Wait, What? Neil Armstrong Died From Botched Surgery!?

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"First Man" Neil Armstrong, having been feted last week on the 50th anniversary of his heroic journey, now appears again on the front pages of the New York Times and Cincinnati Enquirer, this time as the victim of alleged medical malpractice.

And a community hospital in the Cincinnati suburbs, having paid $6 million in what it thought was a confidential settlement 2 years after Armstrong's death in 2012, now finds itself accused of bad care.

Having survived all the risks of space flights in balky rockets and underpowered lunar landers, Armstrong met his end at age 82 after cardiac bypass surgery after which he was up and walking in the halls.

According to leaked documents -- including expert medical reports reviewed by both newspapers but not made fully available to the public -- Armstrong died after suffering a cardiac tear when a pacing wire, routinely placed on the surface of his heart during cardiac bypass surgery, was removed and he suffered bleeding and low blood pressure.

Attempts at treatment first in a catheterization lab and later in an operating room over less than a 2-hour period did not prevent extensive organ damage from low blood pressure, and he died several days later.

Both of the news stories leave a lot of medical and legal questions unanswered. That's because legal records are sketchy and the medical records have so far been examined by the two papers who posted almost simultaneous reports but did not work together, according to Anne Saker who broke the story for the Enquirer.

Temporary pacing wires are often placed at surgery, either on the surface of the right or left ventricle, and sometimes on the surface of the atrium. And they're secured by a slight curve in the tip of the thin pacing wires with or without a stitch.

With bypass surgery, the wires are usually pulled at the bedside on the 2nd or 3rd postoperative day.

One experienced cardiac surgeon I spoke with says these days, wires are not even placed in patients for routine bypass surgery who don't have pre or intra-operative rhythm problems.

But when the wires are pulled, there has to be care. If there is too much tension, pulling too hard could rip the surface of the heart, causing life-threatening bleeding into the pericardial space around the heart, as apparently happened in Armstrong's case.

I spoke with two experienced cardiac surgeons about the reported events in the Armstrong case.

The first surgeon said the left ventricle is usually more vascular than the right ventricle, which has a thinner wall, and the wall of the atrium is even thinner than the right ventricle.

He never has a nurse pull the wires, as the Timesreported occurred with Armstrong. But some surgical teams have physician assistants pull the wires. Still, he has never had a complication like the one that led to Armstrong's death in over 30 years of practice.

Another surgeon told me that if there is tension on a wire, most surgeons would just cut the wire at the skin and let it retract in. In fact, he said some surgeons always clip the wires and never pull them out.

He agreed with an expert for the Armstrong family that once pericardial tamponade was diagnosed at the bedside, Armstrong should have been taken immediately to the operating room for prompt exposure of the heart and stabilization of the bleeding.

But the first cardiac surgeon said he would have even cut open a pericardial window at the bedside to control the bleeding if the patient were in extremis. Or gone to the cath lab to directly view the pericardium and the surface of the heart to stem the bleeding.

From a legal standpoint, these initial accounts of Armstrong's family's threatened lawsuit and actual settlement show how the family of this reclusive, but world-famous person, benefitted handsomely both from his fame and from Ohio being a state without severe tort reform.

The amount of the settlement is enormous for the death of an 82-year-old retired man. Defense counsel usually point out that 82-year-olds have exceeded their life expectancy and have no earning capacity, therefore no economic damages.

But Armstrong wasn't just any person. The attorney for his grandchildren termed him "iconic in the history of mankind." And he still could command enormous speaking or consulting fees if he chose to. That would generate actual economic damages/lost income.

Scott Perlmuter, a Cleveland trial attorney, not connected with this case, explained that the $6-million settlement was not out of line for a person of Armstrong's stature, especially since damage caps do not apply to wrongful death claims in Ohio and the hospital wanted to avoid the negative publicity it is now getting.

To be fair, the hospital did produce expert reports which did not find the hospital at fault, and it's not known from the news accounts how much the hospital or its employees were involved in the alleged negligent actions.

Nor do we know whether Armstrong was on anti-platelet agents or anticoagulants at the time the wires were pulled.

From a legal perspective, in states with caps on damages and in a non-famous person, this would have been a hotly contested malpractice case with no guarantee of a favorable outcome for the family. And for sure, it would have been a case involving the exercise of clinical judgment.

Brant S. Mittler, MD, JD, has been a cardiologist in private practice in San Antonio for the past four decades and has a litigation practice in healthcare law.

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