A young woman was an unhelmeted motorcycle passenger in a crash 4/29/2022. She was brought in as a trauma alert via EMS. She was found to have extensive injuries, including subarachnoid hemorrhage, subdural hematoma, midline shift of the brain, acute respiratory failure, fractures of the face, skull and pelvis, among other things. Her GCS was 13 on arrival, but declined to 8 in the ED, and she was emergently intubated and taken for craniotomy and placement of external ventricular drain.
The patient had a long, difficult hospital course, including complications in early May with the tracheostomy causing a tracheoinnominate fistula and hemorrhagic shock. This was repaired and the patient eventually recovered from it.
By late June, the patient was out of the ICU, off the ventilator and following commands, still with a feeding tube and tracheostomy but mouthing words to communicate. She was medically cleared for discharge as of 6/21/2022, but there were insurance issues with finding an inpatient rehab placement for her. She was working to tolerate a passy-muir valve, but complained that she felt she could not breathe when she wore it. By 7/1/2022 she was eating well by mouth. On 7/5/2022, a rapid response was called because the patient was coughing bright red blood, and according to a nurse's report, there was "blood all over the bed and floor" and a "large bloody mucus plug." The patient remained alert and oriented x3, maintaining her airway, engaging appropriately and with no focal deficits. She was hemodynamically stable, with stable vital signs. The surgery resident ordered a chest x-ray, racemic epi, vascular access team consult, and a lab draw. The chest x-ray impression was "no evidence for acute cardiopulmonary process." The vascular access team tried unsuccessfully to place an accucath, and the patient refused further attempts. The surgical trauma team progress note for that day reads: "She was having some bloody secretions from her trach today. There is no evidence of any significant bleed. Likely there is some irritation within the airway from the tip of the tracheostomy tube. We will continue as needed suctioning...." The patient continued coughing small amounts of thin, bright red blood throughout the day and evening.
Around 02:27 the next morning, 7/6/2022, a code blue was called after nursing staff found the patient unresponsive and in PEA arrest, with a "significant amount of bleeding" from her mouth and tracheostomy. The patient was unable to be resuscitated, and time of death was called at 02:46. An autopsy found that the patient died due to hemorrhagic shock from diffuse alveolar hemorrhage caused by blunt force trauma.
Files:
Q: What evidence of blunt chest trauma was available early in the patient's course: chest CT demonstrating fractures, pulmonary contusions, etc?
A: —
Do you believe there might have been medical error?
This patient should have had a bronchoscopy at the time she started coughing out blood, particularly given her prior history of tracheo-innominate fistula
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There appears to be a delay in diagnosis, and not moving the patient to a higher level of care
What makes you a good expert for this case?
You need someone who treat trauma patient and this was a multiply injured patient who suffered a significant life-threatening complication that may or may not have contributed to her death
How often do you encounter cases similar to this one in your practice?
This is rare. Though the trauma mechanism and the resultant injury is not uncommon, the complications and the manner of death is unusual
Do you believe there might have been medical error?
The autopsy report leaves a bit of doubt. Diffuse alveolar hemorrhage 2 months after the inciting trauma is very unusual. It is possible that the diffuse alveolar hemorrhage is a result of negative pressure on the lung tissue as expected in a patient trying to breath against an airway obstruction (large clot). It is possible that either she developed an AV fistula in the damaged lung that ruptured (less likely) or more likely she had a rebleed event from her tracheoinnominate (TI) fistula repair (these repairs are known to have a high failure rate). If the tracheostomy tube was located too far distally this would be a source of medical error that could account for the TI fistula. It sounds like there was a sentinel bleed event prior to major hemorrhage and if not investigated fully is cause for error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As noted above if the tracheostomy tube was placed too distally there could be causation, though this is somewhat debated in the literature. Bleeding from a tracheostomy tube must always be treated seriously, especially in a patient with a known history of a TI fistula. It is unclear from the presented note components how much investigation was performed regarding the bleeding to rule out more severe causation. If ignored and/or not documented this would be cause for finding of error.
What makes you a good expert for this case?
I am a trauma/acute care surgeon at a busy Level 2 trauma center and encounter patients that have been involved in high energy mechanism accidents daily. I have not treated a patient with a TI fistula but do encounter pulmonary contusions regularly and patients with similar injury patterns.
How often do you encounter cases similar to this one in your practice?
I regularly encounter patients that present similarly to the described patient prior to the TI fistula. Unrelated subsequent care would be very similar to my normal patient population.
Do you believe there might have been medical error?
