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Legal Review & Commentary
Hospital's alleged failure to recognize syndrome leads to permanent injuries, $800,000 settlement
By Radha V. Bachman, Esq.
Buchanan, Ingersoll & Rooney, PC
Leilani Kicklighter, RN, ARM, MBA, CHSP,
The Kicklighter Group
News: A 58-year-old man presented to his local VA hospital with lower back pain and left leg pain. The decision was made to perform a laminectomy. Prior to surgery, the man had no problems with bowel function, urination, or sexual function. A short while later, the man underwent the recommended back surgery. Following the surgery, he began experiencing pain in his right leg as well as numbness in the scrotum. The man was ultimately diagnosed with saddle anesthesia and was taken back to surgery approximately two weeks later. Following the surgery, the man's condition did not improve. He was discharged. A month later, the man was seen by a neurosurgeon and was told that the saddle anesthesia and related symptoms were permanent. The man settled with the United States government pre-trial for $800,000.
Background: After experiencing lower back pain and left leg pain, which became worse with physical activity, a 58-year-old retiree presented to his local VA hospital. The ED physician recommended the man receive an L4-5 and L5-S1 laminectomy with transforaminal lumbar interbody fusion at L4-5. During the preoperative examination, the man did not complain of weakness or problems with bowel function, urination, or sexual function.
The surgery was performed as recommended. Shortly after the surgery was complete, the man began complaining of numbness in the scrotum, inability to feel sensation, and a dull sensation in his right leg. Over the course of the day, the symptoms became increasingly worse such that by the evening, the man was numb from the waist down. The man was diagnosed with saddle anesthesia, a loss of sensation restricted to the area of the buttocks and perineum and frequently associated with cauda equina syndrome. The neurosurgeon on call was notified of the man's symptoms and diagnoses, but no additional tests or exams were conducted. Two days after the surgery, the man's epidural drain was removed. Four days after the surgery, the man was unable to void after the catheter was removed. A neurological exam ultimately concluded that the man had no sensation in the perineum, buttocks, or either foot.
The man was taken back to surgery for thecal decompression and exploratory surgery. He was discharged after the surgery with little improvement in his condition. Approximately a month and a half after the second surgery, the man visited another neurosurgeon who indicated that the man's saddle paresthesia, penile/scrotum anesthesia, urinary and fetal incontinence, paresthesia lateral and posterior aspects of both legs and pedal and lower extremity edema had persisted for too long and were now permanent.
A follow-up evaluation was conducted by another VA hospital in the area. The man was diagnosed with cauda equina syndrome and chronic pain syndrome. Cauda equina syndrome has been defined as low back pain, unilateral or usually bilateral sciatica, saddle sensory disturbances, bladder and bowel dysfunction, and variable lower extremity motor and sensory loss usually due to mechanical compression of the cauda. The VA physician entered a note that the man's symptoms shortly after surgery were manifestations of cauda equina syndrome and that immediate action should have been taken.
The man and his wife sued the United States alleging that postoperative changes were symptoms of cauda equina syndrome and that immediate action should have been taken to reduce pressure on the cauda equina nerves. The government's failure to timely respond to the symptoms fell below the standard of care. The man sued for damages and pain and suffering. The man's wife alleged loss of consortium. The government settled with the plaintiffs pretrial for $800,000.
What this means to you: As a result of this situation a 58-year-old man who apparently had a good quality of life with respect to his physical abilities is now wheelchair bound. Would this unfortunate devastating untoward outcome have been the same if intervention had been timely? That question remains unanswered.
This patient care scenario, as it is presented here, is a risk management challenge because it tends to raise more questions than answers. This scenario would appear to require several root cause analyses, such as one for the ED and the actual surgery, one for the overall care on the post-op unit, one for the medical aspects from initial admission to discharge, and then one overall to address the various issues in this unfortunate situation. In this particular scenario, in addition to the root cause analyses, this entire situation should be referred for a formal peer review evaluation, perhaps more than one, depending on the specialties of the physicians involved and how the peer review process is structured at the VA system.
If indeed the ED physician made the recommendation to the patient to have surgery, one would wonder the qualifications of the ED physician to make such a call, and upon what signs, symptoms, and test results the ED physician based his medical decision and recommendation. Those areas would be ones to further investigate from a risk-exposure and a standard-of-care view. Was the recommended surgery even appropriate? Furthermore, we do not know the specialty of this particular ED physician or whether he/she is a resident or an attending. At this particular VA facility, does the ED physician also perform the surgery? This area is the first challenge: To determine, within the VA Emergency Department structure, in addition to the culture, what is the process for evaluating patients, calling for consults, and making definitive surgical diagnoses. The thread needs to be followed to determine if, when the patient is handed off to the surgical specialist, the specialist acts independently to review and evaluate test results and to order additional tests as might be appropriate to arrive at an independent diagnosis and treatment conclusion. Or, does the specialist assuming the care of the patient take the ED physician's diagnosis and treatment conclusion and follows through on that without further review? In this set of facts, we do not know the specialty of the surgeon who performed the initial surgery either.
From the facts we are provided with, it appears the initial surgery was not done by a neurosurgeon since one was called in on consult after surgery. Our facts indicate the neurosurgeon was notified of the patient's postoperative signs and symptoms, but it does not indicate that the patient actually was seen and evaluated by the neurosurgeon. The diagnosis of cauda equine syndrome was made, and a call put out to the neurosurgeon, though we do not know who made that call. It would seem from the evaluation and comments made by the subsequent consultant evaluation at a different VA hospital that there is some urgency in reversing this syndrome to prevent permanent damage. The facts seem to indicate that the urgency required was not apparent to the parties involved. This raises another challenge for risk management and the peer review and root cause analyses: knowledge of the indications for the initial surgery, the appropriate intervention when the diagnosis is made, and why those interventions were not carried out.
Another issue to analyze and consider is the consult contact when the patient first began having the signs and symptoms. What is the practice for actual time of response? Do this system and the hospital use SBAR or other such communication process to be sure thorough and appropriate information is conveyed when contacting consultants and other physicians/surgeons? (SBAR is a formalized method of communicating with other healthcare practitioners used to report to a provider a situation that requires immediate action, to define the elements of a handoff of a patient from one caregiver to another, and in quality improvement reports.) Was that method used in this situation? Why didn't the neurosurgeon who was contacted evaluate the patient given the patient's history, surgery, and current signs and symptoms postoperatively?
The findings of the peer review process and root cause analyses will give some direction on how to address the many questions this case raises. This particular situation is an example of risk exposures on many levels, all intertwined to create an interesting risk management challenge to address.
United States District Court, C.D. California, Western Division, Case No. 2:2009cv06601.