Medico-legal case review of pneumothorax side mix up in a newborn

Diagnosing pneumothorax in a newborn may have various legal implications for malpractice lawsuits. I talked about these issues in my previous article.

In my analysis here, I want to discuss a reported pneumothorax side mix-up in Sweden. The case was published in the European Radiology Journal in 2002 (source article). I will use only case number 2 from the cited article. 

If you want to learn more about pneumothorax and all medico-legal risks associated with that diagnosis you should also review this article here.

Details of the case as reported in the article

1. Patient – a newborn baby born at 32 weeks of gestational age that developed respiratory distress after birth
2. A chest x-ray was done on the first day of life due to signs of respiratory distress. Side markings were missing on the chest x-ray, but right-left-sided orientation was guessed from other identity markings on the cassette. 
3. On the second day, a repeated chest x-ray with correct side markings showed a small left-sided pneumothorax.
4. Another chest x-ray was done nine hours later due to rapid clinical deterioration, but no side markers were used. The exam showed a large pneumothorax on one side. The radiologist refused to read the exam and recommended repeating it due to missing side markers. 
5. The referring pediatrician decided that there was no time to wait. Given the patient’s rapid and severe deterioration, he performed a left thoracostomy. He chose the left side because the prior examination showed left-sided pneumothorax on the previous exam 9 hours earlier. 
6. The subsequent chest x-ray correctly marked the left-right sides and showed that the thoracostomy was done on the wrong side. The baby had a large tension pneumothorax on the right side, not the left.
7. The right-sided chest tube was introduced to treat tension pneumothorax on the right.
8. The patient died one hour later.
9. An autopsy report found that the initial left-sided needle had perforated the pericardium and the pulmonary artery, leading to hemopericardium and hemothorax (= caused blood collection around the heart and blood in the chest cavity)
10. The case was referred to the Swedish Board of Health and Welfare. Based on the expert’s opinion, that organization indicated that guidelines regarding side marking the x-rays need to be strictly followed. Additionally, no individual healthcare professional was criticized or warned. 

Analysis of the case

What was done correctly in this case?

1. It seems reasonable to repeat the x-ray film when the patient’s condition deteriorates and changes so much that it is difficult to explain it by the natural progression of the previously diagnosed disease. 
2. The radiologist requested a repeat X-ray when he discovered that the important imaging study had missing side markings.
3. When a patient deteriorates rapidly and severely, it is appropriate to make decisions based on incomplete data trying to save the patient’s life. In this case, the pediatrician decided he could not wait for another x-ray because the patient was critically ill. Unfortunately, his clinical decision was wrong regarding which side of the patient’s chest was affected by pneumothorax.

What was done incorrectly in this case?

1. Both the pediatrician and radiologist should have correctly identified the chest sides because the X-ray in question covered the upper part of the abdomen with an easily visible stomach bubble on the left. In addition, they should have known that the previously done x-ray, which had been correctly marked, did not show any “situs inversus.” Therefore, the stomach bubble’s presence should have accurately indicated the left side of the chest. This step was a missed opportunity to diagnose and treat this patient properly.
2. Given how large the tension pneumothorax was, it is surprising that the clinician at the bedside could not diagnose that the pneumothorax had developed on the right side based on clinical exam and transillumination alone.
3. We do not have detailed information regarding the decompression procedures used by a pediatrician to treat presumed pneumothorax on the left with the needle. The technique was inappropriate – the provider had introduced the needle into the pericardium and damaged a pulmonary artery. Furthermore, the needle was left in place until the follow-up x-ray, potentially extending the damage. We can use needle aspiration to treat or diagnose pneumothorax, but it should never be introduced that deep. We should only advance the needle to pass the depth of the chest wall and not any further. In addition, it may be safer to use an angiocatheter rather than a needle to avoid lung or heart damage. 
4. It is surprising that the Swedish National Board of Health and Welfare did not criticize any healthcare providers taking care of this patient. 

What did we learn from this case of misdiagnosed laterality of pneumothorax?

1. Always remind radiology technicians to use side markers for X-rays of newborns (my article on the importance of radiological images in neonatal malpractice suits).
2. Try to correlate and compare the currently being evaluated X-rays to those done previously. 
3. Even when making clinical decisions with limited data, we should always consider all clinical findings, imaging, and laboratory tests. This case shows us two missed opportunities to make better diagnostic and treatment decisions. First, providers missed the chance to identify correctly the left and right chest based on the location of the stomach bubble. Second, the pediatrician presumably did not conduct a good clinical evaluation that could have helped him decide where the pneumothorax was actually located.