“Bad Pneumonia” in DNR Patient

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“Room 4, old septic guy with pneumonia, a trach, DNR, admitted,” says your colleague as he hands over the department. “He’s really hypoxic, but we put in a new trach collar, sats are holding at 90%. I’ve talked with the family. He fell, so we’re getting a CT of the head and C-spine that still pending. Would you check it?”

“Sure,” you say, secretly grumbling a bit about the extra work. Your mild annoyance is quickly forgotten in the day’s opening barrage from the waiting area and EMS. A short while later, the daytime respiratory therapist on rounds remarks to you, “You know that trach guy isn’t breathing all that well, even on the O2”. “Try suctioning out the trach,” you reply. “I did,” she parries, “It’s no better.” You make a note to do a “fly-by” between new cases to check on this patient.

A short time later, the CTs are up for review, and you glance at the C-spine while sipping a second morning coffee. “Oh crap!” you say loud enough to stop all conversation in a 20-foot radius. Too much coffee. Deep breath. You turn to the clerk, and in a calm quiet voice say “Um, call respiratory and the nurse and have them meet me in Room 4.”

Dx: Malpositioned Trach Collar


Good news, no C-spine fracture. Bad news, big airway problem – the Shiley trach collar is NOT in the trachea. When we replaced it in the correct position, we were able to appreciate a very well-developed false passageway for this device. Miraculously, the O2 sats came right up with the trach correctly inserted – how about that! But we appreciated how easily the trach slipped into the wrong spot. Unlike a positive-pressure situation (e.g. a ventilator or BVM) where expanding subcutaneous air might quickly develop and provide a clue to the problem, the passive trach malpositioned might be more difficult to detect in the absence of hypoxia or ventialtory impairment.

This case also illustrates the danger of turn-over patients. My most admired colleagues are not those who see the most patients, but those doctors who NEVER turn over a case for me to finish. It is somewhat human nature to pay less attention to the detail of a case you know will be someone else’s problem to dispo, not to mention the loss of primary information (e.g. family, EMS, prior nurse providers) that may not be communicated to the take-over physician. We tend to accept our turn-over cases at face value. In this situation, the hypoxia was assumed due to the severe pneumonia, rather than the malpositioned trach.

Finally, there is the question of dealing with medical errors. Even in this situation where no great harm was done, it is best to approach the patient and family and address the issue in real-time. A common on-topic script of mine might go like this: “I need to tell you something important. We have just identified a problem/mistake/error. (In this case). Your loved one’s trach collar was in the wrong spot, which explains some of the breathing problems they are having. We have/will correct this problem and will keep you updated.” I will sometimes add “I am very sorry”, although for some families and patients this expression is taken as trite or as an admission of guilt and can make the situation worse.

As physicians, our strongest currency is our integrity and our patient’s belief that we are their advocates. Most people assume doctors are honest, and also understand that doctors are not perfect and will make mistakes. Admitting to a mistake and taking corrective action is always the best strategy. Furthermore, full disclosure is now a Joint Commission requirement. Even a small amount of obfuscation or cover-up of a mistake, when revealed, often causes irreparable damage to your relationship with the patient and family and may increase your liability exposure beyond that of the error itself.

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