Medicolegal review has the opportunity to become the morbidity and mortality conference of the modern era. This column presents a case vignette that explores some aspect of medicine and the applicable standard of care. I hope to bring a critical emphasis on how physicians think and make decisions, with the ultimate goal of highlighting the lesson to be learned by all.
The more we share in our collective failures, the less likely we are to repeat those same mistakes.
Story:
Mrs. G was a 66-year-old woman with a 6-month history of cervical radiculopathy. Following a routine preoperative preparation, she presented to the hospital on a Friday morning for an elective right anterior cervical diskectomy with fusion of C5-C6 with Dr. Neurosurgeon 1. She was planning to spend one night in the hospital.
Mrs. G had a past medical history significant for hypertension, type 2 diabetes, and asthma. Her drug allergies included codeine. She took her usual blood pressure medication the morning of surgery and she received a one-time dose of IV cefazolin for surgical site prophylaxis.
The surgery was uncomplicated, and Mrs. G arrived to the post anesthesia care unit around noon that Friday. Her initial postoperative course was uneventful until approximately 24 hours later. Mrs. G was complaining of a sore throat that limited her oral intake to the extent that she was unable to eat or drink anything for breakfast on Saturday morning. Mrs. G also complained of severe peri-incisional and right-sided neck/throat pain that required ongoing use of intravenous opiate analgesics. At 3:30 p.m., Mrs. G is noted by the nurses to have right-sided facial swelling. A cross-covering neurosurgeon (Dr. Neurosurgeon 2) is contacted via phone, and a verbal order is placed for Dr. Hospitalist-Consultant to evaluate the patient.
At 5 p.m. Saturday, Dr. Hospitalist-Consultant saw Mrs. G for a routine consult. At the time of the examination, Mrs. G was wearing a soft cervical collar. Her vital signs were: T 37.9 C, P 110 beats/min, RR 14 breaths/min, BP 150/70 mmHg. She was noted to have right-sided facial swelling with an inability to open the right eye because of swelling of the eyelid. Mrs. G denied difficulty breathing or the sensation of throat closing. There was no swelling of the lips or oral mucosa. The lungs were without wheezing or rales. Mrs. G continued to complain of severe pain at the anterior neck incision site. Dr. Hospitalist-Consultant did not remove the cervical collar to examine the incision.
Dr. Hospitalist-Consultant was unsure of the etiology for Mrs. G’s symptoms, but felt the highest item on the differential diagnosis was some sort of unilateral allergic reaction. He ordered dexamethasone, diphenhydramine, famotidine, and neuro checks every 4 hours.
Mrs. G did not improve, and her IV analgesic requirements continued to increase throughout the night. The following morning, Dr. Neurosurgeon 3 examined Mrs. G and confirmed crepitance of the face and neck. A stat CT of the neck demonstrated massive subcutaneous emphysema. She was emergently taken back to the operating room to repair an esophageal perforation. Unfortunately, a 6-month complicated hospital course ensued, which included six additional surgeries on her head and neck. Mrs. G was ultimately left with permanent right-sided nerve damage with limited use of her right arm and hand.
Complaint:
Approximately 1 year later, Dr. Hospitalist-Consultant and all of the involved neurosurgeons were sued by Mrs. G for medical negligence. Mrs. G essentially asserted a delay in diagnosis of her esophageal perforation and, as a result, the perforation enlarged unnecessarily and required a more complex repair with higher likelihood for postsurgical complications. Specifically, Mrs. G asserted that Dr. Hospitalist-Consultant performed a substandard examination by failing to remove the cervical collar and examine the surgical incision. She further asserted that Dr. Hospitalist-Consultant failed to reasonably appreciate the crepitance on palpation of her facial swelling that must have been present that Saturday. Had Dr. Hospitalist-Consultant performed an assessment within the standard of care, further imaging would have been obtained on Saturday and the esophageal perforation would have been identified 12 hours earlier. In addition, Mrs. G asserted that the dexamethasone was harmful to her and furthered her injury by blunting her immune system to the bacteria that was contaminating her mediastinum.
Scientific principles:
Anterior cervical diskectomy and fusion (ACDF) is the most common used decompressive procedure of the cervical spine. The advantages of ACDF are that it requires little manipulation of the spinal cord or cervical roots and allows for removal of both lateral and midline disk herniation and osteophytes. Disadvantages include a small risk of damage to the carotid artery, trachea, esophagus, or recurrent laryngeal nerve. Allergic drug reactions, including angioedema, can occur following surgery. However, unilateral reactions are atypical, if not case report material. If the face is involved with angioedema, the lips and oral mucosa will usually be affected.