It's difficult to ascertain from the information above if there was medical error. This is a multifactorial case with many events that may have posed as risk factors leading up to the terminal event which is likely aspiration of blood leading to cardiac arrest. The autopsy result is likely a red herring as the alveolar hemorrhage from blunt force trauma is likely related to CPR after the initial aspiration event. The crux of this case being potentially being related to medical error lies within a deep chart review to see what factors may have potentially led to the patient's ongoing bleeding from the tracheostomy. What is known from the above information is that the patient suffered a tracheoinnominate fistula which has many preventable risk factors: surgical technique, frequent exchanges of tracheostomy, frequent suctioning, high tension on the ventilator circuit, etc. While saving a patient with this diagnosis was an excellent initial outcome, it is very likely that this region remained friable post operatively and it is possible that the same preventable risk factors I mentioned above may have contributed to ongoing risk of bleeding at the tracheostomy site and led to the patient's terminal event. In order to see if there was medical error in this case, I would have to look closely at the chart to see if any of these preventable factors were present.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above, a tracheoinnominate fistula is a preventable outcome and although it was recognized the first time and apparently addressed, the patient had what appeared to be another herald bleed on 07/05, then proceeded to have a larger bleed which was fatal the following day. I would be interested to see if another CTA of the neck was done to ensure the patient did not have a recurrent fistula. Additionally, the patient likely aspirated blood and sustained cardiac arrest as the actual cause of death. I would need to see if the chart coincides with this and more importantly, what risk factors may have contributed to ongoing bleeding from the tracheostomy site/tract. If there were significant preventable risk factors, there is causation in this case.
What makes you a good expert for this case?
I have performed and managed hundreds of tracheostomies in my career as an acute care surgeon and am well versed in managing complications related to these procedures. Additionally, I have experience reviewing prior similar cases from a medical expert standpoint which makes me a good expert for this case.
How often do you encounter cases similar to this one in your practice?
Management of tracheostomies including post-procedure bleeding is part of my routine practice. Management of TI fistulas is very rare in general, but I have managed several over the course of my career.
Do you believe there might have been medical error?
More likely than not with a large caveat: Based on the autopsy results, the patient died due to bleeding from diffuse alveolar hemorrhage (DAH), and it appears the treatment team missed the diagnosis by ascribing the bleeding to tracheal irritation. It appears that the treatment team didn't pursue workup beyond physical exam and a chest X-ray. The CXR demonstrated no abnormalities, which I might not expect in DAH. Bleeding from a tracheostomy is not uncommon but should certainly raise one's suspicions. That being said, diffuse alveolar hemorrhage is not a common complication after trauma. However it is impossible to really render an opinion without additional information. The brief summary makes no mention of injuries to the chest (eg was there a chest CT demonstrating rib fractures or pulmonary contusions or hemo/pneumothorax). The patient had a prolonged course including respiratory failure. Was this due to neurologic injury or pulmonary injury or ARDS? I would also need more information about the tracheal-innominate artery injury. If anything, I would have been concerned that the tracheal bleeding the day prior to the patient's death was related to a TI fistula. Overall I think more information would be necessary to determine causality.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The missed diagnosis meant that the treatment team couldn't render appropriate care. This may be classified as a failure to rescue from the complication. It is unclear from the summary, but because the vascular access team was called, did the patient not have intravenous access?
What makes you a good expert for this case?
I am an acute care surgeon practicing trauma surgery and emergency general surgery, and I am the medical director of the trauma/surgery intensive care unit at a Level 1 trauma center. I manage patients with severe poly trauma including traumatic brain injuries, blunt chest trauma, ARDS and prolonged respiratory failure. I have managed patients with diffuse alveolar hemorrhage.
How often do you encounter cases similar to this one in your practice?
I have seen diffuse alveolar hemorrhage related to trauma roughly once every year or two. The last case we managed with inhaled TXA to good effect.
Do you believe there might have been medical error?
After sustaining life-threatening injuries and a prolonged hospital stay, the patient had significant recovery and was ready for discharge. She then developed fatal pulmonary hemorrhage more than two months after her initial presentation indicating that it is unlikely that there was a medical error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient had major recovery from significant injuries and succumbed to life threatening pulmonary hemorrhage months after initial presentation. As it is unlikely that there was a medical error, it is less likely there is causation.
What makes you a good expert for this case?
I am an academic trauma surgeon in active practice for nearly a decade. I manage critically injured patients on a daily basis.
How often do you encounter cases similar to this one in your practice?
I manage critically injured patients similar to the one described on a daily basis.
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