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Legal Review & Commentary
Alleged Failure to Perform Adequate Follow-Up Care and Investigate Cause of Pain Leads to $500,000 Settlement
by: Radha V. Bachman, Esq.
Buchanan, Ingersoll & Rooney P.C.
NEWS: At the age of 69, a woman underwent rectal prolapse surgery. After conducting a preoperative history and physical exam on the woman, her internist released her for surgery. The preoperative lab results showed that the woman had a hemoglobin lower than usual, indicating possible anemia. The internist informed the surgeon of the hemoglobin level, but no additional blood work was requested on the woman. Two days after the surgery, a hospital resident saw the patient, who was complaining of severe abdominal pain. The resident prescribed a muscle relaxer and discharged the woman. Two hours after discharge, the woman died. During the fourth day of trial, the hospital settled with the plaintiff for $500,000. The other defendants in the case received a directed verdict in their favor.
BACKGROUND: A 69-year-old woman underwent rectal prolapse surgery at an area hospital. This surgery is meant to treat a condition in which the rectum falls, or prolapses, from its normal anatomical position because of a weakening in the surrounding supporting tissues. Risks associated with rectal prolapse surgery include potential complications associated with anesthesia, infection, bleeding, injury to other pelvic structures, recurrent prolapse, and failure to correct the defect. The surgery was performed by a colorectal surgeon after receiving clearance from the woman's internist. Prior to the surgery, the woman had visited her internist, who had performed a presurgical history and physical and lab work. The lab work indicated that the woman's hemoglobin was 7.4, lower than usual and a possible indication that the woman may have been suffering from mild anemia. The results were discussed with the colorectal surgeon, but no additional tests were ordered by either physician, as the physicians attributed the numbers to the woman's bleeding rectal prolapse. During the surgery, the woman received multiple blood transfusions due to the ongoing loss of blood. Two days after surgery, a resident physician employed by the hospital visited the woman, who was complaining of severe abdominal pain. The resident believed that the pain was due to spasms that may have been caused by the position the woman was forced to lie in during the surgical procedure and prescribed the woman a muscle relaxant. The woman was discharged by the resident. Two hours after discharge, the woman died.
An autopsy revealed hemorrhagic pancreatitis, which caused internal bleeding and shock, resulting in the woman's death. The plaintiff alleged that the woman's hemoglobin was well below normal ranges and should have been at least 10 to allow for the loss of blood during surgery, but allowing the woman to survive. The plaintiff further argued that the colorectal surgeon should have ordered more blood during the surgery to combat the blood complication, and that the resident should have further investigated the abdominal pain.
The internist physician argued that no additional testing was required based on the low hemoglobin and that it was not his responsibility to ensure that adequate blood transfusions were accomplished during the procedure. Both the colorectal surgeon and the resident claimed that their actions were reasonable and met the standard of care. All three defendants further contended that the hemorrhagic pancreatitis complication could not have been diagnosed in advance and that no treatment is available for the condition, such that death was the inevitable outcome.
The resident and the hospital settled with the plaintiff on the fourth day of trial for $500,000. With regard to the remaining defendants, the colorectal surgeon and the internist, the court found that the alleged deviations from the standard of care were not the proximate cause of the woman's death and directed a verdict in their favor.
Cook County (IL) Circuit Court, Case No. 06L-11429
WHAT THIS MEANS TO YOU: This case of a 69-year-old woman who died two hours after hospital discharge following rectal prolapse surgery raises questionable assessment, diagnosis, and monitoring concerns. While the litigation outcome resulted in defense verdicts and a hospital settlement, what this case means to you is the importance of implementing assessment, risk-prevention, and risk-reduction strategies for all those involved in providing safe patient care. To discharge a two-day postoperative patient complaining of severe abdominal pain, with a prescription of a muscle relaxant and no diagnostic studies to confirm the source and/or cause of the pain, is a prescription for high-risk scenarios, litigation potential, and negative outcomes.
One of the risk factors in this case began with the patient's pre-op low hemoglobin result of 7.4; a normal hemoglobin range for adult females is 12-16 and for elderly females, 11.7-13.8. Physicians frequently consider blood transfusions for those with a hemoglobin level of 8 or 9. A low hemoglobin may indicate anemia, recent hemorrhage, or fluid retention which dilutes hemoglobin in the body. This test measures the severity of the anemia and also monitors response to interventional therapy. Although proceeding with surgery in a patient with such a low hemoglobin rests within the surgeon's professional judgment, reducing risks by repeating the test and considering provision of interventional therapy prior to surgery would have been prudent in minimizing bleeding risk. In addition, hematocrit levels (which also detect anemia and other abnormal blood conditions) serve as a monitor for blood loss and evaluation of blood replacement, and are important in assessing patient status and potential blood replacement needs.
It was noted in the case summary that the patient required and received multiple units of blood during the surgical procedure. This is another risk factor that might have been prevented, but still should alert all staff monitoring the patient postoperatively to the potential of subsequent additional bleeding. Signs and symptoms of bleeding can include tachycardia, tachypnea, hypotension; bleeding in the abdomen may include severe abdominal pain, tenderness, guarding, distention, rigidity, diminished or absent bowel sounds; clinical signs of hemorrhagic pancreatitis may include all of the above plus vomiting, diarrhea, fever, and basilar rates especially in the left lung.
Hemorrhagic pancreatitis is a potentially fatal inflammation of the pancreas characterized by formation of necrotic areas on the surface of the pancreas and omentum, which may lead to bleeding. Statistics related to acute pancreatitis indicate such a diagnosis in 40 cases per year per 100,000 adults. In 20% of those presenting with acute pancreatitis, there is a mortality rate of 30%. In the case presented here, the post-mortem findings of hemorrhagic pancreatitis benefited the defendants and overshadowed the failure to determine/diagnose and attempt to treat the cause of the severe abdominal pain. In a failure to order diagnostic tests case, Steeves v. United States, physicians failed to perform tests and diagnose a patient's condition; the court pointed out that "a wrong diagnosis will not in and of itself support a verdict of liability in a lawsuit. However, a physician must use ordinary care in making a diagnosis." In Steeves v. United States, failure to perform additional diagnostic studies was found to be a breach of good medical practice.
Severe abdominal pain, particularly in that of a two-day post-op patient, warranted and required thorough and methodical assessment and monitoring. What does this mean to you? To provide a prescription for pain medication at discharge in a patient with unresolved and undetermined severe abdominal pain, with no opportunity to clinically monitor the effects of the prescribed medication in respect to the pain, was careless. To discharge a post-surgical patient who was experiencing severe abdominal pain was reckless; such actions do not serve to prevent or minimize risks for the health care provider and health care organization. Most importantly, such actions do not promote safe patient care. In spite of the favorable defense verdicts, this case gives pause for reflection as to what could have been done differently to achieve a more positive outcome for the patient. While it is true the post-mortem diagnosis rendered the deviations from the standards of care not proximate to the cause of death, and ultimately the patient's diagnosis may have been fatal, to die two hours after discharge with a noted complaint of severe abdominal pain is tragic.