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Legal Review & Commentary
Plaintiffs Allege Failure to Assess Severity of Condition; $11.5 Million Verdict in Illinois
by: Radha V. Bachman, Esq.
Buchanan, Ingersoll & Rooney, P.C.
Suzanne Gruszka, RN, MAS, CLNC, LHRM
a.ministrator, Clinical Support Services
Lynn Rosenblatt, CRRN, LHRM
NEWS: A 30-year-old pregnant woman presented to a hospital ER complaining of abdominal pain at a level of 10 out of 10. The woman was seen by an ER physician who diagnosed the woman as having a partial bowel obstruction. No further testing or procedures were immediately ordered, and the ER physician communicated to the surgeon that the situation was not serious. A few days after presenting to the hospital, the woman began experiencing the increased level of pain initially complained of and requested morphine. The woman's blood pressure also dropped at this time, and she was transferred to the postpartum unit. Early in the morning, the woman tried to access the rest room but became unconsciousness. It was discovered shortly thereafter that the woman had suffered a miscarriage. Ultimately, the woman underwent surgery, which uncovered that the woman's small intestine was twisted around the superior mesenteric artery, causing the small intestine to become ischmetic and necrotic. As a result, five meters of the woman's intestine were removed and she ultimately had to undergo an intestinal transplant. The woman sued the ER physician, surgeon and hospital. A jury verdict in favor the woman and against the hospital was entered in the amount of $11.5 million.
BACKGROUND: A 30-year-old woman, 14 weeks pregnant, began experiencing severe abdominal pain requiring her to leave her place of employment. She was unsuccessful in reaching her husband and ultimately called 911 and had an ambulance transport her to a local hospital. Around five hours after first experiencing the pain, the woman was seen by an emergency room (ER) physician, who determined that the pain was related to the woman's pregnancy and ordered an ultrasound. The ER physician consulted with the OB-GYN physician, who determined that the pain was not pregnancy-related. Based on this information, the ER physician then determined that the pain was related to partial bowel obstruction and consulted with a surgeon.
Fluids were ordered for the woman, and during this time her pain fluctuated between a 5 and 10 on a scale of 1 to 10. The woman's blood pressure was also not stable and at one point dropped from 126 over 72 to 87 over 52. The woman was transferred to the hospital's postpartum unit. A couple of days after being in the hospital, a nurse noted that the woman's pain had increased and that she had requested morphine. In the early morning, the woman attempted to access the rest room, where she lost consciousness and bladder control and went into septic shock. It was confirmed later that her baby had died.
Later that day, the woman underwent surgery, where it was discovered that she was suffering from a twisted small intestine which was cutting off blood supply to the intestine, causing the small intestine to become ischemic and necrotic. As a result, the surgeon was forced to remove five meters of the woman's intestine. The woman remained in the hospital for nearly a month with no fluids or food before being discharged home. Five months later, the woman developed liver failure and jaundice, and an intestinal transplant was performed in order to save her life. Following the transplant, the woman and her husband lived in a hotel while she underwent constant evaluation and biopsies. One year after the transplant, the woman was able to ingest solid foods.
The woman sued the ER physician, surgeon, and the hospital for medical malpractice and alleged that the ER physician had not recognized the severity and urgency of the woman's situation based on her medical history and sought recovery of $6.7 million in past and future medical costs. The plaintiffs, which included the unborn baby, sought wrongful death damages for loss of consortium. The woman also sought damages for psychiatric, psychological, and/or emotional injuries, as well as other unspecified personal and pecuniary damages. The woman's spouse sought compensation for loss of spousal consortium.
The plaintiffs alleged the hospital failed to recognize a significant and abnormal decrease in the woman's baseline blood pressure upon arrival in its emergency room; failed to assess her blood pressure upon arrival on the floor and compare it to her baseline blood pressure; failed to recognize her increasing heart rate; and failed to recognize pain disproportionate to the admitting diagnosis ruling out ileus for abdominal discomfort.
Specifically, the woman alleged that the hospital's nursing staff was negligent in failing to monitor her condition and call a physician when her pain increased to a 10 out of 10. At the time she requested morphine, the woman claimed, no morphine was administered and no physician was called. The plaintiff's expert agreed with the woman's claim and stated that the nursing staff should have appreciated the severity of the situation given the woman's pain and her falling blood pressure. The plaintiff introduced a number of experts in various fields that set forth damaging testimony for the defense regarding the circumstances surrounding the woman's miscarriage and ultimate need for a transplant.
