Man Sues ENT for Wrongful Tracheostomy

Image from ParaMedicine101

In December 2012, a West Virginia man suffered angioedema causing tongue swelling due to a not uncommon reaction from lisinopril. Presumably due to airway concern from the tongue swelling, an urgent tracheostomy (cutting a hole in the throat) was performed.

The patient later filed suit against the ENT who performed the tracheostomy stating that it was unnecessary as the tongue swelling was getting better. [link]

Although a tracheostomy is not always performed for tongue swelling due to angioedema, it also is not unusual to do so, mainly because the alternative outcome is airway loss and death. It is a judgement call on the physicians who are caring for a patient with angioedema whether close monitoring alone is sufficient versus performing a tracheostomy. If the tongue swelling is large enough to cause some airway obstruction, no physician or ENT would ever question the need for a tracheostomy, regardless of whether the swelling "might" be getting better or not.

If one waited until the airway became critical before performing a tracheostomy, the risk of death and complications become MUCH larger. As such, a tracheostomy is performed well before there's any chance of airway loss. (Intubation is not recommended or at times even possible as the act of trying to intubate may trigger airway loss.)

Indeed, the patient who is suing the ENT may not be alive today to sue the ENT if it weren't for the tracheostomy. Instead, it would be the family who would be suing the ENT for wrongful death for NOT doing a tracheostomy.

Check out this lawsuit where an ENT did NOT perform a tracheostomy for airway swelling resulting in death. Here's another lawsuit for similar though under more convoluted circumstances.

Source:
Clay Co. man says doctors performed unnecessary tracheostomy. West Virginia Record. 1/29/14

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Tracheostomy Fire During Surgery Burning Patient

Image from Wikipedia

In early 2012, a surgeon was performing a trach (breathing hole in the neck) when the oxygen used during the procedure caught fire severely burning the patient. Apparently, the surgeon used an electrocautery device which most likely emitted a spark igniting the oxygen being given to the patient leading to the fire. [link]

What happened?

Tracheostomy procedures are performed typically in very sick patients who have been intubated for a prolonged period of time. Often, such patients require higher concentrations of oxygen than normal in order to maintain oxygen levels in the body.

Problem in this scenario is that higher concentrations of oxygen also mean a higher risk of accidental fire when using instruments that help stop bleeding like an electrocautery device.

During a tracheostomy, an opening is created in the windpipe (watch video below). This allows oxygen that is being given to the patient to leak out into the surgical field. If electrocautery is used in this oxygen rich environment, any spark from an electrocautery device can lead to ignition and a flash fire.

Typically, in order to minimize this risk of fire, the surgeon should avoid using any electrical instruments in the surgical field that may create a spark after entering into the airway. Cutting into the airway would allow oxygen to escape into the surgical field. That usually means meticulous surgical technique and controlling all bleeding BEFORE cutting into the airway. If possible, reducing the oxygen given to the patient as much as possible is also beneficial.

Nitrous oxide should be avoided as an anesthetic agent as it is also ignitable like oxygen.

If electocautery use is unavoidable after the airway is surgically entered, the endotracheal tube cuff should re-inflated and advanced past the tracheostomy incision. Vacuum suction should be applied to evacuate as much oxygen from the surgical field and if possible, a period of apnea while cautery is applied.


Source:
Revealed: The chief of surgery who set patient on fire when his electronic scalpel caused 'EXPLOSION' Mail Online. 5/6/12

References:
Airway fire during tracheostomy: prevention strategies for surgeons and anesthetists. Ann R Coll Surg Engl. 2001 November; 83(6): 376–380.

Fatal inhalation injury caused by airway fire during tracheostomy. Acta Anaesthesiol Scand. 2007 Apr;51(4):509-13.

Tracheostomal fire during an elective tracheostomy. Chang Gung Med J. 2005 Mar;28(3):186-90.

