By Damian D. Capozzola, Esq.
The Law Offices of Damian D. Capozzola
Los Angeles

Jamie Terrence, RN
President and Founder, Health Care Risk Services
Former Director of Risk Management Services (2004-2013)
California Hospital Medical Center
Los Angeles

Morgan Lynch, 2018 JD Candidate
Pepperdine University School of Law
Malibu, CA

News: In 2008, a hospitalized 88-year-old man was given a feeding tube by a first-year resident at a hospital. An X-ray was ordered to confirm the placement of the feeding tube, but the radiologist incorrectly read the X-ray. The feeding tube was placed in the patient’s lung rather than in his stomach. It later was discovered that the X-ray study used was not the proper study to confirm accurate placement of the feeding tube. Relying on the incorrect interpretation of the X-ray study, the patient was given feeding fluid for 12 to 14 hours into his lung. He was restrained to his bed due to a prior attempt to leave the bed. He exhibited symptoms of distress, which the healthcare providers failed to associate with an incorrectly inserted feeding tube. He died from suffocation. The jury awarded the patient’s estate $5 million, and it attributed 25% of the liability to the hospital and 75% to the radiologist and her radiology group.

Background: In December 2008, a man was sent to the hospital to be treated for two episodes of syncope, or temporary losses of consciousness. He was transported to a local hospital and was given a feeding tube, which he pulled out. A second feeding tube was inserted, but it was removed after an X-ray indicated it was placed into the patient’s left lung. The following day, a first-year resident inserted a third feeding tube into the patient. An X-ray technician X-rayed the patient’s chest and abdomen, and the defendant radiologist reviewed the X-ray study. The radiologist incorrectly read the study as a correct placement of the tube, but once again the feeding tube had been inserted into the patient’s left lung. The radiologist testified in her deposition that she incorrectly read the study and that she later learned that the X-ray that was taken was not the correct study to determine the placement of the tube.

Because the radiologist misread the X-ray study, the patient was given feeding fluid directly into his lung. Because he previously tried to get out of his bed, the patient was in restraints and could not pull out the tube. As he began to drown from the fluid, he exhibited symptoms of distress, which the healthcare providers failed to recognize as being associated with an incorrectly placed feeding tube. The patient received the tube feeding fluid into his lung for 12 to 14 hours. Midway through the feeding, the patient’s daughter called the hospital to speak to her father, but she was told that he was “sleeping comfortably” and tolerating his tube feedings well. The next morning the feeding tube was removed, and after failed attempts to resuscitate the patient, he was pronounced dead at 7:11 a.m. An hour later, another radiologist read a stat X-ray that had been taken of the patient’s chest at 4:46 a.m. That radiologist noticed that the feeding tube was misplaced and told the ICU Critical Care Team, but the radiologist was informed that the patient already was dead.

The man’s daughter filed a negligence action on his behalf against the hospital and the radiologist who read the initial X-ray. The complaint alleged that the defense was negligent for failing to have policies dictating the proper X-ray study to determine the correct placement of feeding tubes, administering the incorrect X-ray study, incorrectly reading the study, delivering feeding fluid into the patient’s lungs, and failing to recognize the patient’s symptoms as signs of respiratory distress. In an attempt to reduce damages, the defense pointed to the patient’s old age, short life expectancy, and history of medical issues. Furthermore, and somewhat ignoring the horrifying circumstances surrounding the patient’s death, the defense also argued that the distressed symptoms the patient exhibited, including elevated heart rate and increased blood pressure, were not unusual considering the patient’s advanced age and medical problems. The use of the restraints preventing the patient from removing the feeding tube when he began to feel distressed was justified by the defense due to the patient’s past removal of his feeding tube and attempt to leave his bed. The jury unanimously sided with the plaintiff after a three-hour deliberation. The jury awarded the patient’s estate $5 million, attributing 25% of the liability to the hospital and 75% to the radiologist and her radiology group.

What this means to you: This case highlights the importance of proper X-ray and monitoring procedures for hospitals and doctors. The student doctor also should not have been permitted to place the tube without proctoring. Indeed, unfortunately, the standard procedure for placement of a feeding tube is well known to nurses but probably not well known to first-year residents.

Once the tube is placed and secured, there are two immediate steps to ensure correct placement, even without X-ray confirmation. The first involves withdrawing stomach contents with a large syringe. If stomach contents are seen, the tube is in the stomach. If air is withdrawn or nothing can be withdrawn, the tube may be in the lung or coiled in the back of the throat. In this case, the tube should be reinserted. A second method is to push a small amount of air through the syringe into the tube while listening with a stethoscope placed over the patient’s stomach. If air is heard rushing into the stomach when the syringe is pressed, then the tube probably is in the stomach. These placement tests are required every four hours while a tube feeding is running because, even though the tube may be placed correctly, it can become dislodged at any time. Had these simple but important steps been taken by the nurses, this tragedy may have been avoided.

This case also illustrates the need for medical practitioners to pay close attention to a patient’s symptoms. This man was drowning in fluid for no less than 12 hours. His heart rate was elevated. His blood pressure was high. A cardiologist believed he suffered from aspiration. The signs all seemed to point toward the patient suffering from a misplaced feeding tube, especially considering that an earlier X-ray showed a prior tube entered the patient’s lung. The nurses never attempted to ascertain why the patient acted agitated. While patients with feeding tubes sometimes do require restraints, a patient in restraints requires very close monitoring, which includes the release of the restraint every few hours. The nurse who noticed an increase in the patient’s heart rate failed to call a supervising doctor to check on the patient’s symptoms.

REFERENCE

  1. Montgomery County Court of Common Pleas. Case Number 2010-35494, May 13, 2016.