheal tube was not disclosed.
These unique circumstances led the parents to contact a lawyer. I had the privilege of being the lawyer who was contacted. My investigation revealed that the child had an unexplained need for a resuscitation because of an allegedly sudden drop of oxygen levels in his blood which coincidentally occurred at the same time that the child’s endotracheal tube suddenly became displaced for no particular reason. Being a former respiratory therapist who had worked with respirator-dependent patients for many years, I was well aware that, in this child who had no lung disease or lung injury, there would not have been any sudden drop in his oxygen level from a displacement of an endotracheal tube because such a displacement would be immediately recognized if the alarms were properly set.
Eventually, I was able to discover and establish that the airway accident was easily avoided and that improper monitoring had led to such a delay in the recognition that a tube displacement had occurred. The child was needlessly suffocated and anoxic brain damage had occurred.
Because of requirements of confidentiality imposed by a state agency on all medical malpractice cases, I am unable to report the means by which I was able to discover and prove the truth. Similar confidentially requirements also prevent me from reporting the method or means by which Paul Giuffre and I and other lawyers of Meyers Giuffre Evans & Schwarzwaelder were able to help this child and his family meet the many economic and other challenges they faced.
This story is just one of many such stories untold. Regrettably, because so many of these stories are untold, many victims of malpractice are unaware of what happens and where it happens and that it happens in every hospital.
When unexpected tragedies occur and doctors have inadequate or suspicious explanations, an experienced lawyer may be the only way victims can ever discover the truth. By then taking action victims are no longer powerless. Indeed, they help make the healthcare system better. After all, you cannot fix something you don’t think is broken.
The Archives of Internal Medicine, June 22, 2009, published results of a retrospective medical record review involving nineteen community based and four academic medical center primary care practices. The researchers were intent upon examining how frequently patients were not informed of clinically significant abnormal outpatient test results. The researcher’s conclusion was that it is common [...]
According to Alan Mozes’ report, Monday October 10 in Health Day Reporter, a new study suggests more than 12 percent of cancer patients in the U.S. are undiagnosed initially. Apparently this leads to treatment delays and lost opportunities for better outcomes.
The study was conducted by a team of researchers from Canada, China and the United [...]
Each year many die of multiple myeloma. It is a cancer principally affecting bone but capable of metastasizing to the lung and soft tissue. A man or woman in their 40’s or 50’s suddenly suffering a fracture of some spinal element without any precedent trauma that they can recall is certainly a possible victim of [...]
According to the CDC 99,000 people die annually from hospital-acquired infections. As Betsy McCaughey Ross, the former Lieutenant Governor of New York put it, “You don’t often come across such a big problem that you can prevent.” McCaughey started the committee to reduce infection deaths in New York.
In Pennsylvania we suffer similar problems from hospital-acquired [...]
