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Case 1: A sticky situation

Created: 9/6/2010
Updated: 2/7/2010

A sticky situation

January 2008

Mr R was a healthy 17-year-old student who suffered with a severe form of palmar hyperhidrosis. Mr R’s GP referred him to Mr F, a cardiothoracic surgeon. Following discussion about possible alternative treatment, Mr R was very keen on the surgical option, so Mr F placed him on the waiting list for a right-sided transthoracic endoscopic sympathectomy.

On the day of the operation, Dr A, consultant anaesthetist, assessed Mr R before going to theatre.

Dr A induced anaesthesia and intubated Mr R uneventfully with a double-lumen endotracheal tube. Dr A then verified its position and the ventilatory isolation of the left lung by auscultation before Mr F started the procedure. Mr F induced a right-sided controlled pneumothorax by insufflating 450ml of carbon dioxide into the pleural cavity. Thoracoscopy port and thoracoscope were introduced and their correct positioning confirmed by visualisation of the upper thoracic chain.

At this point, Dr A alerted Mr F that Mr R has developed neck vein distension and they both noticed sudden swelling on the right side of Mr R’s chest. Mr R developed a supraventricular tachycardia and his blood pressure dropped to 90/50. His O2 saturation at this point was 89%.

Dr A and Mr F quickly agreed that Mr R had probably developed a right-sided tension pneumothorax so Dr A reintubated Mr R with a standard cuffed endothracheal tube and ventilated him with 100% oxygen. At the same time, Dr F inserted a right-sided intercostal drain. Unfortunately, Mr R continued to deteriorate becoming deeply cyanosed. Mr F wondered if Mr R had suffered a contralateral pneumothorax and decided to perform a median sternotomy to decompress both pleural cavities.

The nurses informed Mr F that there wasn’t a sternotomy pack ready because nobody had mentioned that this could be needed. Luckily one of the nurses remembered that they were doing a full list of CABGs in the theatre next door and simply ran for one. There was a delay of about two minutes. As soon as Mr R’s chest was opened there was a dramatic improvement in his colour and cardiovascular parameters. The initial procedure was abandoned and Mr F closed the chest. Dr A supervised the transfer to ICU. A small left-sided pneumothorax was diagnosed with a CXR and a chest drain inserted.

Thankfully, Mr R made a full recovery. He was understandably unhappy with having his chest opened, spending a week in ICU and having a large scar in the middle of his chest. He stated that he would not have undergone the procedure if he had known about the possibility of having to undergo thoracotomy. He made a claim against both Mr F and Dr A with multiple allegations against both doctors, largely concerning their anaesthetic and surgical technique and their reactions to the emergency.

Expert opinion

Expert cardiothoracic and anaesthetic opinion on the case was uncertain as to the exact cause of the disastrous chain of events. Both experts commented that none of the allegations could be upheld and the quick reaction of both doctors to turn endoscopy into open surgery had probably saved Mr R’s life.
However, they were critical of the failure to warn Mr R about the possibility of direct intervention. They also criticised the lack of provision of sternal thoracotomy instruments that was only resolved by chance.

The claim was settled for a substantial sum.

Learning points

• Consent – the doctor taking consent for any endoscopy or keyhole technique has to inform the patient of the possibility of an open procedure. This should be a standard part of the consent. Information leaflets about procedures are a useful way of imparting risks, including the need for open surgery. Any such material should be written in plain English, accredited, peer-reviewed and kept up-to-date. The discussion with the patient and the leaflet that was used should be documented.

• Provision – It is important to give operating theatre and nursing staff adequate briefing prior to any operation. In particular, to advise them as to the nature of the proposed operation, the possible complications and the need for additional equipment. In this particular case chest drains and, in rare cases, thoracotomy equipment might be needed and should therefore be available.

• Elective thoracic endoscopic sympathectomy – It is important that consent is taken carefully, and that patients are warned of the relevant risks. In particular, as in this case, it may be sensible to warn of the risk of converting from an endoscopic to an open procedure.

[Facts have been altered to preserve confidentiality]

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