Neonatal X-rays: Legal Implications

Neonatologists often utilize radiological imaging in the NICU. We can obtain X-rays quickly, cheaply, and at the bedside, making this technique very useful and popular. Sometimes, providers do not get them when they should or misread them. Therefore, the plaintiff’s lawyer and experts must know how to analyze X-rays and their interpretations in neonatal malpractice work. 

The role of neonatal X-rays in Neonatology

As mentioned above, the availability of X-rays makes them the first-line imaging technique for many purposes. 

As a neonatologist, I use this imaging modality in the following situations: 

• Diagnosis of lung conditions or breathing problems (source article)
• Diagnosis of abdominal issues such as abdominal distension or feeding intolerance
• Suspected bone fractures
• Screening of the baby after admission from another institution (mainly to make sure that all catheters or tubes are in the correct position)
• After performing a procedure during which we insert something into the baby’s body and leave there (central lines, chest tube, NG tube)

Depending on the baby’s condition, some X-rays can be ordered as routine, and others should be obtained immediately at the bedside. We would order STAT X-rays if the baby suddenly deteriorates (for example, a sudden increase in oxygen requirement, and we suspect pneumothorax). 

I can think of two most common instances where X-rays may have a role in neonatal malpractice lawsuits. The first would be when the neonatologist does not order the imaging or gets it much later than expected. The other instance would be when a neonatologist misreads the imaging. Many hospitals do not have a radiologist available on-site or do not have a pediatric radiologist. Neonatologists work as intensive care doctors; therefore, they are expected to possess expertise in reading X-rays. One can look at the requirements for neonatology board certification to determine what should be their expertise and experience in this area. 

Establishing causation using radiological proof

In several situations, an X-ray may add a lot of value and point an expert in the right direction while searching for the causation of the bad outcomes. 

I describe the most important cases below:

1. Presence of the ET tube in the right stem bronchus. It is expected that after intubation, a doctor will obtain an X-ray to determine the location of the ET tube (ET tube is a breathing tube we insert via the mouth into the baby’s trachea, and later, we connect that tube to a ventilator). The ET tube must stay above the trachea’s bifurcation into two bronchi. If it is left in one of the main bronchi, all the air from the ventilator will travel only to one lung and may cause damage due to excessive pressure. This complication is called pneumothorax. 
2. Placement of the ET tube (breathing tube) in the esophagus. The esophagus is part of the digestive system. When we drink fluids or eat something, the food passes through the mouth into the esophagus and later into the stomach. The air for breathing enters our body through the nose or mouth and later is supposed to go into the trachea. That’s why, when we want to insert an ET tube to breathe for the baby, it must be inserted into the trachea, not the esophagus. If the ET tube was in the esophagus, the baby would not receive any air or oxygen and would be suffocated. 
3. Documentation of placement of the central line tip. After inserting the central line catheter, we must determine where the tip is. If the tip is too deep, it can perforate the heart. If the tip is too shallow, the catheter may leak or get more easily infected. If the tip is near renal vessels, it may cause kidney thrombosis and long-lasting hypertension. Finally, if the catheter goes into the wrong vessel, it may cause thrombosis and obstruction of the blood vessel, resulting in limb necrosis needing amputation. As we can see from these examples, obtaining an X-ray right after the procedure may help us avoid post-procedural bad outcomes in babies. 

Establishing evidence through radiological images

Sometimes, evidence is hidden. It may not be clear from the medical charts and documents created by doctors and nurses. Docotr may misread or try to obscure facts. Every expert reviewing neonatal charts should request copies of actual X-ray images and transcribed readings from radiologists. 

I emphasize that reports from radiologists are often performed after the patient develops severe complications, is transferred out, or dies. Even if a radiologist is on-site, getting an official report takes, on average, an hour. In neonatology, if a baby has pneumothorax, we have only 5-10 minutes to make a lifesaving decision. Therefore, neonatologists often must rely on their own skills to read X-rays. 

A reviewer must verify how a neonatologist interpreted the X-ray and his actions afterward. As a result, a neonatal chart reviewer should be a neonatologist or pediatrician who can read common neonatal X-rays. Otherwise, the process will not yield any valuable results. 

Neonatal X-rays and institutional responsibility

The radiology department in the hospital is always a separate organizational unit from the NICU. The hospital administrators will be responsible for purchasing all the necessary equipment and staffing. In almost all cases, radiology technicians who come with an X-ray machine to the NICU and take an image are hospital employees. Radiologists who read X-rays and generate final reports may be contractors, hospital employees, or telemedicine radiologists. Knowing these facts and exact contract conditions among those parties may be necessary to determine who is responsible for what. 

Below, I give a few examples where an institution may be blamed for issues related to obtaining neonatal X-rays:

• Significant delays in obtaining X-rays due to inadequate staffing (shortage of radiology technicians on call)
• Malfunctioning or lacking equipment
• Difficulty in obtaining radiologist’s interpretation of X-rays
• Malfunctions of electronic systems make it impossible for radiologists or neonatologists to view digital X-rays on monitors
• Excessive irradiation exposure due to malfunctioning equipment (source article)

Significance of radiological expertise

Sometimes, despite his training, a neonatologist has doubts regarding the proper interpretation of the image. The radiologist should always be available for consultations, even if absent from the hospital. 

In this age of digital communications available to everybody, it is hard to explain if nobody is available in the radiology department for such consultation on an emergency basis. 

Administrators have a duty to their patients to make their radiologists reachable around the clock or contract with appropriate telemedicine services, which are abundant. 

In Summary:

Given the important role of radiology imaging in NICU, a neonatal chart review must include an actual review of digital films and an analysis of radiologists’, pediatricians’, and neonatologist’s interpretations.