Commentary:
Despite a poor patient outcome, medical expert testimony established the defendant pulmonologist provided the appropriate care and treatment, and the jury returned a defense verdict.
The Case:
A 58 YOWF (5’2”, 180 lbs.) presented to the hospital for a revision of her prior spine surgery. The defendant pulmonologist was asked to consult by the treating neurosurgeon after a pre-surgical chest x-ray revealed bilateral pulmonary infiltrates. The patient’s history revealed she was a heavy smoker and had a chronic cough, and that she had reflux esophagitis, rheumatoid arthritis, and hypothyroidism. Examination revealed no orthopnea, no paroxysmal nocturnal dyspnea, and no edema in the lower extremities. Chest x-rays revealed bilateral alveolar opacities. The defendant pulmonologist diagnosed hypoxemic respiratory failure and possible pulmonary edema. Intravenous levofloxacin, oxygen supplementation, arterial blood gas studies, and repeat chest x-rays were ordered.
The following day, the defendant pulmonologist examined the patient and reviewed the test results. He noted a slight improvement on repeat chest x-rays with respect to bilateral alveolar opacities. Sputum cultures showed only mixed flora with few yeasts. The defendant pulmonologist ordered Diflucan® to treat a possible fungal infection. His impression, based on the chest x-ray, was that the hypoxemia and bilateral opacities related more to an infectious process than fluid. The defendant pulmonologist cleared the patient for surgery since the revision spine surgery was not an invasive procedure. He also a recommended cardiology clearance.
On day three, the patient was reexamined by the defendant pulmonologist. A stress test was negative, and a few crackles were noted in the lungs. The neurosurgeon felt the patient had hypoxemia and canceled her antibiotics. Physicians jointly reviewed the patient’s findings. Due to the lack of improvement and worsening of hypoxemia, surgery was postponed the following day. The patient continued to improve and was discharged home with a full course of antibiotics.
The patient presented to the hospital five days later for outpatient preoperative lab draws and a repeat chest x-ray. The x-ray was interpreted as follows: “Bilateral predominately air space disease located more peripherally in the mid and lower lung regions; this probably reflects infiltrate with edema fluid being less likely; the possibility of eosinophilic pneumonitis must also be considered.”
Two days later, the patient presented to the defendant pulmonologist with stable vital signs. Lung examination revealed only minor crackles. The repeat x-rays showed no significant worsening or active pneumonia. A differential diagnosis included cryptogenic organizing pneumonia, rheumatoid disease-related pneumonitis, and other rheumatologic disease. The defendant pulmonologist recommended to proceed with a video-assisted open lung biopsy at the same time as the planned revision spinal surgery. The neurosurgeon would handle the coordination of surgeries.
The patient was readmitted for spinal revision surgery the next day. The open lung biopsy was not performed due to scheduling issues. Chest x-rays taken on post-operative day one revealed patchy alveolar infiltrates in both lungs that had become markedly more prominent, particularly within the upper lungs. The defendant pulmonologist examined the patient on post-operative day two and noted the patient’s decompensating status, increased dyspnea, hypoxemia, and bilateral lung crackles. The patient’s O2 SAT was 93% on oxygen, and 80% without oxygen. The defendant pulmonologist’s impression was hypoxemic respiratory failure, questionable bilateral pneumonitis, and questionable cryptogenic organizing pneumonia.
Two days later, the patient was diagnosed with profound hypoxemia, a low-grade fever, no dyspnea, and basilar lung crackles. The patient’s O2 SAT was 85% on supplemental oxygen. The patient was transfused for anemia. The defendant pulmonologist’s impression was bilateral pneumonitis and hypoxemia respiratory failure requiring BiPAP/O2. He recommended an open lung biopsy.
The patient was reevaluated the next day. The risks of the lung biopsy were explained to family members, and they agreed to proceed despite risks due to the gravity of the patient’s condition. The defendant pulmonologist performed the thoracotomy and lung biopsy. Two days later, the patient was in respiratory failure with interstitial pneumonitis. She was placed on continued ventilation support, high doses of intravenous steroids, and antibiotics. The biopsy results revealed acute interstitial pneumonitis. Four days later, a tracheostomy tube was placed due to the patient’s continued respiratory failure and inability to wean off the vent. She was also transferred to the ICU.
Four days after the tracheostomy tube was placed, the patient remained critically ill and vent dependent. Discussions were held with the patient’s family to transfer her to a higher level of care/pulmonary critical care, upon bed availability. Three days later, she was transferred with continued current ventilator support. The patient expired from interstitial pneumonitis three days after being transferred.
The patient’s estate brought suit alleging negligent evaluation and pulmonary clearance for revision spine surgery, and failure to diagnose interstitial pneumonia resulting in death. A plaintiff’s expert testified the pulmonologist breached the standard of care by clearing the patient to undergo the revision surgery without an established definitive evaluation of the patient’s pulmonary status. The expert further testified a proper work-up of her lung condition after the first surgery could have saved her life.
Defense experts stated the pulmonologist complied with the standard of care in all respects. The plaintiff’s terminal lung condition required a biopsy be performed as quickly as possible in order for treatment to be initiated.
The jury returned a verdict in favor of the defense.
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