An 80-year-old female with a history of stroke, hypertension, coronary artery disease and diabetes presented for placement of a gastrostomy tube. As a result of the stroke, she had significant dysphagia and had to be fed by way of duotube for many weeks until her family agreed to have a permanent G-tube placed.

The patient underwent the G-tube placement without difficulty. But because she had a history of pulling out her IV lines as well as the duotube on countless occasions, staff applied an abdominal binder and wrist restraints immediately after the procedure to prevent her from pulling out the newly inserted G-tube. Tube feedings were started the day after surgery. The patient's assessment was unremarkable until the fourth post-op day, when she began to spike temps. Her temperature was 38.2?C. Blood cultures were negative. The patient was watched closely throughout the night. By 6 a.m., the patient was cold and diaphoretic. She had tachycardia. Her blood pressure was 90/palp. She had rales one-third of the way up on the right and half the way up on the left. The patient was transferred to ICU, where she required intubation and vasopressors.

After a battery of tests, she was diagnosed with septic shock. The source was a tube leak that led to massive peritonitis. During an exploratory laparotomy, the surgeon drained 1,500cc of purulent fluid from her peritoneal cavity. She was transferred back to the ICU, where she had a turbulent recovery. She was discharged to a nursing home four weeks later.

T-fasteners and restraints
The family filed suit on her behalf, alleging that the physician breached the standard of care during the insertion of the tube by failing to use more than one T-fastener. Had the physician used multiple T-fasteners, the suit alleged, he would have created an airtight seal at the site of insertion and thereby decreased the possibility of a leak. The family also named the hospital as a defendant, alleging that the nursing staff didn't properly restrain the patient - specifically noting that the failure to place hand mitts on the patient breached the standard of care.

The plaintiffs claimed that the patient had pulled the tube and caused it to dislodge, thereby leading to the tear that let the tube infuse into the peritoneal cavity, causing a systemic infection and resulting shock. They relied on medical literature to support their position concerning the restraints. The medical literature supported the use of restraints in patients who were agitated and confused when feeding tubes were in use.

The plaintiffs produced the treating trauma surgeon as a testifying witness. The surgeon was the attending for the patient once she was admitted into the ICU and diagnosed with septic shock. He testified that the physician responsible for the tube placement didn't take into consideration that the patient was a known tube-puller and that he should have taken greater care in determining whether there was a proper seal. Interestingly, while under the care of this physician, she lay in ICU for 12 hours before the surgeon made a definitive diagnosis and began treatment. The plaintiff never contended any wrongdoing on behalf of this surgeon for delaying treatment of the peritonitis despite the notion that every minute counts under such circumstances.

Three-pronged defense
The physician-defendant argued that

• the use of one T-fastener was within the standard of care and the use of multiple T-fasteners wouldn't have increased the likelihood of an air-tight seal (medical literature supported both methods)
• there was no objective evidence to support the plaintiff's position that the tube had been pulled, causing the tube feeds to leak into the peritoneal cavity (the medical record documented the continuous use of the abdominal binder and wrist restraints throughout the patient's admission) and
• a leak can occur in the absence of negligence and that this particular plaintiff was at an increased risk of developing an infection due to her history of uncontrolled diabetes.

The plaintiff's initial demand was $350,000. The case ultimately went to trial because the defendants didn't consent to settle the case. At trial, the plaintiff's expert admitted that he had never placed a G-tube, yet was able to offer an opinion based on his experience that was derived through his readings. After five days of testimony, the case went to the jury, which returned a unanimous verdict in favor of the defendants after deliberating for only one hour.