74 year old female patient is involved in a motor vehicle accident at approximately 1500 wherein her vehicle rolled over after having been struck by another vehicle. EMS notes that she is complaining of SOB and back pain at scene. Lung sounds clear and equal, +nausea. Her initial vitals taken at scene are bp- 154/84, P- 108, RR- 20, O2 stat- 88%. Her GCS is 15. Taken to Level II Trauma Center. No trauma alert/criteria called to hospital by EMS.
1546 Arrives at hospital. Vitals at 1552 are bp- 126/77, P- 103, RR- 28, O2- 81 on RA. Placed on 6 liters O2 and sats are 92%. ED MD evaluates at 1611 and notes patient involved in rollover and reporting moderate chest and back pain. GCS is 14. Abrasion to lower abdomen and tender left chest wall with abrasion. FAST exam normal. He orders CT scans of chest, head, abd/pelvis, spine and chest x-ray. Labs at 1625 show Hgb-13.3 and Hct 40.1. No trauma alert called.
1645 patient's vitals are bp-94/54, P-98, RR-32, O2-89 on 10L. Nurse informs ED MD. Nurse also calls radiology to expedite CT. Charge nurse notified.
1700 Nurse notifies ED MD that patients BP dropped to 83/54 and her O2 is 90% on 10L. At 1715, the bp is 109/53, p-101, RR-40 and O2 is 89%. Patient is then placed on 15l with non-rebreather. At 1730, ED MD notes he informed trauma surgeon of patient's status and that tests were pending. (Trauma surgeon denies this conversation took place.)
The CT chest report is available at 1749 and shows multiple rib fractures and contusion to left lung without pneumothorax. CT of abdomen/pelvis shows contusion of segment 7 lobe of liver, grade 1-2 without extravasation. At 1750, RN informs ED MD that patient is not making sense and is confused. In the meantime, the charge nurse approached a second ED MD to come see the patient given the lack of response of the first ED MD. The second MD asks trauma surgeon to come see the patient with him. At 1800 RN notes patient is lethargic with coffee ground emesis.
At approximately 1800, trauma surgeon evaluates patient. He notes patient to be somnolent with GCS of 10. She was also pale with no distal pulses. He charted that she had a deformity of the left chest with bruising and slightly distended abdomen. She was tachy and hypotensive. He immediately called a Level 1 trauma alert. Apparently, the first ED MD had called a Level 2 alert minutes earlier unbeknownst to the trauma surgeon.
Patient transferred to trauma bay and intubated at 1814, Central line placed and 2 units of RBC and 2 units of FFP given as part of mass transfusion protocol. Pressors also given. At 1820, the point of care Hgb is 8.5 and Hct is 25. ABG drawn at that time shows pH of 7.15, pCo2 of 47 and Hco3 of 16. Left side chest tube placed at 1822 and 400ml of blood drains. Bicarb adminstered at 1830. Patient is transferred to ICU.
As patient was resuscitated with mass transfusion protocol, repeat studies revealed low fibrinogen and very increased PT and PTT. She started to develop red foaming in the endotracheal tube and signs consistent with pulmonary edema. She had an additional 1300ml of drainage in chest tube and a second tube was placed. TXA and 4 units of cryo with FFP, PRBC and KCentra were ordered at 2125 by trauma surgeon.
At 2158, she had asystole and a code blue was initiated. Nurses notes reflect TXA given at 2210. She died at 2223.
Cause of Death on autopsy was blunt trauma. Findings included fractures of vertebral column and ribs, bilateral hemothoraces and hemoperitoneum, pulmonary contusions and friable liver.
I am looking for an opinion related to the care and treatment rendered by the surgical critical care specialist (trauma surgeon). I am also looking for an opinion as to whether earlier intervention (including earlier trauma alert activation) would have likely prevented the outcome either through medical treatment, surgical treatment or both. The patient was not called a trauma alert until nearly 3 hours following the auto accident. For 2 hours she was in the ED waiting for radiology imaging. It appears the only intervention in those two hours other than O2 supplementation was 1000ml of LR when bp was dropping.
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Do you believe there might have been medical error?
Hypotension in a trauma patient is a very ominous and not a common finding: it affects only 7% of patients presenting as trauma activation. Hypotension should have immediately triggered the highest level of trauma activation even if the patient did not meet activation criteria. When a trauma patients is hypotensive, the overwhelming suspicion needs to be to rule out active hemorrhage and start transfusion. FAST should be repeated and if the patient is persistently hypotensive and requiring blood, they likely belong in the operating room not the CT scanner or the ICU. Having said that, the details of the case will matter in terms of transient response to transfusion, chest tube output rate, and CT findings.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Failure to get source control of bleeding leads to trauma coagulopathy with decreased fibrinogen, increased INR, increased PTT and decreased platelets. Once that coagulopthy ensues, it is a bit late So delay in recognition and mitigation is possible as a cause here.
