The Medico-Legal Advisor ®
DEATH IN THE RADIOLOGY DEPARTMENT
Although death is not a common outcome in the radiology department, it is far more common than it ought to be. A certain number of deaths are expected in the emergency room or even in surgery and the recovery room, where desperately ill patients are often treated and a number succumb to their disease. Often deaths that occur in the radiology suite are unexpected and preventable. This article is not meant as a perjorative exposé of errors in the radiology department. Rather we shall attempt to define those circumstances which most often lead to undesirable outcomes in the radiology department with the hope that those hospitals which share the problems discussed herein can consider corrective action. Factors Leading to Death or Significant Injury in Radiology Departments: 1. The Patient: In spite of the fact that many radiology departments now have satellite operations in the emergency rooms and intensive care units which are capable of taking and developing routine radiographs, the trauma patient from the emergency room and critically ill patients from the intensive care units must often be transported to radiology. With few exceptions, radiology departments are ill-prepared to handle these patients. Yet the modern acute care hospital is rapidly finding its smaller inpatient population restricted to a patient who is "sicker" than in the past. 2. Accompanying Personnel: When seriously ill patients are transported to the radiology department, even teaching hospitals may not have protocols which define who must accompany the patient. Nursing shortages have made the situation worse since few emergency rooms or intensive care units are so well-staffed that a nurse can be sent with the patient. Doctors (including residents) are frequently too busy to stay with the patient for long procedures. The result is that unstable patients are not infrequently allowed to be transported to an area lacking in monitoring equipment and persons trained to treat the sick with undertrained aides or orderlies and no one to stay with the patient. 3. The Setting: What is it about the radiology suite itself that can cause a patient's demise? Typically this topic includes the architecture, available equipment and the personnel in attendance in most radiology departments. a. Architectural factors: Most radiology departments are designed for routine procedures. Except in cardiac catherization suites and some special procedures rooms, there is often not enough room to adequately treat the patient who suddenly takes a dive toward immortality. The patient may have to be moved out of the room before resuscitation can commence. Sick patients are often left to languish in the halls without anyone being able to observe them except casual passersby. Visualization of the patient even during a procedure may be severely hampered or made impossible by lack of a protected observation post out of the line of exposure. The radiology suite is often far removed from the critical care units and the emergency room. Transport of patients may involve a long trip down corridors and on elevators, allowing for additional opportunities for patients to get into difficulties which are not well observed; and during transit there is little opportunity for resuscitation. Newer hospitals have solved these problems with satellite radiology suites or by grouping radiology and critical care and emergency rooms in close proximity to one another. b.Equipment: At the bare minimum, a crash cart should be available and properly stocked in each radiology suite. In larger department, several carts should be available to serve each region. Of particular importance is the availability of resuscitation equipment and drugs to any room where contrast media is injected intravenously. We have seen a number of cases in which patients developed anaphylactic reactions to iodinated contrast injections who should have been salvageable but died because of delays in getting proper equipment and drugs to the scene. In fact, many radiology suites are very ill-equipped and there seem to be no specific standards requiring additional crash carts in areas where contrast media is administered. c. Personnel: Radiologists, by nature, are not usually interested in treating the sick, are not trained to do so and have usually had little training or experience with resuscitation. Likewise those who work as radiology technicians. Some may have basic CPR course work but that is no substitute for experience and interest. When a disaster occurs, the response id often inadequate unless other physicians happen into the department or the radiology suite has ready access to emergency room physicians or others who know how to resuscitate. The Use of Contrast Media Aside from those patients who are rolled into radiology in critical condition and die due to lack of observation or monitoring, contrast media injections account for most deaths accuring in the radiology department. It is estimated that as many as 8,000,000 (eight million) patients will receive radiographic contrast media each year in the United States alone. One large study documented that one patient in every 146 (one hundred forty six) had a severe reaction. Other studies would put the number between 1 in 1700 to 1 in 4500. Assuming the highest reported incidence, about 54,000 reactions would occur yearly or about 12 per hospital (using the number of hospitals over 100 beds). Assuming the lowest incidence reported, the incidence per hospital would be about one every two years. As usual the true number is surely somewhere in between. Experience tells us that a lot of cases coming out of radiology where death has occurred during injection of contrast material end up in litigation. Often they are success stories for the plaintiff since the negligence is frequently rather astounding. One frequent cause of litigation arises when contrast media is injected without a venous access line in place. Once the patient has developed anaphylaxis it is extremely difficult to insert one. We believe that the standard of care requires that intravenous or intra-arterial contrast media be used only in patients who have IV lines in place. A note stating that there was difficulty starting an IV line in a patient already in shock is a strong admission of negligence and will not be overlooked by an alert plaintiff's attorney. Absence of appropriate resuscitation equipment and drugs is another frequent cause of disaster. In a number of cases which we have seen, it is obvious from the notes that defibrillator-monitors and lifesaving resuscitation drugs were not at the scene of a reaction and had to be "hunted down" during those critical few minutes when the patient is going into shock. The standard of care ought to be that crash carts, properly equipped and frequently checked and re-stocked, are instantly available to any room where contrast media is used. The final frequent component in the usual disaster related to contrast media is the lack of trained personnel. This often had to do not only with inadequately trained technicians and radiologists who may have long since forgotten anything they ever knew of CPR, but with the fact that many radiology suites are isolated far from the areas of the hospital frequented by physicians and staff who would be effective in treating anaphylaxis. Considering the frequency of reactions to contrast media, documentation that the patient has not had a previous problem with contrast agents ought to be a part of the record. Likewise, some litigation could be avoided by more adequate reporting of adverse reactions. Often the only documentation of an adverse reaction is the apologetic note of the radiologist which will be considered self-serving and subject to doubt if litigation results. Comment Treatment of severely injured or diseased patients and patients who suffer adverse reactions within the radiology department is often not what it ought to be. Perhaps the fact the American College of Radiology (ACR) had not published standards applicable to such patients (we have searched and can find none but we hope we are wrong.) The proposed standards of the ACR which are now in draft form give brief mention to the area of seriously ill patients and even less to the treatment of emergencies created in and by the radiology department and staff. If the predominant organization representing radiologists does not address the issues in this area, one can assume that its members do likewise. Bibliography ACR Task Force on Standard Setting, Draft-ACR Standard Monitoring and Evaluation in Departments of Diagnostic Radiology and Nuclear Medicine. American College of Radiology, August 1989. Cohan, R.H., et sl. Intravascular Contrast Media: Adverse |