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Scam Tracheostomy in Hospital Leading to Arrests

Image from Wikipedia

A Chicago hospital owner and a few doctors were arrested in a horrific scandal involving deliberately over-sedating patients thereby ensuring a patient will not be able to come off the breathing machine leading to the excuse needed to perform a tracheostomy [link]. All done in the name for greater profits.

This scandal is particularly notable given it has come right at the heels of a New York Times story which reported that hospitals often profit from surgical errors, though in this criminal case, it was deliberate rather than unintentional errors.

Tracheostomy is typically performed whenever a patient is on a breathing machine for a prolonged period of time and there is a low likelihood of recovery.

However, prior to tracheostomy consideration, sedation is turned off so that the patient is allowed to wake up and try to breath on their own. If able to breath on their own with machine assistance, the breathing tube may be removed thereby avoiding a tracheostomy.

However, according to the lawsuit, the hospital and physician colluded to over-sedate patients thereby ensuring the patient is "ventilator-dependent" for which a tracheostomy is (erroneously) "justified".

Furthermore, patients who have undergone tracheostomy were intentionally made to stay in the hospital longer than required ("28 days") in order to earn as much money as possible in insurance reimbursements for the hospital.  [link: paragraphs 123-142]

According to media reports, this scam has so far involved 28 patients... 5 who ultimately died within 2 weeks. The most recent unnecessary tracheostomy was performed on March 1, 2013.

Because of the trach and subsequent prolonged hospitalizations, the hospital received up to $160,000 for each patient from Medicare and Medicaid.

There's more... there was a massive kickback scheme whereby the hospital paid doctors to refer cases to the hospital (clear violation of Stark Laws), doctors ordered unnecessary ER visits, and fraudulently referred patients to nursing homes and ambulance services which the hospital had a relationship with.

This awful scam was brought to light by hospital workers (administrators, physicians, and nurses) who secretly worked with the FBI and other federal investigators.

Sources:
Feds raid Sacred Heart Hospital, arrest owner and doctors. Chicago Sun-Times 4/16/13.

United States of America Criminal Case Record. 4/15/13

Hospitals Profit From Surgical Errors, Study Finds. New York Times 4/16/13

Relationship Between Occurrence of Surgical Complications and Hospital Finances. JAMA. 2013;309(15):1599-1606. doi:10.1001/jama.2013.2773.

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Celebrity Actors Who Have Received a Trach (Catherine Zeta Jones Included)

Image Taken From www.TopScarCream.com

Tracheostomy (also known as trach) is when a hole is made in the midline neck directly into a person's windpipe (watch video). Although many people may shy away from this deforming procedure, it can be life-saving.

On that note, here is a short list of famous celebrity actors who have undergone an emergency trach for one reason or another:

Catherine Zeta-Jones
Apparently, when she was a child, she had an emergency trach done. She still has a 1.5 inch scar from this procedure which she elected to not have removed [link].

Gary Coleman
He was hospitalized for 3 months due to complications from thyroid surgery for which he underwent an emergency trach [link].

Watch video of thyroid surgery.

Elizabeth Taylor
In spring of 1961, she developed a case of pneumonia which led to an emergency trach [link].

Christopher Reeve
Of the original Superman fame, he became paralyzed from the neck down after a horse-riding accident. A tracheostomy was required for him to breath due to ventilator dependence. [link]

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Is Patient Abandonment in the Operating Room Ever Justified?

I ask this question mainly because there WAS an ENT who WAS sued for NOT abandoning his patient in the operating room [link]. No way to verify, but additional details can be found in this facebook post.

Imagine this hypothetical scenario (as details from original case are not available)...

You are an ENT surgeon in a rural community hospital performing a fairly difficult but elective sinus surgery on a 12 years old child with cystic fibrosis with extensive pan-sinus nasal polypoid disease. Given the extensive nasal polypoid disease, a fair amount of bleeding is occurring which was not unanticipated.

