Patient Suffers Fatal Hemorrhage After Lung Biopsy

This case involves a female patient with a history of coronary artery disease, as well as a number of different cardiovascular defects, for which she had undergone multiple surgeries and was on blood thinning medication. A routine chest x-ray had revealed the presence of a mass in the lower lobe of her lung, and her pulmonologist recommended that she undergo an endobronchial ultrasound in order to obtain a more definitive diagnosis. Leading up to the procedure, she was admitted for an anticoagulation bridge before the endobronchial ultrasound, where she was placed on a Heparin drip. During the procedure to biopsy the mass, it was noted that the patient’s airways filled with blood and she began to hemorrhage, causing her to bleed out despite the surgeon’s efforts to implement a laryngotracheal reconstruction. A subsequent autopsy revealed evidence of vein injury, possibly related to the biopsy procedure, however there was no definitive evidence tying the bleed to an acute traumatic event. Nevertheless, the decedent’s estate alleged that the patient’s death was caused by an error on the part of her treating physicians.

Question(s) For Expert Witness

1. Do you routinely treat patients similar to the one described in the case?

2. How do you determine if a patient is a good candidate for the procedure?

3. Is it common to perforate the vein wall during the EBUS procedure?

4. Do you believe this patient may have had a better outcome if the care rendered had been different?

Expert Witness Response E-011844

I routinely see and evaluate patients with diagnosed and undiagnosed lung masses, as in this case. I have two multidisciplinary clinics per week aimed at such evaluations and see on average 5 new patients with lung nodules, masses or adenopathy requiring evaluation and diagnostic procedures. I was trained in EBUS as a Fellow and have performed well over 500 EBUS's since then. I routinely use both radial EBUS and linear EBUS. Imaging with CT scans of the chest and/or PET/CT scans provides the most assistance in determining if the patient has a lesion that would be accessible by EBUS. As far as if the patient is able to tolerate the procedure, that depends largely on their medical history, ASA classification, and prior experience with the sedation used for these procedures. In a patient at higher risk, electing to use MAC anesthesia or general anesthesia instead of conscious sedation is an option. In linear EBUS where a needle is being used to sample a lymph node or a mass using real-time ultrasound, it is rare that a large vein is perforated because the vessels are visualized during the actual needle insertion. That being said, there have been case reports of Pulmonologists traversing large veins with an EBUS needle on purpose to reach the mass below the vessel. In radial EBUS, the ultrasound is inserted to find the mass or nodule and then removed. Forceps are then inserted and, using fluoroscopy biopsy, forceps are guided back to the same area. I have expertise in bronchoscopy and routinely evaluate patients such as the one described in the case. I perform a large volume of advanced diagnostic procedures such as EBUS, and teach these procedures to Fellows in training. I have also done a number of research projects involving EBUS, and have published on the topic.