Case Study

Case Study

Mrs. Taylor had a 3-day history of progressive fevers, nausea, and vomiting. She presented to

the emergency department at 2:30 a.m., where she appeared to be moderately ill and

dyspneic. Her initial temperature was 38.3 C, her blood pressure was 112/70 mm Hg, her

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heart rate was 118 beats/min, and her respiratory rate was 26 breaths/min. Her oxygen

saturation was 92% on room air. The examination was remarkable for crackles at her right

lung base. The examination of her cardiac, abdominal, and neurologic systems was

unremarkable. Laboratory studies showed a leukocyte count of 1410 9 cells/L with a left shift, a

creatinine level of 1.3 mg/dL (114.9mol/L), and a sodium level of 129 mmol/L. A chest

radiograph showed a dense right lower lobe infiltrate. Bacterial pneumonia was diagnosed.

The patient began receiving levofloxacin, metronidazole, and oxygen and was admitted to the

medical ward of the hospital. A pulmonologist was consulted by telephone about the initial

treatment choices.

At 7:45 a.m., a nurse found Mrs. Taylor profoundly dyspneic and diaphoretic. Her oxygen

saturation had fallen to 69% on 2 L. The patient was immediately placed on a nonrebreather

mask at 15 L/min, which increased the oxygen saturation to 91%. Dr. Harris, who had

assumed Mrs. Taylor’s care that morning, was paged and arrived within minutes.

Dr. Harris found the patient in marked respiratory distress. She had a temperature of 37.6 C,

a blood pressure of 140/88 mm Hg, a heart rate of 140 beats/min, and a respiratory rate of 50

breaths/min. On examination, she had diffuse rhonchi, as well as crackles, throughout the

right lung field. The rest of the examination was unremarkable. An arterial blood gas showed

a pH of 7.41, a PCO 2 of 29, and a PO 2 of 63 (on the nonrebreather mask). Portable chest

radiography showed a worsening of the right lung infiltrate.

Dr. Harris diagnosed progressing pneumonia and impending respiratory failure. She

considered intubating the patient herself on the floor but opted to immediately transfer Mrs.

Taylor to the care of a pulmonologist and intensivist who was standing by in the ICU, for

probable intubation and mechanical ventilation.

Dr. Harris: In my mind, it was a matter of what would be safest. I really don’t have a lot of

experience with awake intubation, and I knew that a pulmonologist was already involved in the

case, so it was a really easy decision from my standpoint to get the patient transferred to the ICU

for intubation.

Dr. Harris first saw the patient at 7:57 a.m. and completed her evaluation by 8:20 a.m. It took

a few minutes for the logistics to be organized and for Mrs. Taylor to be physically

transported. She arrived in the ICU at 8:37 a.m. By this time, her respiratory distress was

more pronounced and she had become delirious. Her blood pressure was 142/65 mm Hg, her

heart rate was 145 beats/min, her respiratory rate was 38 breaths/min, and oxygen

saturation on the nonrebreather mask was 64%.

The pulmonologist preoxygenated Mrs. Taylor with a bag-valve-mask apparatus,

administered a dose of midazolam, and attempted intubation at 8:45 a.m. Unfortunately, the

attempt was complicated by ventricular fibrillation and a cardiac arrest. The physicians and

nurses resumed bag-valve-mask oxygenation, and the oxygenation saturation, which had

fallen to the mid-30s, rose to the 80s. Standard cardiopulmonary resuscitation was

performed, including 2 to 3 minutes of chest compression, accompanied by boluses of atropine



and epinephrine. The patient was defibrillated with 200 J and intubated successfully on the

second attempt at 8:49 a.m. Arterial blood gas values after intubation were a pH of 7.09, a

PCo 2 of 72, and a Po 2 of 39 on 100% Fio 2 .

The patient’s oxygenation ultimately improved and her cardiopulmonary status stabilized, but

she suffered profound and presumably irreversible brain damage. At the time of discharge, she

could not recognize family members or independently perform any activities of daily living.

Although the case was informally discussed among the providers involved, it was not

forwarded to or reviewed by the hospital’s risk management committee. The patient was

discharged to a long-term care facility for total custodial care. Several months after discharge,

the patient’s family sought legal counsel and decided to pursue a malpractice claim. About 20

months later, Dr. Harris received notice that she had been named in Mrs. Taylor’s malpractice


Dr. Harris: I was sitting in the ICU and my partner calls me up and says, You’re getting sued,

and that’s why I’m leaving medicine.