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Incorrectly Positioned Catheter Causes Woman’s Heart Failure
A 42-year-old Arizona woman entered the hospital for what should have been a non-life-threatening condition and died because the hospital and the three physicians who were responsible for treating her failed to meet the applicable standards of care.
The patient was admitted to the hospital by her gastroenterologist with a presumed diagnosis of Crohn¹s disease, an inflammatory bowel disease that causes inflammation in the intestines. The gastroenterologist ordered a central venous catheter in order to administer IV fluids and a liquid nutritional supplement. (Patients suffering from Crohn¹s disease require additional nutrition because the disease prevents their small intestine from absorbing nutrients.)
On the gastroenterologist’s orders, a general surgeon performed the catheterization procedure. However, the surgeon incorrectly positioned the catheter in the right atrium of the patient’s heart. A central venous catheter must be positioned in the superior vena cava, above the pericardial reflection; it should not be positioned in the heart.
The surgeon discovered that the catheter was in the wrong position after reviewing chest x-rays, but contrary to medical standards of care, he left it in the misplaced position, and ordered that it could be used in that position. He did not inform either the patient or the gastroenterologist of the error or that the incorrectly positioned catheter could perforate the heart, causing the IV fluid to collect in the space between the heart and the pericardial sac that surrounds it. The collection of fluid in the pericardial sac inhibits the heart from expanding and pumping blood. This condition, called a cardiac tamponade, is an emergency condition that can lead to heart failure.
When the gastroenterologist discovered that the catheter was positioned in the patient’s heart, she did not adhere to medical standards of care: she did not reposition the catheter, nor did she request that the surgeon do so. She left town to attend a medical conference, without informing the on-call physician of the misplaced catheter, which was infusing IV fluids and liquid nutrition into the patient’s pericardial sac.
The patient awoke one evening and complained of chest pain and chest tightness. Her blood pressure was 68/44; 130/85 is considered normal for women age 18 and older. The nurse contacted the on-call physician, who ordered diagnostic tests. The on-call physician did not follow procedures that would have been consistent with the standard of care: he did not order the patient to be transferred to ICU immediately for intensive monitoring; he did not go to the hospital immediately to assess her condition; he did not order physicians who were at the hospital to her assistance; and he did not order fluids to increase her blood pressure and stabilize her.
The patient’s condition continued to deteriorate over the next hour and ten minutes—until a code was called—but it was too late. The autopsy demonstrated that the catheter had perforated her heart, and that her pericardial sac had filled with the liquid nutritional supplement, causing an acute tamponade and cardiac arrest.
Following her death, the patient’s husband and adult children filed suit against the hospital and the three doctors overseeing her care, alleging medical malpractice and wrongful death. The hospital settled the case before trial, but the three physicians defended themselves in court. On the last day of the trial before closing arguments, the three doctors settled the case for a confidential amount. The hospital settled for an additional confidential amount.