This is a 62-year-old patient who was struck by a vehicle on September 2022. She was taken by ambulance to trauma center and was intubated as a trauma alert due to her combative nature and head injury. A summary of her injuries include nondisplaced fracture of C2 a nondisplaced fracture of c7 right rib fractures and a possible narrowing of the right vertebral artery at the level of c2, in addition, has small subarachnoid hemorrhage.
The neck CT did not show any esophageal injury.
PC was intubated during entire stay and in early October the trauma surgeon was attempting to discuss with the family switching to a tracheostomy. There did not appear to be any complications with the intubation, however was plan for long term care.
The next day, trauma surgeon attempted a bedside tracheostomy. During the procedure the endotracheal tube was retracted and the initial attempts to introduce the needle into the trachea were unsuccessful due to calcification. The surgeon then left bedside to consult with colleagues who were not present at the time. The operative notes states that there were several attempts made and it was difficult in multiple ways due to excessive blood in the airway, excessive secretions and airway size.
There is an additional note from Dr. ***** who came to assist surgeon that the insertion required "more than usual force", also stated there were subsequent attempts to cannulate the trachea that were not successful.
His note also says that "my assumption is I created a false tract outside of the trachea and subsequent chest x-rays revealed bilateral pneumothorases and considerable air in the mediastinum and probably related to attempt at ventilation when the tracheostomy she was in the wrong place outside the trachea"
As a result, the esophagus was perforated and PC developed bilateral pneumothoraces with mediastinal shift and pneumomediastinum and pneumoperitoneum. This required bilateral chest tubes. A GI consults the next day revealed a 2 cm defect of the proximal esophagus it was noted that the defect was too big to close the clips in too high to place a stent it was recommended that the PC be seen by surgery at a different hospital for possible intervention and repair.
2 days later, thoracic surgery team attempted to repair esophageal rupture. 4 days later, new trach was placed with tracheal stent and a PEG tube was placed.
On 10/ 17 she underwent a posterior cervical laminectomy of cervical 7.
On 10/27/22 she underwent exploration of the neck with tracheal repair, total thyroidectomy with tracheal T-Tube placement, as well as EGO, bronchoscopy, tracheoesophageal fistula repair, trachea resection and sternal split; tracheal stent was removed.
10/28/2022 gastrostomy tube jejunostomy tube conversion with IR.
11/ 13 patient coded-patient was recannulated; resulting in TE fistula repair rerupture. Patient downgraded from ICU on 11/18. After discussions with surgeons laryngectomy was advised.
Patient refused laryngectomy. Patient requested secondary opinion from ear nose and throat specialist at 3rd hospital. She was seen by ENT in consultation who offered the patient surgery to repair tracheoesophageal fistula though it would include laryngectomy.
The patient declined stating that she did not want to lose her vocal cords. ENT then recommended for patient to allow for approximately 3 months for vocal cord healing and then consider another surgical approach depending on healing process and outcome. During this hospitalization at this facility, she was treated for pneumonia with sputum cultures growing MRSA.
PC still has difficulty speaking and has pain/disfigurement from procedures.
We are looking for a surgeon to evaluate if this bedside trach complications were a deviation and if the subsequent visits/transfers/vocal cord damages, etc were due to the surgeons mishandling the original procedure.
We have full records available to further review.
Files:
Q: Did the the Trauma Surgeon attempt a bronchoscopy and EGD when he/she had difficulty placing the trach?
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Q: Given the complexities of the patient’s injuries why was the patient’s tracheostomy not performed in a controlled setting?
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Q: How long was the ETT in place prior to the trach placement?
A: —
Do you believe there might have been medical error?
Given the patients scoliosis and Cervical spine trauma , an open tracheostomy should have been performed
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As stated above and the procedure should have been abandoned when difficulty was encountered and there was no indication that a bronchoscope was used.
What makes you a good expert for this case?
I perform over 50 bedside and open tracheostomies per year
How often do you encounter cases similar to this one in your practice?
Once a year, this is relatively rare but a known complication. the sequelae in this case is devastating
Do you believe there might have been medical error?
