We recently resolved a case involving the tragic death of a 47-year-old woman. We had the honor to represent three generations of heirs. This beautiful woman left behind a husband, a son, and two parents.
We will call her “Beverly”.
Beverly went into the hospital for the removal of an abscess in her chest. It was just below her Adam’s apple and above her sternum. The visible, infected lump on the surface of Beverly’s skin unfortunately represented the tip of the iceberg. Unknown to the surgeons, Beverly had a “fistula tract” of infected material that ran from the surface of her neck all the way down to her heart.
After removing the superficial abscess, the surgeons decided to sterilize the abscess pocket with hydrogen peroxide.
Unfortunately, blood acts as a “catalase” when hydrogen peroxide is mixed with it. The minute surgeons poured 20 mL of hydrogen peroxide into a closed cavity in Beverly’s body, the resulting chemical reaction released millions of oxygen molecules into Beverly’s bloodstream. The oxygen traveled down the fistula track into Beverly’s heart, causing a fatal air embolism. One organ after another in Beverly’s body died from the effects of the air embolism. She passed away the next morning.
LESSONS LEARNED:
- Read a drug’s warning label before you use it.
Every bottle of hydrogen peroxide sold in the United States contains essentially the same warning: Use only for superficial scrapes and abrasions. Do not use hydrogen peroxide on a deep or penetrating wound.
The surgeons had not read the warning label.
2. Always get an updated CT scan before operating on a patient’s chest. The surgeons in this case were relying on a three-month-old CT scan. They didn’t want to bother with getting a new scan. (If they had done so, they would have realized that Beverly had a deep fistula that went all the way down into her heart.)
- Know the literature about a drug before you use it. There are many case reports of death and serious injury following the use of hydrogen peroxide in deep wounds.
Most doctors do a good job most of the time.
But even good doctors can make terrible mistakes if they forget to follow basic rules: Read the warning label first, get updated imaging and know the relevant medical literature.
We hired two of the finest heart surgeons in the world to serve as experts on this case. When we disclosed our experts to the hospital, it decided to settle. We can never replace Beverly. But the significant settlement will give the family closure. The hospital finally accepted responsibility for this tragedy. We are proud of this result.