This is no ordinary case for us, as it involves Sharon's 72-year-old grandmother, who is no longer with us. She presented to a hospital with complaints of abdominal pain and jaundice persisting for three days. She had a history of mild hypertension, drug-induced lupus and a partial hysterectomy for fibroids. She was admitted to rule out gallstones. After a failed endoscopic retrograde cholangiopancreatography due to encountering a severe stricture, the plan was to proceed with a percutaneous transluminal coronary angioplasty and to place a catheter to drain the bile.
She was taken to the radiology department in stable condition and with stable vital signs. With the exception of her abdomen, her physical assessment was essentially negative. During the course of the PTCA, she experienced several episodes of hypotension. She was treated with fluid boluses, but the hypotension recurred throughout the procedure. Upon completion of the PTCA, the patient's abdomen was grossly distended and she was complaining of severe abdominal pain.
A CT scan revealed what appeared to be a bleed. Staff informed the family that the patient had "developed a bleed during the course of the procedure" and would have to be transported by helicopter to a hospital that could handle the surgical repair. She was taken to ICU and prepared for transfer. About two hours had elapsed from the first episode of hypotension until doctors decided to transfer the patient out of the facility.
Coroner rules a medical misadventure
Upon arrival at the level I trauma unit, the patient's condition was critical - she was unresponsive and was taken into surgery immediately. The surgeon placed two sutures to repair the tear in the hepatic artery, but by this point she had lost a vast amount of blood and had received several units of packaged red blood cells and fresh frozen plasma.
Later that evening, her kidneys began to fail and she developed disseminated intravascular coagulation. All treatment options at this point were ineffective. About 12 hours after the PTCA procedure was initiated, the patient went into cardiac arrest and died. Since the patient had died less than 24 hours after being admitted to the trauma unit, the local county rule mandated a coroner's inquest. The official manner of death was ruled a medical misadventure.
The central issues
The med mal case focused on two key questions:
- Was the radiologist liable for failing to diagnose a bleed in a timely manner?
- Once the bleed was identified, was the surgeon in charge of the case liable for not proceeding to surgery in order to stop the bleed?
The plaintiffs alleged that the radiologist failed to diagnose the bleed in a timely manner. The patient showed clinical signs of an internal bleed shortly after introduction of the catheter, such as hypotension, tachycardia, progressive distension of the abdomen and complaints of increased abdominal pain.
The defense focused on the fact that bleeding is a known risk of PTCA, and that this complication can occur even in the absence of negligence. Factors other than a bleed could have caused the patient's clinical symptoms, said the defense. Specifically, during trial, the radiologist testified that he thought the patient was potentially experiencing a myocardial infarction. But the defense lawyer, evidently inexperienced in medical malpractice, failed to ask the physician what his course of action was after he determined that the patient was having an MI. The record did not reflect the usual course of action, such as application of O2, EKG, ASA, CPK MB or troponin levels. Instead, the physician completed the procedure and sent the patient for a CT scan despite the fact she'd have to wait another 45 minutes for a machine to become available.
Shortly after the suit was filed, the surgeon settled for a confidential amount. At the close of the defendant's case, the radiologist's testimony focused on the surgeon's involvement and why he chose to settle the case. The plaintiff immediately moved for a mistrial, which was granted.
Six months later, the second trial commenced. This time, without incident, the jury returned a defense verdict.
On a personal level
As we said at the outset, this was no ordinary case for us. It was also the loss of a mother, grandmother and best friend. At the time, Sharon wasn't yet a lawyer, but she was a nurse, and this incident gave her an appreciation that all of our patients are others' loved ones. They're not MIs, urosepses, pneumonias or symptoms of unknown etiologies.
Risk management has become such an ominous force in today's healthcare arena with the advent of patient safety committees, increased policies and procedures, designation of patient safety officers, and more and more regulatory red tape. We're all practicing at our best and safest when we employ simple common sense and sensitivity. Regulatory compliance is an absolute must, however. Proceeding with every patient as though she was a cherished loved one is at times the best thing we can do for the health and safety of our patients and their families.
As for my grandmother, I miss her more than anything, I have a lot of guilt associated with her death because I was the nurse in the family and I wasn't at the hospital when the incident occurred. I will always wonder if my being there would have altered the outcome in any way. Perhaps not, but I can only hope that the patients that came after her in that radiology department were in safer hands from that day forward.