12 Years Old Girl Dies After Tonsillectomy

Tampa Bay Times reported on June 10, 2012 a 12 years old girl died after a tonsillectomy performed on Aug 13, 2010 for chronic tonsillitis. From the details provided from the news report, it seems that several independent issues all contributed together that lead to this child's unfortunate and tragic death.

This case was also complicated by subsequent non-medically related actions taken by medical personnel which will not be discussed here.

Strictly medically speaking...

Local Anesthetic With Epinephrine

It is unclear exactly when the local anesthetic bupivacaine (Marcaine) with epinephrine was injected into the tonsil region which may help with post-tonsillectomy pain control in the pediatric population. Also unclear is what concentration and how much got injected.

However, it is far from common practice (though not rare) and it is not something I personally inject in the pediatric population for a few reasons in spite of its well-known suspicion to minimize a sore throat after surgery. (There are plenty of papers that report such injection offers NO additional pain control in children. See references below.)

1) The risk of bupivacaine is toxicity to the heart leading to arrhythmias that may ultimately lead to a heart attack.
2) Epinephrine can result in hypertension as well as further exacerbate cardiac problems

Given report of "bloody froth" in the endotracheal tube along with acute onset of tachycardia and hypertension, I suspect the child suffered from pulmonary edema, most likely secondary to accidental intra-vascular injection of the local anesthetic (causing cardiac failure) and epinephrine (causing tachycardia and hypertension).

Given these risks and fact that kids are so much smaller and more susceptible to medication risks, I personally never inject this medication during/after tonsillectomy. Even in adults, I never inject routinely, though I do offer to adults undergoing tonsillectomy (but than I use bupivacaine alone without epinephrine).

The hypertension itself led to problem #2...

Congenital Cerebellar Vascular Anomaly

The child had a congenital cerebellar vascular anomaly that ruptured leading to a life-threatening bleed in the brain.

In and of itself, this anomaly would not have been a problem, but given the reported sudden hypertension, the rupture is akin to inflating a tire with too much air causing it to pop.

Most likely, if the child's cardiovascular compromise never occurred, this bleed never would have happened in the first place.

It's also entirely possible if the local anesthetic was never used, this death would not have happened as well.


Source:
Lawsuit claims doctors' mistakes caused Palm Harbor girl to die after tonsillectomy. Tampa Bay Times 6/10/12.


References:
Comparison of clonidine, local anesthetics, and placebo for pain reduction in pediatric tonsillectomy. Arch Otolaryngol Head Neck Surg. 2011 Jun;137(6):591-7. Epub 2011 Mar 21.

Preincisional bupivacaine in posttonsillectomy pain relief: a randomized prospective study. Arch Otolaryngol Head Neck Surg. 2002 Feb;128(2):145-9.

Control of early postoperative pain with bupivacaine in pediatric tonsillectomy. Ear Nose Throat J. 1993 Aug;72(8):560-3.

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Should You Have Surgery Far From Home???

I am in the fortunate position of seeing patients who live locally as well as a handful who travel across one or more state lines to see me on a weekly basis, as well as the sporadic few who come from even other countries.

When patients travel great distances to see a doctor, this puts the physician in a particularly humbling position. However, it also places additional strain on how care can be provided efficiently and reasonably when geography logistically makes it difficult.

To begin, why would a patient even want to travel great distances to see a doctor? The basic answer is due to the perception that they would receive better care than can be obtained locally. If true, such long distance travel is justified. After all, if you have thyroid cancer and there are no surgeons who can remove this cancer, than by all means, travel is merited.

However, too often, I see patients travel great distances to see a surgeon due to the perception that this one particular doctor is better than the one found locally, EVEN if the local surgeon is quite competent. Here is where the decision to travel becomes... well... less logical, especially if the surgery is for a routine problem.

IF there's a local competent surgeon, I feel it is ALWAYS better to get the surgery done locally. Why? Because if there's any problems after the surgery, it can be easily addressed quickly and with minimal fuss. If the surgery was done hours away, think of the travel, expense, missed time from work, etc NOT just for the surgery, but for any post-operative problems that develop. Oftentimes, the patient concern ends up being unfounded and only reassurance is required, but in order to make that determination, the surgeon needs to do an exam. Imagine the frustration of the patient when a surgeon requests a visit before answering a question about a post-surgical concern... hours of driving to the office, waiting in the exam room, being seen by the surgeon for a few minutes only to hear that everything is fine and normal, and finally driving hours back home.

Even in the hands of the BEST surgeon, problems can arise after surgery. Is the surgical wound becoming infected? Where is that fever coming from? There's a little drainage occurring... is that normal? Why is the skin red? There's a lot of pain and his medications aren't working.

To complicate things further, narcotic pain killers can NOT be called in by federal rules. A hardcopy prescription is required. Now, wouldn't that be mighty inconvenient if a patient (who mind you is in pain), needs to drive hours to the surgeon's office just to pick up a hardcopy narcotic prescription.

The logistical difficulties of dealing with post-operative care after patient discharge is tremendous for both the surgeon as well as the patient if the distance between the two is large.

Now when should a patient travel to have their surgery done?

DO travel to see a surgeon when your local surgeon feels it imperative that you do so either due to the complexity of the problem or inexperience. Especially, if the local surgeon is well-respected and honest. This serves two purposes... you get the surgery done by the best possible... AND, if any problems develop after surgery, your local surgeon is in the loop and can probably handle most routine post-surgical concerns.

I should state that I HAVE performed surgery in patients who live hours away (some even an airflight away) but I ALWAYS encourage patients to try and get the surgery done locally if at all possible due to the reasons stated above. If a competent local surgeon is not available, than that's fine. But if competent local surgeons are present... I do my best to steer patients to get the surgery done locally as it IS for the patient's best interest.

I have also referred patients to other surgeons a long drive away due to one reason or another, even if the patient desperately wants me to do the surgery. I'll be the first to admit if I lack experience to address a given problem. I also follow-up in stating to the patient that if there's any problems that occur after the surgery, to please return to see me rather than making a long-distance trip as there's a good chance I'll be able to address the concern. Everyone wins this way.