[Untreated hemothorax with fatal sequelae].

A 52-years old woman fell downstairs at home and suffered fractures of the left 9. and 10. rib. She was admitted to hospital; a small subcutaneous emphysema was seen over the fractures. Primary radiograph of the chest showed no internal complication. The patient was observed over night on intensive care unit without abnormalities. Next morning she was transmitted to the regular ward; on this way a control chest-radiography was made. A large hematothorax was seen. The radiologist tried to telephone with the surgeon at the new ward, who was not available because of operating. The nurse at phone (novice) misunderstood the message or the correct message was wrong interpreted by the other nurses in the sense that they believed that the patient had a history of (treated) hematothorax, so that no acute treatment was necessary. The surgeon was not informed, when he came later; the patient was brought from the x-ray station and nothing more happened. About 10 hours later the woman died. The radiologist has been condemned by reason of killing due to carelessness; the fine was placed on probation. In the opinion of the court the radiologist--as the only person, who knew the acute and unexpected condition of the patient--rejected against his liability to guarantee the life of the patient, since he not maked quite sure that the woman really received the needful treatment.