Medical Malpractice Insights: Failed communication of incidental mediastinal mass

Failed communication of incidental mediastinal mass

Patient dies of malignant teratoma 4 years later

Facts: A 48-year-old male presents to the ED with severe right shoulder pain radiating to his anterior chest. Exam is unremarkable. The EKG and troponin are normal. D-dimer is elevated at 1.6. A CT angiogram to rule out PE is reported by offsite “nighthawk” radiologist as showing “a 3.7 cm anterior mediastinal mass which appears to contain calcium.  No prior CTs are available at this time. Follow-up is recommended.” The images are not viewed by the ED physician. The EP’s assessment includes the following entries:
* “There is a calcified lesion in the mediastinum that appears to be chronic. Follow-up recommended.”
* “I am able to reassure the patient that there is no evidence of PE or other sinister life-threatening pathology.”
* “Shoulder bursitis. The patient can manage this with pain meds and follow-up with his PCP. “
* “Chest pain. I am able to reassure him there.”
The patient is discharged from the ED with written instructions that have no mention at all of a mediastinal mass. The next day the official over-read of the CTA includes thymoma and teratoma in the differential. The ED is not notified of this nor does it receive a copy of the final reading, which is simply filed in the patients chart. Four year later the patient develops SOB and SVC syndrome. A new chest CTA reveals a mass surrounding the vena cava. The patient recalls his prior CTA – which is requested for comparison and mailed directly to the patient. He and his physician are shocked at the report and the lack of follow-up. The patient is treated for metastatic germ cell cancer but dies 3 years later. A lawsuit is filed against the emergency physician, radiologists, PCP, and hospital.

Plaintiff: You (the hospital) had no system in place regarding non-congruent over-reads by “nighthawk” radiologists. You never told me, you never told my PCP and you never told the emergency physician that I even had a mass and that it could be cancer. Any sort of mass in the chest is abnormal. You should have done some research and followed up on it. You just put the report of a life-threatening condition in my chart, and that was the end of it – and of me.

Defense: The ED and emergency physician are there to treat emergencies. This was not an emergency. Most calcified lesions in the anterior mediastinum are benign. “I didn’t want to use the word ‘cancer.’” You lived another 4 years before other symptoms developed. You saw your PCP and HE never looked up the final CTA report. HE was responsible for missing the importance of your mediastinal mass.

Result: The PCP settles before trial. After a 3 week trial, the jury renders a somewhat surprising defense verdict for the others, acknowledging that the “empty chair” represented by the PCP had more responsibility than the emergency physician, hospital or radiologist.

Takeaways:

• Despite the defense verdict, never trust a jury to absolve you of failure to communicate.
• A mediastinal mass – or any “OMG” imaging result warrants discussion with radiology and sharing the information with the patient.
• Give the patient a copy of the radiology report and provide follow-up information in writing. Verbal communication is not enough.
• Assure that the PCP or referral physician receives a copy of your ED record.
• View the images of DI studies you order. A 2018 survey of EP’s showed that many do not: 30% for plain films and 57% for advanced imaging like CT and MRI.
• Avoid the temptation to think that calcium in a mass means it is benign.
• Anterior mediastinal masses are “cancer until proven otherwise.” The vast majority are due to thyroid cancer, thymoma, teratoma, aortic dissection and lymphoma.

References:

1. Anterior mediastinal mass. Radiology. St. Vincent’s University Hospital, Dublin, Ireland. http://www.svuhradiology.ie/case-study/anterior-mediastinal-mass/
2. Teratomas and Other Germ Cell Tumors of the Mediastinum. Mueller DK. Medscape eMedicine, August 2, 2021. https://emedicine.medscape.com/article/427395-overview