By Suzanne Tate, litigation solicitor, and Dr Clare Devlin, medicolegal consultant, Medical Protection
Ms R underwent a shoulder arthroscopy under general anaesthetic and consultant anaesthetist Dr E also administered an interscalene block prior to the surgery for pain relief. Postoperatively she developed a sore throat and hoarseness, and produced some blood-stained sputum, so she was kept in overnight. After discharge the following day, she contacted the hospital complaining of sore throat, difficulty swallowing and otalgia. On readmission, haemoptysis was recorded, together with a hoarse voice and bilateral neck crepitus. She was kept under close observation to ensure her airway was not compromised by the surgical emphysema, which later spread to her face and chest wall.
Over the months that followed she experienced alterations in her voice, which was rough, strained and breathy, and caused difficulty in her recreational singing in a choir. An ENT voice clinic diagnosed muscle tension dysphonia, a functional disorder of the laryngeal muscles, for which she underwent speech therapy, with partial improvement. She also complained of ongoing neck pain.
Ms R made a claim against Dr E for the discomfort she suffered.
Consultant anaesthetist and ENT experts tried to unpick the aetiology of this rare and unexpected complication. Ms R alleged a gross error in needling when Dr E administered the interscalene block, puncturing her trachea and causing the surgical emphysema. This explanation was never accepted by our experts.
Firstly, such a complication has never been reported for an interscalene block. Secondly, there were a number of logical arguments why this was highly unlikely to have been the explanation. The length of the needle used by Dr E meant it was unlikely the tip of the needle would have reached Ms R’s trachea from its entry point – certainly not without inserting the needle right up to its hub and probably applying further pressure.
For the needle to reach the trachea from its point of entry, it is likely to have passed through the carotid artery and surrounding structures, which would have caused immediate and significant complications, which did not occur during Ms R’s surgery. Also, the tip of the needle used was so fine that a simple puncture was unlikely to have been sufficient to allow air to escape. The trachea is sometimes punctured with a needle for other therapeutic reasons and this does not lead to surgical emphysema. Our ENT expert thought the tip of the needle would have had to have been used to scrape the trachea in a knife-like motion in order to cause a laceration sufficient to allow air to escape.
Experts on both sides had ruled out a pneumothorax, or air escaping from insufflation of the surgical site in the shoulder, as possible causes.
The remaining and most likely explanation was a rupture of the trachea during intubation. Whilst rare, this is a recognised and non-negligent complication of intubation. This explanation was not accepted by Ms R’s experts, but if this explanation had been preferred by a court she would have asserted this was also negligent. There, was, however, no evidence of any negligence on Dr E’s part during the intubation period.
We defended the claim in full and made no offers at any time. Ms R pursued her claim for three years, right up until the days before a full trial, when she discontinued her claim. Dr E was happy with the level of expertise and robust support from his Medical Protection legal team, who were determined to fight the case at a full trial if needed.
If this case had occurred in New Zealand there may have been a complaint to the Health and Disability Commissioner (HDC). The usual process would be that the HDC would ask an anaesthetist to provide an expert opinion regarding the potential causes for Ms R’s symptoms. It is likely that an HDC expert would draw similar conclusions; that there is no breach of the Code of Patient Rights on the part of Dr E.