Suddenly, you get a phone call from the emergency room regarding a patient with progressive difficulty breathing suspected to have epiglottitis.

What do you do if you are the only ENT in the hospital?

Do you "abandon" the 12 years old child in the operating room, still bleeding, still under general anesthesia and attend to the ER patient who himself might die without an emergency tracheostomy? Doing an evaluation to determine how critical the ER patient may take anywhere from 15 - 60 minutes including the tracheostomy itself. Keep in mind that 99% of the time, a tracheostomy is NOT necessary.

And, if a tracheostomy WAS needed, you are now performing two different surgeries in two different rooms simultaneously which must break some rule somewhere... perhaps JCAHO?

Or, would you finish the surgical case first, and than proceed to see the ER patient?

What if you are the only ENT available in the region let alone the hospital? No fellow ENT colleagues to call upon for help. General surgery is "unavailable" or not comfortable with performing tracheostomies especially given ENT performs all tracheostomies in the hospital?

Patient abandonment is defined as:

• Failing to transfer a patient to an appropriate level of care
• Failing to respond to calls from a hospital regarding a patient
• Refusing to care for a patient after arranging the patient's admission
• Failing to treat a patient until new coverage is arranged

Proving patient abandonment includes:

• Your doctor had a duty to treat you - a duty was created when the physician-patient relationship was established
• You had a reasonable expectation that your doctor would treat you
• Your doctor failed to treat you although he or she was obligated to do so
• You suffered injury as a result

Well, according to one lawsuit, it seems that the ENT was required to abandon his patient in the operating room and attend to the ER patient. The lawsuit stemmed from the fact that the ENT did not abandon his patient in the operating room and the ER patient did die as a result of not being attended to quickly and competent emergency tracheostomy performed. Of course, the settled lawsuit also blamed the hospital, general surgery, and anesthesiology.

However, abandoning a patient on the operating room table is also tantamount to medical malpractice according to the very definition of patient abandonment.

And, I would not be surprised if the patient on the operating room table would have sued the ENT if he DID leave the operating room in the middle of surgery to attend to another patient for a long period of time (and even starting another operation without ever finishing the abandoned patient's surgery first).

What to do?

I have no answer...

Doing an emergency tracheostomy is HARD, even for someone who has performed hundreds of elective tracheostomies. I know... I've done perhaps a half-dozen emergency trachs in my career so far. In this particular lawsuit, I found it incredible that a hospitalist (not a surgeon) was the one who finally attempted the emergency tracheostomy (albeit unsuccessfully).

Do you consider the patient you are CURRENTLY caring for has a higher priority than a patient you have never met, even if possible life-threatening illness is involved? (Keep in mind that when called for an airway problem, that 99% of the time, an emergency tracheostomy is not needed.)

OR, do you prioritize the patient you have never met given the possible life-and-death circumstances involved, even if 99% of the time, no surgical airway is required.

What would YOU do? What should you do? Feel free to comment below!

The way I see it, the ENT would have been sued no matter what decision was made. It would have been a lose-lose and lose proposition.

By deciding to stay with his current patient, the ENT was sued by the ER patient's family. If the ENT left his current patient on the operating room table, the ENT would have been sued for abandonment. If the ENT did abandon the current patient and the ER patient still died in spite of an emergency tracheostomy, the ENT would probably be sued for wrongful death by the ER patient's family AND the patient he abandoned on the operating room table.

Source:

Hospital settles wrongful death lawsuit. Curry Coastal Pilot 10/31/12

ADDENDUM 12/5/12:
Information obtained from an anonymous source reported that the ENT who was sued ultimately had charges dismissed with prejudice. It was maintained from the beginning that the ENT's obligation was to the patient on the table and that there was no doctor-patient relationship with the deceased.

