Continuing Education

A 38-year-old man sustained multiple injuries in a motorcycle crash, including head trauma, chest injuries, and spinal fractures. Attempts to intubate him to manage his respiratory distress were unsuccessful and he underwent emergency cricothyroidotomy. Despite initial neurological evaluations indicating normal extremity movements, he developed progressive paralysis of his lower extremities over the hospital course. A delayed MRI revealed a significant epidural hematoma compressing his spinal cord from C3 to C7, prompting emergency surgery. Despite decompression, he suffered permanent paralysis. The commentary highlights the cognitive pitfalls associated with managing and processing large volumes of clinical information and the importance of effective communication and active engagement among all clinical team members.

A man in his mid-50s presented to the hospital with a persistent headache after a sledding injury. A head CT scan was read as normal and he was diagnosed with a minor head injury and discharged without any specific treatment. Three weeks later, he presented with ongoing symptoms including worsening cognition and increased headache and was diagnosed with post-concussive syndrome and discharged without specific treatment. He was later diagnosed with a large frontal subdural hematoma requiring urgent surgery. The commentary discusses risk factors for delayed acute subdural hematoma and the importance of repeat brain imaging in patients with risk factors and persistent symptoms.

A man presented at the emergency department (ED) after a motorcycle crash. He had superficial lacerations on his left elbow, where wood chips were noted on exam and x-ray but were not fully removed before discharge. He was discharged with antibiotic prescriptions, but returned three days later with worsening symptoms, including pain, swelling, and pus, leading to additional foreign material being removed and further antibiotic treatment, but without repeat x-rays. Ultimately, he developed osteomyelitis, requiring multiple surgeries and a long hospital stay due to the retained foreign bodies. The commentary highlights the importance of evaluating patient risk of wound infection and poor wound healing, the role of imaging modalities to help identify foreign material in wounds, and diligent follow-up to prevent complications.

A 54-year-old man with a history of tobacco use presented to the emergency department (ED) with acute chest pain. He was initially stable upon arrival, though with signs of fluid overload and electrolyte abnormalities including hyponatremia and hyperkalemia. Despite treatment including heparin, amiodarone, and metoprolol for atrial fibrillation, and interventions for hyperkalemia, the patient deteriorated rapidly into cardiac arrest characterized by Torsades de pointes, which was mistaken for ventricular fibrillation. Despite resuscitative efforts, he did not achieve return of spontaneous circulation and autopsy revealed sudden cardiac arrest without myocardial infarction as the cause of death. The commentary highlights how the misinterpretation of a common laboratory complication can lead to incorrect treatment and patient harm.

During elective rhinoplasty, a patient became aware that she was awake. She heard the conversation among the surgical team members and felt that the breathing tube was pushed up against the inside of her throat, impeding her ability to breathe. She was unable to move but recalls making a “monumental effort” to utter a small groaning noise, which alerted the surgeon to the fact that she was awake. She heard the surgeon verbally acknowledge her condition and offer reassurance that the operation was almost over. During the first follow-up visit, the surgeon did not address the situation, so the patient brought it up at the end of the visit. The surgeon seemed surprised and embarrassed that the patient remembered waking up during the operation but could not explain what happened. The commentary discusses the risk factors for intraoperative awareness, approaches to prevent awareness, and the importance of validating and addressing the patient’s experience, including addressing symptoms of post-traumatic stress syndrome. 

A 55-year-old woman with a history of panic attacks, obesity, and untreated hypertension, experienced syncope after feeling flushed and lightheaded. On arrival at the emergency department, she had severely elevated blood pressure and hypoxemia. Diagnostic tests revealed acute heart failure exacerbation with pulmonary edema, marked elevation of brain natriuretic peptide (BNP), and elevated troponin-I. Despite treatment with diuretics and antihypertensives, her condition deteriorated, leading to intubation due to respiratory failure and subsequent cardiac arrest; cardiopulmonary resuscitation resulted in with return of spontaneous circulation. However, she suffered from ischemic stroke and intracranial hemorrhages, ultimately leading to a transition to comfort care and subsequent death. The commentary discusses the contraindications for beta-blockers in the setting of acute decompensated heart failure and appropriate treatment for hypertensive emergencies in the emergency department and intensive care unit. 