Based on the anatomy, an injury to the esophagus is very unusual. Perforation of the posterior wall of the trachea through to the esophagus is rare The risk of this complication can be reduced by directing the bevel of the of the introducer needle and dilators caudally (distally) during insertion along with direct observation that the guidewire appropriately migrates towards the carina Management of subtotal tracheal section with esophageal perforation: a catastrophic complication of tracheostomy. AU Caronia FP, Fiorelli A, Arrigo E, Santini M, Castorina S SO J Thorac Dis. 2016;8(5):E337. Herein, we reported a catastrophic condition as the almost complete rupture of trachea associated with esophageal lesion following an urgent surgical tracheostomy performed for unexpected difficult intubation. The extent of lesions required a surgical management. We decided against a resection and an end to end anastomosis but preferred to perform a direct suture of the lesion due to the presence of local and systemic infection. Then, the diagnosis of a tracheal fistula led us to perform a direct suture of the defect that was covered with muscle flaps. Actually the patient is alive without problems. Emergency situations as unexpected airway difficult intubation increase morbidity and mortality rate of tracheostomy also in expert hands. Sometimes these events are unpredictable. Mastery with a number of advanced airway technique should be sought when faced dealing with unexpected difficult intubations and written consent of such a concern should be given to the patient.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Once the procedure is noted to be difficult, a reasonable surgeon would stop, and proceed to the operating room. Choosing between surgical or percutaneous tracheostomy depends upon several factors, including the following: ●Institutional expertise – Percutaneous tracheostomy is a relatively new technique requiring a different skill set to surgical tracheostomy. Percutaneous tracheostomy is generally performed by surgeons, interventional pulmonologists, or intensivists.. ●Select conditions – Surgical approach may be preferred in patients with features listed on the table (table 1). Contraindications for both surgical and percutaneous tracheostomies include: •Uncorrectable bleeding diathesis (eg, International Normalized Ratio >2.0, platelets <50,000 x 109/L). •Hemodynamic instability. •Severe hypoxemia (eg, fraction of inspired oxygen [FiO2] >0.6 and/or positive end expiratory pressure [PEEP] >12 cm H2O).
What makes you a good expert for this case?
Understand the reasons to perform, have done these at the bedside and in the OR. The ability to explain complex medical issues to the court and jury.
How often do you encounter cases similar to this one in your practice?
1-2 year. Most Tracheostomies are done by ENT in our hospital. Still have more experience than most in this area.
Do you believe there might have been medical error?
There is concern on many fronts with this case. It is recommended that there be a provider who is monitoring the sedation in addition to the proceduralist. This would have allowed immediate help and not have to leave the patient to get help. The calcification was likely the cricoid cartilage and likely an approach that was not anatomically sound for this patient. With all the issues, and multiple attempts to get the procedure done, the procedure should have been aborted and the patient reintubated with the oral endotracheal tube and then done a re-evaluation of the situation. With the known 2 cm tear int he esophagus, immediate repair would be indicated rather than waiting 2 days to do the repair.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is clear based the documentation offered that an esophageal injury occurred during the course of the procedure. This is a known complication for this procedure. The delay in repairing the injury is more troublesome. It is also documented that multiple passes were attempted to get the procedure done. It should have been recognized early on and therefore the procedure should have been aborted and the patient reintubated with an oral ETT. Then further evaluation could have been done to assess the reason for the problems encountered during the procedure. It may have been related to the C spine fracture and a hematoma distorting the anatomy.
What makes you a good expert for this case?
I am professor of surgery at a busy verified level one trauma center. I work in a high-volume practice and open and percutaneous tracheostomy is a very common procedure for me.
How often do you encounter cases similar to this one in your practice?
I deal with challenging airways as a significant part of my practice. I am aware of the potential complication with airway procedures, especially in the setting of other injuries that may distort the anatomy such as concomitant spinal injuries. We perform several airway procedures per week in our practice.
Do you believe there might have been medical error?
I do believe there was medical error but esophageal injuries are a known but unfortunate risk factor. I would need to see the operative report but if they used bronchoscopic guidance and visualized the wire and dilators throughout then this would be proper procedure with an unfortunate complication. I suspect this was not the case as this complication would not be likely or frankly even possible if they did that throughout. It is possible to get an introducer needle injury but not a 2cm tear unless the initial needle hole progressed which while unlikely, is possible. Again, review of the records would be helpful here. Tracheoesophageal fistula are notoriously hard to fix and prone to refistulization. If there was too much bleeding conversion to an open procedure ideally in the OR would be an expected next step. It is difficult to tell from the presentation above how much they had. Sometimes in the setting of mild to moderate bleeding the best course is to finish the procedure as the tracheostomy tube will tamponade the bleeding. However, the accepted standard of care in the presence of large volume bleeding is to go to the OR if possible control/repair the bleeding source and complete the operation. Adequate exploration of injury would be warranted as well.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above I suspect a step was omitted in the placement as it is not likely that this injury would occur if all the normal steps with bronchoscopic visualization occurred. This likely made the hole and they should have stopped; proceeded to the OR and fixed things; this would have had the best chances at a definitive fix.