Counsel for the defendants argued that the ER physician acted properly based on the diagnosis of a partial bowel obstruction and the woman's pregnancy. The hospital's counsel also maintained that morphine was administered to the woman, which was evidenced by the woman's drop in blood pressure.
The surgeon's counsel also contended that he acted within the standard of care based on the information presented. Further testimony was presented that the woman's intestine had, in fact, died approximately five hours prior to the woman presenting at the hospital.
Considering only the claims against the hospital the ED physician and the surgeon, a jury returned a verdict finding only the hospital negligent. It awarded the woman and her husband $2 million for past and future pain and suffering, $2 million for past and future loss of a normal life and $6.5 million for past and future medical expenses. It also awarded the woman, as special administrator of the estate of the unborn baby, $1 million for wrongful death.
The judge in the case entered judgment in accord with the jury verdict the same day.
Circuit Court of Illinois, Eighteenth Judicial Circuit, DuPage County, No. 05L1192
WHAT THIS CASE MEANS TO YOU: This case presents an interesting study on the interaction of various natural biological and pathological processes and the diligence that physicians and nurses must apply to the art of diagnosis and treatment.
While pregnancy is a natural biological condition, it can also be a potentially life-threatening pathological process when something unexpected and/or unnatural occurs. In the absence of a trauma-induced event, the emergency room physician appeared correct in his initial assumption that the patient may have been experiencing complications of her pregnancy.
The abdominal ultrasound would have been the first step in ruling out common complications of early pregnancy such as an ectopic pregnancy or miscarriage. The ultrasound examination will show whether the uterus contains a developing fetus or if masses are present elsewhere in the abdominal area. But the ultrasound might not be able to detect every ectopic pregnancy. The physician should also complete a pelvic exam to locate the areas causing pain, to check for an enlarged, pregnant uterus, or to find any other suspicious masses. There are also blood tests that are useful in diagnosis of ectopic pregnancy. In this case there is no indication in the narrative that any other testing was completed when the ER physician consulted with the OB-GYN physician.
Eventual miscarriage is the probable outcome of ectopic pregnancy. As the fetus grows, it will eventually burst the organ that contains it. This can cause severe bleeding and endanger the mother's life. A classical ectopic pregnancy does not develop into a live birth. Presentation of a pregnant patient with classic symptoms of ectopic pregnancy is a medical emergency that requires immediate attention, not a five-hour delay.
Her severe abdominal pain is classic of both situations. The first warning signs of an ectopic pregnancy are often pain in the pelvis and abdomen. Most women describe the pain as sharp and stabbing. It may concentrate on one side of the pelvis and come and go or vary in intensity. Additional symptoms that also suggest an ectopic pregnancy include vaginal spotting, lower-back pain, dizziness or fainting, and low blood pressure. The latter are generally attributed to blood loss.
The narrative does not indicate why the ER physician came to the conclusion that the patient's pain was attributable to a partial bowel obstruction, but he did refer the case to a surgeon, which was an appropriate course of action.
a. intestinal obstruction is a significant impairment to the passage of contents through the bowel. The symptoms include, cramping pain, vomiting, constipation, and lack of flatus. The diagnosis is usually confirmed by X-rays. Obstruction of the bowel may be partial or complete. About 85% of partial small-bowel obstructions resolve without surgical intervention; however, about 85% of complete bowel obstructions result in surgery. The standard treatment for small-bowel obstruction is IV fluids, nasogastric tube, and IV antibiotics. The patient received IV fluids; however there is no mention of a nasogastric tube, or antibiotics. It also appears that no other diagnostic studies were performed prior to her surgical emergency.
Strangulating obstruction is obstruction with compromised blood flow; it occurs in nearly 25% of patients with small-bowel obstruction (SBO). Strangulating obstruction can progress to infarction and gangrene in as little as 5-6 hours. Venous obstruction occurs first, followed by arterial occlusion, resulting in rapid ischemia of the bowel wall. The ischemic bowel becomes edematous and infarcts, leading to gangrene and perforation. If untreated, strangulated obstruction causes death in 100% of patients.
