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News: A pregnant 39-year old woman was having seizures and went to an emergency department (ED). She was unable to communicate and share her medical history, including her pregnancy. Her eclampsia was not diagnosed, the treatment allegedly resulted in pulmonary edema and cardiopulmonary arrest. The woman died one week later. A jury returned a verdict of $800,000.
Background: The 39-year-old housewife and mother entered the ED with new-onset seizures. She was unable to give her medical history, including the important fact that she was pregnant. During an examination by the ED physician, she was found to have elevated blood pressure and protein in her urine. The diagnostic tests lead the physicians to believe that she had either encephalitis or meningitis. As fluids were being administered, she developed pulmonary edema. A chest X-ray was ordered, but it was not shown to the attending physician. During an attempt to intubate her, she went into cardiopulmonary arrest. Although resuscitated, the patient sustained brain damage and died one week later.
The plaintiff claimed that the defendants missed the diagnosis of eclampsia and, in an effort to treat what they thought was encephalitis or meningitis, was given too much fluid, which resulted in pulmonary edema and ultimately cardiac arrest. The plaintiff also claimed that if her attending physician had reviewed her chest X-ray, her underlying condition would have been properly diagnosed and treated. The plaintiff claimed that attempts to intubate and ventilate her led to a lack of oxygen and cardiopulmonary arrest.
The defendants argued that a diagnosis of eclampsia was unclear, that the patient was extremely obese, and that her husband did not know of her pregnancy. The defendants further countered that the pulmonary edema was unavoidable and was handled properly as were the attempts to intubate her under the circumstances.
The jury awarded the plaintiff $800,000, consisting of $500,000 in economic damages and $300,000 in noneconomic damages, finding the hospital 50% negligent and the physicians 50% liable.
What this means to you: As seen in the previous case, sometimes even when the patient knows his or her medical history and can describe his or her current ailments, providing the proper diagnosis can be difficult. The situation is particularly challenging when the patient is unable to provide a medical history or summary of current symptoms. Nonetheless, this type of situation occurs often, especially in EDs. The physicians who care for patients under these circumstances must assume all possibilities until those possibilities can systematically be eliminated.
"While the defendants stated that a diagnosis of eclampsia was far from clear, seizures, elevated blood pressure and protein in the urine are classic symptoms of eclampsia," says Cheryl A. Whiteman, risk manager at CIGNA Healthcare of Florida Inc. in Tampa, FL.* "Pregnancy should be considered in every female of childbearing years, and it should be recognized that pregnancy may be masked in an obese patient. Further, one should not automatically assume that a woman has shared the news of her pregnancy with her partner or perhaps even be aware of the situation herself. While there is no indication as to whether tests were done to confirm a diagnosis of encephalitis or meningitis, a pregnancy test, physical exam, and possibly ultrasound could easily have been done soon after her arrival to the ED to rule out or confirm pregnancy. Had pregnancy been determined, it is likely that the patient would not have received fluids in the amount that resulted in pulmonary edema, which would have lessened the probability of cardiac arrest."
This case also includes a "systems error," as the misplaced chest X-ray may have contributed to the failure to arrive at the correct diagnosis in a timely fashion.
"The fact that the patient’s chest X-ray was lost may have contributed to the patient’s compromised cardiopulmonary status," Whiteman explains. "Systems errors like lost films and reports never aid in the defense of a medical malpractice case against the responsible facility. The risk manager’s review of this incident should include scrutiny of the processes around management of the test results and imaging films."
*These comments do not necessarily reflect those of CIGNA Healthcare of Florida Inc.
• Girish Shah, Purvi Shah, by and through GAL, Girish Shah v. Corona Regional Medical Center, Michael Bear, MD, and Kitcha Ranch, MD, Riverside County (CA) Superior Court, Case No. 300079.