What makes you a good expert for this case?
I place about 100 tracheostomy tubes per year at a busy Level 2 trauma center and stroke referral center. I place these in both a percutaneous/bronchoscopic guidance method and traditional open methods. I am versed with the possible complications and have fixed many injuries at these levels due to trauma and am thus versed in the relevant anatomy and risks/repair strategies. I have been in clinical practice for over 10 years and am the division chair for general surgery and medical director of the Acute Care Surgery program and Surgical ICU at my institution. I am therefore often tasked with record and case review and evaluation.
How often do you encounter cases similar to this one in your practice?
I perform about 100 tracheostomy procedures per year. I have seen complications as have all surgeons. I have not had an esophageal perforation from this procedure but have been called to treat several due to trauma and iatrogenic endoscopic trauma.
Do you believe there might have been medical error?
As described, the percutaneous tracheostomy attempt was difficult requiring multiple passes with the needle guide and more than the usual force. The procedure should have been abandoned before multiple attempts were made that proved difficult due to prohibitive secretions, blood, and trachea size. The bed side percutaneous tracheostomy is a wonderful and convenient tool that can be done efficiently and effective at the bed side. However, minimally invasive percutaneous options should be abandoned when the do not proceed normally. Multiple attempts at access should not be made. The endotracheal tube should have been put back into place and the patient taken to the OR for a conventional tracheostomy under direct vision.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
In order to create an esophageal injury, the force used was enough to perforate the trachea posteriorly and injure the esophagus. This much force and degree of difficulty should give a surgeon pause and take the patient to an operating room to perform the procedure under direct vision.
What makes you a good expert for this case?
I am a general surgeon. In the past I have performed tracheostomy percutaneously and open.
How often do you encounter cases similar to this one in your practice?
Over the last 15 years my number of tracheostomy cases are few as I stopped doing trauma.
Do you believe there might have been medical error?
The patient had a significant injury to her c-spine and head. I have concerns as to why this patient was not taken to o the OR for a controlled tracheotomy.. Her cervical spine should have been immobilized and an attempt at a bedside trach is not the standard of care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Please see above. A bedside trach is indicated for a healthy person not a patient with a protracted ETT or cervical spine injuries.
What makes you a good expert for this case?
I have done trauma for 17 years. Our practice stopped bedside tracheostomies a few years ago. It is safer for the patient to be in a controlled operating room environment. The beside procedure is complicated and high risk.
How often do you encounter cases similar to this one in your practice?
We stopped doing the bedside procedure because of the associated risks
Do you believe there might have been medical error?
Although esophageal perforation is a known complication of tracheostomy, it is a rare complication. Bedside percutaneous tracheostomy is standard practice, however, at the time that the surgeon walked away to consult with colleagues, he should have take the patient for urgent operation and exploration with open tracheostomy, rather than forcing the tracheostomy tube to be done in percutanous fashion. Furthermore, once the esophageal perforation was recognized, there was delay in open repair, which should have been done as soon as the esophageal perforation was recognized in order to maximally heal the wound.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The percutaneous tracheostomy procedure should not be technically difficult, and when there are technical difficulties, the patient should go for open exploration. The error here is in forcing the tube in which "more than usual force," which was the time that the injury to the esophagus occurred - this is a medical error in the procedure and not consistent with the teaching of how this procedure is performed, nor consistent with the recommendations from the percutaeous kit manufacturer.
What makes you a good expert for this case?
I am a trauma surgeon with more than 10 years experience. i have performed hundreds of tracheostomy tube procedures, both percutanous and open, and have had challenging procedures that resulted in complications that were appropriately managed.
How often do you encounter cases similar to this one in your practice?
We have tracheostomy tubes weekly. Complications of tracheostomies are rare and I have only seen 2 esophageal perforations from perc trach in my career.
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