Ruptured Esophagus
A 78-year-old man presented to the ED with symptoms of choking and chest discomfort. The patient stated that he had experienced a sudden onset of difficulty swallowing, along with chest pain, while he was eating dinner at a restaurant earlier that evening. The patient initially thought he had a piece of carrot stuck in his throat. He denied any previous history of similar symptoms. He complained of mild shortness of breath, but denied any drooling or vomiting. His medical history was significant for hypertension, which was controlled with medication. He denied tobacco or alcohol use and had no known drug allergies.
On physical examination, the patient’s vital signs were: heart rate (HR), 106 beats/minute; blood pressure (BP), 144/82 mm Hg; respiratory rate, 22 breaths/minute, and temperature, 98.6°F. Oxygen saturation was 95% on room air. The patient’s oropharynx appeared normal and without foreign body obstruction; his lungs were clear to auscultation bilaterally; and his HR was tachycardic but with a regular rhythm. Other than mild diaphoresis, the remainder of the physical examination was normal.
The EP ordered a complete blood count (CBC), a basic metabolic profile (BMP), and a portable chest X-ray, which the EP interpreted as normal. In addition, an intravenous (IV) saline lock was placed, and the patient was given morphine 4 mg IV and ondansetron 4 mg IV. He was also placed on 2 L of oxygen via nasal cannula. Since the patient continued to complain of chest pain and dysphagia, the EP consulted with a gastroenterologist; unfortunately, there was no documentation of this.
The EP admitted the patient to the floor with a diagnosis of esophageal obstruction, probably secondary to a piece of carrot. During the night, the patient’s shortness of breath worsened, requiring an increase in supplemental oxygen. The next morning, the patient’s HR increased to 120 beats/minute; his BP dropped to 96/50 mm Hg, and he developed a low-grade fever. He was transferred to the intensive care unit, where he was started on IV fluid resuscitation with normal saline and broad spectrum antibiotics. A CT scan of the chest was also ordered, which revealed an esophageal perforation. The patient was taken immediately to the operating room; surgery revealed a large esophageal perforation with evidence of mediastinitis and gross contamination of the left hemithorax. The patient died 2 days later.
The patient’s family sued the EP for failure to diagnose and treat the esophageal perforation in a timely manner. The EP argued that the patient’s symptoms were consistent with an obstruction, not esophageal perforation. The defendant also argued that the initial chest X-ray was normal. The case was resolved for $800,000 prior to going to trial.