In a study conducted by Meyerson S, Holtz T, Ehrinpreis M, Dhar R., at two Detroit hospitals, it was determined that over a 20-year period, nine cases of SBO were identified and 150,386 deliveries occurred (one case per 16,709 deliveries).1 Abdominal X-rays were compatible with SBO in seven patients. Ultrasound identified SBO in one of four cases. Patients were hospitalized 6 h to 23 days before surgery. The admission diagnosis was incorrect in four cases. One patient was treated conservatively and, at 36 weeks, vaginally delivered a healthy infant. The eight surgical patients had lysis of adhesions, with one requiring resection of gangrenous small bowel. There were three fetal deaths (at 22, 24, and 30 wk of gestation). No maternal deaths occurred.
Furthermore, only one-third of patients with prenatal bowel obstruction complete term pregnancies after operative resolution of their obstruction. These findings emphasize the importance of remembering that two patients are at risk when intestinal obstruction complicates pregnancy. The delay from presentation to admission and from admission to definitive management continues to be a significant cause of morbidity and mortality. A high index of suspicion is mandated in this patient population, especially in those women presenting with a history of previous abdominal or pelvic surgery. The high incidence of necrotic bowel found in this subset of patients demonstrates the need for aggressive surgical intervention. Only through diligent and urgent intervention can the morbidity and mortality be decreased. The diagnosis and treatment of a pregnant patient suspected of having a bowel obstruction should be no different from those given to a non-pregnant one.
The conclusion was that SBO is a rare, but often catastrophic, complication during pregnancy. Clinical suspicion is critical and should be increased in a patient with abdominal scarring as internal adhesions seem to play a significant role in SBO during pregnancy. If suspected, prompt abdominal X-rays, ultrasound, and surgical consultation are warranted, all of which initially occurred in this case.
a.ditionally, the severe pain associated with obstruction will frequently subside after the initial event, particularly with rupture as the pressure is released. Then as the bowel becomes necrotic and inflammation and infection develop within the perineum, the pain intensifies. Eventually sepsis sets in and surgical intervention is the only recourse to save the patient's life. In this case, unfortunately, the patient had to endure the removal of 5 meters of her small intestine. The removal of the small intestine resulted in the patient being unable to absorb the necessary nutrients to sustain her. Patients who have their small bowel removed have different nutritional requirements. They receive nutrition called total parenteral nutrition (TPN), which is delivered through a central venous catheter. No food or fluids can be taken by mouth. The use of long-term TPN can result in complications including bone disorders, catheter-related infections, and liver failure.
The woman developed liver failure after five months, requiring an intestinal transplant. After receiving the transplant, patients can be transitioned from TPN to an oral diet, which much improves their health and quality of life. However, intestinal transplant should not be considered a cure, but a last-resort therapy, which requires diligent medication administration and close monitoring to be successful.
The ER physician apparently arrived at an appropriate diagnosis, but the surgeon decided to treat the patient conservatively, perhaps because he was under the impression that the woman's symptoms based primarily on her pain threshold were not serious. The patient was admitted to the hospital and treated palliatively with the reasonable expectation that the nursing staff would monitor her pain, vital signs, and any indications of fetal distress, reporting concerns to the managing physicians. This is where the standard of care appears to have deviated from reasonably accepted norms to a situation that most likely represented the end result of this case.
Either the postpartum staff were poorly acquainted with the dangers of bowel obstruction or they were aware but failed to report significant findings to the surgeon in a timely manner. Nurses on the postpartum unit do not frequently encounter this type of presentation as the bowel occlusion is rare. Perhaps a better situation for pregnant patients with medical complications not related directly to the pregnancy would be on a surgical unit where the nursing staff is better informed on the perils of bowel obstruction.
In this case, obviously the surgeon mounted a reasonable defense, but the hospital had some extremely weak areas to overcome. It is clear from the narrative that the documentation did not support the contention that the patient was receiving morphine as ordered and that the physician had been notified of her increased pain levels and diminishing blood pressure. In every litigation the medical record becomes the verification that the standard of care was met. The old adage "not documented, didn't occur" applies, and it becomes extremely difficult to overcome important missing documentation.
In most root-cause analyses, failure in communication is usually one of the primary causes. It appears that in this case, if there had been better communication, a more timely diagnosis could have been accomplished and may not have resulted in this serious loss.
The hospital's liability was most likely evident during pre-trial discovery, and there should have been some attempt to avoid a courtroom trial as juries are very sympathetic to any individual who not only lost a child but also required an organ transplant to remedy a serious breach in the recognized standards of care. Settlement after mediation may have proven to be more judicious.
1. Meyerson S, Holtz T, Ehrinpreis M, Dhar R. Am J Gastroenterol. 1995 Feb;90(2):299-302.