A 67-year-old man with severe low back pain was admitted to the hospital for anterior lumbar interbody fusion (ALIF) with bone autograft from the iliac crest. The surgical team had difficulty controlling bleeding and the patient left the operating room (OR) with the bone graft donor site open and oozing blood. In the postanesthesia care unit (PACU), the nurse called the attending physician three times to report hypotension and ongoing bleeding. Each time, the surgeon ordered hetastarch for volume expansion. Over the next 14 hours, the patient’s blood pressure remained at or below 90/60 with continued complaints of back and pelvic pain. The next morning, the patient was unresponsive and in severe hypovolemic shock. Electrocardiography confirmed a non-ST segment elevation myocardial infarction (NSTEMI). The patient was transferred to an intensive care unit and resuscitative efforts were initiated, but the patient expired from multiorgan failure resulting from hypovolemic shock. The commentary discusses appropriate management of ongoing intraoperative and postoperative bleeding and how a culture of safety can enable care team members to voice concerns about patient safety. 

Five weeks after gastric bypass surgery, a woman experienced persistent nausea and vomiting, leading to dehydration and multiple outpatient treatments. Despite visiting an outpatient clinic and emergency department (ED) for ongoing symptoms and significant weight loss, the nausea and vomiting persisted. Eventually, she was admitted to the ICU with pancreatitis and dehydration. Subsequently, she exhibited neurological symptoms including difficulty walking, tingling sensations, and cognitive impairment. She was discharged with orders for total parenteral nutrition (TPN). Three days after discharge, she was readmitted for worsening confusion and profound motor weakness, which progressed to respiratory failure requiring mechanical ventilation. Laboratory tests revealed an extremely low thiamine level, and the patient was diagnosed with advanced Wernicke-Korsakoff Syndrome, exacerbated by a lack of proper nutrition, and resulting in permanent brain damage, necessitating ongoing care. The commentary discusses how biases associated with medical conditions, such as obesity and its treatment, can lead to poorer outcomes, as well as strategies to continually re-evaluate diagnostic reasoning in light of ongoing, intensive management and management reasoning

A 55-year-old man with a history of osteoarthritis and supraventricular tachycardia was admitted the hospital with severe COVID-19 and required endotracheal intubation and invasive mechanical ventilation. Following transfer to a long-term care hospital (LTCH) for continued weaning from mechanical ventilation, inadequate tracheostomy management protocols were evident, with no specific instructions provided. Subsequently, the patient experienced respiratory distress and cardiac arrest due to a blocked tracheostomy tube, highlighting critical deficiencies in care and communication. The commentary summarizes the risk factors for tracheostomy complications, the importance of tracheostomy tube maintenance and monitoring, and strategies to safeguard tracheostomy tube care during transitions of care. 

A 77-year-old man was admitted for coronary artery bypass graft surgery with aortic valve replacement. The operation went smoothly but the patient went into atrial fibrillation with hypotension during removal of the venous cannula. The patient was shocked at 10 Joules but did not convert to sinus rhythm; the surgeon requested 20 Joules synchronized cardioversion, after which the patient went into ventricular fibrillation and was immediately and successfully defibrillated with 20 Joules. While the patient was being transferred to his gurney, the operating room team noticed that the electrocardiogram cable that enables synchronized cardioversion was only connected into the anesthesia monitor and was never connected to the patient’s defibrillator. The commentary discusses the risks of unsynchronized shocks or pacing, the role of standardized processes to ensure that operating room equipment is prepared and set-up correctly, and the importance of operating room team preparation to urgently address life threatening complications