What makes you a good expert for this case?
I am a trauma surgeon and intensivist with more than 18 years experience total and nearly 10 years experience in one of the busiest if not the busiest level 1 trauma centers in New England and the main teaching hospitals of Harvard Medical School. I treat such patients almost on a daily basis. I am also the Director of the quality and safety center that evaluates care across 8 surgical and procedural departments, reviewing similar cases weekly.
How often do you encounter cases similar to this one in your practice?
I see similar injury cases almost on a daily basis. In my safety and quality roles, I review cases with potential delays in recognition of severity on 2 to 3 times a month.
Do you believe there might have been medical error?
Trauma is a difficult field with evolving conditions. Pulmonary contusions most often don't manifest this quickly but when they do they are very severe. This patient should have been intubated at ~1700. Trauma absolutely should have been activated at 1645. This should have been a level one activation at this time due to her hypotension. This is an unstable patient, she should not go to CT unaccompanied by a doctor let alone the 2 hour delay in imaging. I am curious if a hemothorax was noted on CT, no mention made in the documentation above. It is clear to me that the trauma surgeon should have been activated much earlier and their interventions as noted above should have been performed an hour earlier. By the time the trauma surgeon was present the patient was in very poor condition with a high resultant probability of mortality. All of the Trauma Surgeon's interventions were appropriate, with exception that the patient should have been evaluated for surgical intervention for the chest given the high chest tube output (1300mL) though with the severe coagulopathy this may not have been appropriate, I would have to further review the chart. All that aside there is medical error with regard to the ED's response to this trauma and failure to activate the trauma team sooner.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is fault to be found with the ED response but the trauma surgeon's response was appropriate and within the guidelines for resuscitation. I would have to review the full chart and am curious what the response was to the initial resuscitation to determine if she should have been resuscitated further during this time period but given her pulmonary edema concerns (foaming red sputum) this might not have been helpful. In fact surgical intervention at this point might well have been lethal, again I would have to have further details to evaluate.
What makes you a good expert for this case?
I am board certified in general surgery and surgical critical care. I work as a Trauma/Acute Care Surgeon at a very busy Level 2 trauma center for >8 years. I have been the ICU director of my facility for many years and am now the division chair of general surgery at my hospital. Reviewing charts and looking for opportunities for improvement is a frequent job duty. I have also participated in various quality review committees for nearly 9 years including time at my fellowship in Trauma/Critical Care.
How often do you encounter cases similar to this one in your practice?
As a trauma surgeon I encounter cases similar to this multiple times per week.
Do you believe there might have been medical error?
There appear to be both system and provider factors contributing to the outcome. At our level 1 trauma center, the patient would have been a level 1 activation based on respiratory compromise (based on room air saturation). Initial trauma evaluation would have included a chest X-ray to rule out pneumothorax or hemothorax. Persistent hypoxemia and tachypnea would have triggered intubation. With the hypotension, in addition to obtaining large-bore venous access and initiating massive transfusion (as was done), we would have also repeated the FAST exam with plans for emergent laparotomy if positive. Based on data suggesting increased mortality if administered after 3 hours, we would not have given TXA so late in the patient's course.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient was hypoxemic and in hemorrhagic shock. There were delays in recognition and appropriate treatment -- intubation and initiation of transfusions and correction of coagulopathy. Furthermore, there did not appear to be any interventions to achieve source control of the hemorrhage. Lack of extravasation from the liver does not rule out bleeding. Treatments such as bicarbonate and pressors do not address the primary problem of hemorrhagic shock.
What makes you a good expert for this case?
Trauma surgeon at a busy Level 1 trauma center with patients with high acuity (high Injury Severity Score)
How often do you encounter cases similar to this one in your practice?
Our team encounters several a month.
Do you believe there might have been medical error?
This patient arrived as a nonactivated trauma that had a significant change on status and there was a failure to rescue after the patient became hypotensive.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
When the patient had a change in status, it was not recognized and there was a delay in treatment and further diagnostic evaluation (repeat FAST or even laparotomy) should have been done . This patient sat in decompensated shock for 5-6 hours from which she could net recover once it was recognized. Additionally, TXA has a worse outcome when given > 3 hours after injury when compared to giving none at all
What makes you a good expert for this case?
I have 15 years of experience caring for patients with these types of injuries. My practice is 90% trauma and acute care surgery. I have managed many cases that are similar to this oven my career as the operating surgeon, the resuscitating physician and the intensivist.
How often do you encounter cases similar to this one in your practice?
I work at a busy level one trauma center for a large population and we are the only level one trauma center in our city (Milwaukee, WI) and we are a referral center for a large population in SE WI and northern IL. I see patients like this several times per month.
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