I also find it interesting that the hospital where the lawsuit occurred, now does not even have ENT coverage at all. I guess that's what happens when a lawsuit occurs when there's only solo specialist coverage. I'm predicting that this hospital will have a very difficult time to recruit another ENT to work there given this case even though the ENT was ultimately found blameless.

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Creative Ways to Wear a Scarf for Patients with a Trach or Ugly Neck Scar

[Watch the video below!!!]

Given I operate on the neck not uncommonly... a common fear for a patient is how the incision will look afterwards. For a simple neck mass excision, the incision almost always heals just fine to the point nobody will notice the scar.

However, this concern is multiplied a hundred-fold when a patient undergoes a tracheostomy (hole in neck) for severe obstructive sleep apnea or for some other airway reason. It could even be a laryngectomy where the entire voicebox is removed for cancer reasons. 

Who wants everybody to know that there's a hole in the neck... especially for a woman??? Even if there's no hole, sometimes the scar IS noticeable, especially after thyroidectomy, and therefore undesirable.

Scarring from an incision can potentially be addressed with dermatologic procedures, but if no surgery is desired and honestly, what really can be done with a hole defect in the neck... it really boils down to a scarf of some kind to obstruct the neck from causal view.

I mistakenly thought there's only 2 ways to wear a scarf around the neck.

The video below shows 25 ways to wear a scarf! Even if a patient or an individual decides NOT to wear a scarf ever... you should STILL watch the video. The video editing is AMAZING!!!

The actress in the video is Wendy Nguyen who is a prolific fashion blogger who my wife pointed out to me one day.

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Singer George Michael With Tracheostomy

Reuters reported today that singer George Michael suffered from severe pneumonia and underwent a tracheostomy during his hospitalization. A tracheostomy is when a hole is made in the throat for a patient to breath through.

Here is a video of what his trach surgery may have looked like.

Michael apparently was in the middle of a tour when he became ill requiring him to cancel upcoming shows.

A tracheostomy is often performed whenever a patient has been intubated (tube down the throat) on a breathing machine for a prolonged period of time.

For more information on trachs, click here. Watch a video of a trach being performed here.



Reference:
Gaunt George Michael says "fortunate to be here" Reuters 12/23/11

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Nasal Congestion Affected By How Well the Nose is Able to Cool Itself

Researchers at Monell Chemical Senses Center have figured out that nasal congestion is influenced by more than just nasal airflow. Apparently temperature and humidity influence the perception of nasal congestion just as much as how physically obstructed the nose is.

By having volunteers breath air with variations in temperature and humidity, they have determined that cool and dry air minimizes nasal congestion without any change in how open the nasal cavity is.

By taking into account other measured variables, they have deduced that nasal congestion is influenced by how well the nose is able to cool itself from the nasal airflow specifically. The more warm and humid the air is, the less able the nose is able to cool itself leading to perception of nasal congestion.

With actual nasal obstruction, it may be not so much that you can't breath that causes the feeling of nasal congestion, but rather the reduced ability of the nose to cool itself from the absence/reduction of air circulation within the nasal cavity.

So... if nasal cooling influences perception of nasal congestion, this may be one of many factors that may help explain the phenomenon of Empty Nose Syndrome. Patients suffering from Empty Nose Syndrome have an abnormally open nasal cavity from extensive surgical removal of internal nasal structures... yet complain the most bitterly about how congested their nose feels.

This information may also help guide treatment in patients with tracheostomy who also have a totally open nose, but because they breath thru an opening in the neck, have no nasal airflow in the nose which leads to the sense of nasal congestion.

Based on this new research, in these particular patient populations, providing allergy medications like steroid nasal sprays and anti-histamines may not be the best way of addressing nasal congestion.

Clearly, more research is needed on this topic, but certainly opens other new avenues of possible treatment protocols.


Reference:
Perceiving Nasal Patency through Mucosal Cooling Rather than Air Temperature or Nasal Resistance. PLoS ONE 6(10): e24618. doi:10.1371/journal.pone.0024618

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