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Warning signs

01 May 2005

Mr Y, a 41-year-old father of five, was involved in a high-impact, head-on road crash late at night on a country road. He was wearing a seatbelt and was able to talk to the ambulance crew when they attended. On initial assessment, his BP was 140/90 mmHg with heart rate at 120 bpm.

He was taken to a rural A&E department, then referred to the on-call surgical registrar, Dr Q, at 11.30pm. Dr Q noted Mr Y’s BP to be 90/50 mmHg. After a rapid crystalloid fluid infusion this came up to 140/90 mmHg. He remained tachycardic at 140 bpm. He was correctly orientated and had a GCS of 15/15 with good peripheral perfusion and pulses.

Mr Y complained of upper back pain and pain on inspiration. He had extensive thoracic and upper abdominal skin contusions. Dr Q noted tenderness along the whole length of the spine. Chest and cardiac auscultation were normal.

Dr Q inserted a urinary catheter and arranged blood group and save, baseline routine blood tests and relevant x-rays.

Mr Y’s initial haemoglobin (Hb) was 13.3 g/dl. An AP CXR, performed using a portable x-ray machine at 12.05am, showed widening of the mediastinum. There was no evidence of pneumothorax.

The x-rays showed fractures of thoracic and lumbar vertebrae but no other major injuries. There was no on-call radiologist available, so Dr Q interpreted the films in isolation. No out-of-hours CT scanning facility was available at the hospital. Dr Q telephoned Dr V, general surgical specialist, for advice.

The time of the call was not documented. Dr Q reportedly told Dr V of the widened mediastinum, but added that the CXR was difficult to interpret because of the AP view and Mr Y’s weight. Dr V thought Dr Q was not too concerned about Mr Y because of his good general condition and normal haemoglobin.

He advised admitting Mr Y to the HDU on a spinal board for close observation, with repeat Hb estimation. Dr V did not come in to the hospital to review Mr Y, but asked to be informed of any change in his condition.

Mr Y’s urine output was only 126ml overnight despite a fluid input of 7.5 l. When checked at 3.20am, his Hb was 8.9 g/dl; at 6.20am it was 11.5 g/dl. His blood pressure fluctuated between markedly hypertensive and borderline hypotensive. He remained tachycardic and tachypnoeic throughout the night.

Dr V reviewed Mr Y at 7.00am, and found him confused, disorientated and clearly unwell. Dr V noted clear widening of the mediastinal outline on the CXR and arranged an urgent CT scan of thorax. Unfortunately, Mr Y had a cardiac arrest whilst en route to the scanner and died.

Mr Y’s family started a legal claim against Drs Q and V and the driver of the other car involved in the crash.

Expert opinion

Our experts in emergency medicine and cardiothoracic surgery agreed the CXR was grossly abnormal and should have prompted an urgent CT scan. If this was unavailable, then urgent transfer to the nearest hospital with CT scanning and cardiothoracic surgical facilities should have been arranged.

They also thought the excessive fluid input may have induced hypertension, which may have made any aortic tear worse. 

The emergency medicine expert commented: ‘The management of the patient was substandard. Signs of grave physiological upset indicative of serious injury were overlooked.’

The cardiothoracic surgical expert stated: ‘Dr V should have come in to review the x-ray and the patient. Dr Q should have re-contacted Dr V overnight to report the low urinary output, the subsequent haemoglobin results and the raised heart and respiratory rates.’

Given the above criticisms, both Dr Q and Dr V had probably acted negligently. Even so, it was uncertain whether or not early CT scanning and surgery would have saved Mr Y’s life, as the logistics of transfer and work-up for theatre would have taken some hours.

However, his relative youth, lack of significant co-morbidity and initial stability through the first night after his injuries indicated that he had at least an outside chance of survival.

The case was settled for a sum equivalent to £325,000 (US$608,431). The insurers of the at-fault driver paid 50% of the settlement. Drs V and Q were held to be 33% and 17% liable respectively. 

Learning points

The use of protocols for managing trauma patients has been shown to improve outcomes.

If you work in an emergency department, familiarise yourself with your local, current guidelines and protocols.

For a useful overview of diagnostic and management issues in cases of chest trauma, see the following extract from the New York State University’s Department of Surgery’s trauma handbook,