A Medical Malpractice Who (or what) Done It
The mystery began when a patient in a hospital died on the operating room table during procedures to place a Quinton dialysis catheter into the left internal jugular vein. Shortly after the operative procedures were completed, the patient went into ventricular tachycardia and a code was called. Within minutes, the patient became pulseless. Efforts included CPR, shocking the patient, and the administration of medicines. After 35 minutes without success, the surgeon inserted a temporary pace maker into the left femoral vein and tried to get it into the right ventricle of the heart. Minutes after passing the pace maker, a chest x-ray was taken showing the pace maker in the superior vena cava and a minimal to moderate left pleural effusion. Unfortunately, nothing worked and the patient expired after approximately 55 minutes of resuscitative efforts.
On autopsy, the medical examiner found a left hemothorax and three perforations of the left pulmonary artery. He began his investigation. At first, the usual suspects were rounded up. This included the guidewire, dilator, and catheter from the Quinton catheter kit. These suspects were deemed by the medical examiner to be the culprits. One or more of them must have perforated the left pulmonary artery causing a left hemothorax which then caused the ventricular tachycardia resulting in the death of the patient.
Several expert sleuths were placed on the case in the defense of the accused. Critical evidence was found lacking. There were no fingerprints! Upon careful forensic work, it was determined that the innocent bystander pace maker was in reality the perpetrator. However, by the time the pace maker had made it to the scene of the perforations, the patient was already essentially dead.
In a scene reminscent of the Perry Mason series, the Quinton catheter kit on trial was exonerated by the jury’s verdict, and the pace maker was taken out of the courtroom in handcuffs. Justice was served.