By James C. Post, MD, PhD, MSS, FACS
Over 500,000 tonsillectomies a year are performed in American children. While the number of surgeries is declining, the procedure remains one of the most common surgeries performed in the pediatric population. Although advances in anesthesia and surgical technique have made this a safer procedure, bleeding during or after the surgery is one of the most feared complications. Such bleeding may or may not indicate a breach of the standard of care which results in harm to the patient (i.e. medical malpractice).
One way to approach such a case as a pediatric otolaryngology expert witness is to break it down into Pre-operative, Surgeon and Institution, Nursing Notes, Pathology Reports, and Post-operative course. The timing of the bleeding is also important. Bleeding within the first 24 hours of the surgery is termed “Primary” bleeding, and is generally the result of intra-operative error. Bleeding at 7-10 days post-operatively is termed “secondary” bleeding, and generally results when the throat scabs (eschar) slough. The causes of secondary bleeding are less under the surgeon’s control, albeit this can still result from surgical error.
- Was the procedure performed for recurrent infection or to alleviate obstruction? Are there sufficient documented indications for performing the surgery? The frequency of T&A varies from region to region. If the child did not have sufficient severity of disease, the child should not have been in the OR in the first place.
- Documentation for recurrent streptococcal infections includes documenting the number of strep-associated episodes, which are defined by specific findings.
- Does the child have a personal or family history of bleeding? As a T&A is frequently the patient’s first surgical experience, it is important to document if there is a family history of hemophilia, von Willebrand disease, or uncharacterized excessive bleeding with surgery or childbirth.
- If bleeding studies are obtained, ensure that the surgeon checked the results before proceeding.
- Conversely, if the surgeon claims the bleeding studies were normal, ensure that there is laboratory documentation that independently supports this claim.
- Was informed consent obtained?
Surgeon and Institution
- Is the patient in the correct institution? The majority of healthy children can safely undergo a routine tonsillectomy performed by a trained general otolaryngologist in an ambulatory setting.
- Take a look at the surgical time. An uncomplicated T&A should take about 15-20 minutes. Any time longer than 30 minutes is a signal that complications were encountered, even if there is no notation in the surgical note.
- Operative note- was brisk bleeding encountered? This event suggests that branches of the external carotid artery were transected, which could lead to problems when the eschar sloughs at 7-10 days post-operatively. The surgeon is either too deep into the muscle bed or the branches of the external carotid were more medial than normal.
- If there is extensive intra-operative use of the electrocautery, a deeper and more extensive zone of necrosis is created, with the potential exposure of significant vessels when the eschar sloughs.
- Was thrombin or DDAVP used in the OR or immediately post-operatively? Thrombin is part of the clotting cascade, and can be used if there is excessive bleeding. DDAVP (Desmopressin or 1-deamino-8-D-arginine vasopressin) is used to treat inherited bleeding disorders such as hemophilia or von Willebrand disease, and is used empirically when a patient with presumptively normal clotting mechanisms develops abnormal bleeding. If DDAVP is used in the peri-operative period, a hematology specialist should be consulted to advise on further workup and management.
- Did the patient undergo an unanticipated blood transfusion? If so, this is a strong indication that significant bleeding was encountered.
- When was the operating room note dictated?
- Was the patient kept overnight? The vast majority of healthy patients who undergo T&A are sent home the same day. An unplanned overnight stay is an indication that the surgeon was concerned.
- Look at the condition of the patient on discharge. If there is any documentation that gives a sense that the patient is doing poorly at discharge (such as guarded or fair)?
- Did the child receive codeine after the T&A? After several deaths, the FDA has issued a “Black Box Warning,” the FDA’s strongest safety statement, and now strongly recommends against the use of codeine to manage pain in children after a T&A.
- What was the timing of the initial post-operative visit? Most surgeons see post-operative T&A patients two weeks after the surgery. If the patient is seen one week after the surgery, this could be an indication that something had gone wrong intra-operatively.
- Was there communication with the referring physician? If significant difficulties were encountered, the surgeon has an obligation to inform the referring practitioner.
- Take a look at the estimated blood loss (EBL). With modern techniques, the EBL should be 100 cc or less.
- Check to see if the nursing notes document the use of topical thrombin applied intra-operatively, particularly if the surgical notes do not discuss.
- What was the condition of the patient in the Recovery Room?
- Look at the pathology report describing the tonsils. If skeletal muscle is described, that is a clue that the surgeon was too deep in the dissection.
- Correlate the weight of the tonsils with the pre-operative physical examination. Be on the lookout for a gross difference. The size of the tonsils is clinically graded on a 5-point scale, with 4 being the largest. “4” implies that the tonsils are approaching each other in the midline. If the tonsils are touching, the condition is known as “kissing tonsils”. The mean weight of tonsils removed from children is 7.3 grams. Thus, if the indication for surgery is OSA, and the pre-operative tonsils are described as 4+, the weight of the tonsils post-operatively should be consistent.
About the Author
James C. Post, MD, PhD, MSS, FACS is a full time actively practicing and teaching subspecialist in pediatric otolaryngology (pediatric ENT) with Board-certification in Otolaryngology. Dr. Post trained at Massachusetts General Hospital, The University of Florida, and Children’s Hospital of Pittsburgh. He has organized over 300 national and international scientific presentations and meetings and published over 150 peer-reviewed papers and chapters. He serves as Professor, Otolaryngology, Microbiology & Immunology, Drexel University College of Medicine, and Professor, Otolaryngology and Microbiology, Temple University School of Medicine. Dr. Post is licensed in PA and FL and has earned multiple honors and awards, including Best Doctors in America, 1999-present, John Gorrie Award, Hamburg Fellow, Edmund Prince Fowler Award, Order of Military Medical Merit, Army Surgeon General 9A Proficiency Designator, and the Bronze Star. Dr. Post is an experienced expert witness. He can be reached at firstname.lastname@example.org