Transfer of patient in active labor leads to death

Facts

A pregnant Michigan woman went to a hospital emergency department (ED) with signs and symptoms of severe preeclampsia, but was mistakenly diagnosed with pneumonia. No treatments for hypertension or seizure prevention were administered. The emergency physician contacted the woman’s attending obstetrician, who was 45 miles away and refused to come to the hospital. The obstetrician wanted her admitted to the internal medicine service but the Internal Medicine service refused because it was determined that obstetric care was needed.

Unknown to the ED physician, the obstetrician then tried to transfer the woman to a maternal-fetal medicine  (MFM) specialist at a tertiary care center. Transfer was refused because the patient was deemed too unstable and a cesarean delivery was recommended.

The ED physician could not get the obstetrician to come in or to arrange for another obstetrician to see the patient, so he decided to transfer the patient to another hospital roughly 50 miles away even though she was now in active labor. A different MFM specialist accepted transfer, and after 5 hours in the ED the patient was taken by ambulance to the other hospital.

During transport the patient suffered a placental abruption and hemorrhage and by the time she arrived at the receiving hospital, she was in critical condition. A cesarean delivery was immediately performed, but the woman died. The infant was born severely brain damaged and later died.

In the lawsuit that was filed on their behalf claiming negligence in the patient’s treatment, it was alleged that both the mother and the baby would have survived with proper treatment.

The verdict

A $900,000 settlement was reached.

Analysis

The care of this patient in the ED in this case would be subject to the Federal Emergency Treatment and Active Labor Act (EMTALA), 42 US Code 1395dd. This statute should be well known to most EDs, physicians, and obstetricians and requires that any patient presenting to an ED with a request for examination or treatment for a medical condition must be provided an appropriate medical screening examination, including any ancillary services routinely available, to determine the presence of an emergency medical condition or active labor, regardless of the patient’s ability to pay.

The statute is very specific in its definitions of medical screening and requirements for appropriate transfer.

In this case, the care at the original hospital is problematic for the defense for many reasons. The lawsuit claimed that the ED physician not only withheld criticalinformation from the transferring physician-including the patient’s severe hypertension, proteinurea, and edema-but he also did not conduct an evaluation of the woman before departure and certified the transfer even though she was highly unstable and in active labor.

It is unlikely the care would meet the standard for the EMTALA statute, and therefore the hospital would be subject to fines as well as the malpractice case settlement.

Delay in diagnosis of ruptured uterus after prior cesarean

Facts

A 34-year-old Virginia woman was scheduled for a repeat cesarean delivery, but went into labor 9 days early in 2010. Labor progressed quickly and she delivered vaginally with no complications. After the delivery the patient complained of sharp abdominal pain, which was rated as 10/10 and unrelieved by morphine. Moderate bleeding was noted. The obstetrician decided to perform a manual exploration and dilation and curettage procedure.

After the procedure, uterine scar rupture was ruled out and the patient was treated for uterine atony. No blood products were ordered and for 1.5 hours the woman was consistently hypotensive and tachycardic; the nurses noted moderate bleeding.

The obstetrician was kept informed of the patient’s condition, including hemoglobin and hematocrit levels, which were lower than prior to delivery.

When the obstetrician came to the woman’s bedside, the patient was becoming restless and short of breath. Within minutes of the physician’s arrival she coded; she was resuscitated and blood transfusions were started.

A second obstetrician took over the woman’s care and for the next 4 to 5 hours, she was monitored closely, receiving 7 units of packed red blood cells (RBCs) and 7 units of fresh frozen plasma. Her blood results revealed low hemoglobin and hematocrit values and her bleeding was noted as being “off and on.”

The patient was ultimately taken to an operating room for a hysterectomy. She coded again and required resuscitation. By the time the operation was complete she had received a total of 14 units of packed RBCs and 14 units of fresh frozen plasma, along with other blood products. Her bleeding stopped after the hysterectomy, but she remained on a ventilator for 9 days, suffered renal failure and adrenal insufficiency, and her condition necessitated calling 2 additional codes while she was hospitalized.

The patient suffered brain damage and did not remember giving birth or the events thereafter. Her injuries required transfer to a rehabilitation facility to re-learn how to walk, talk, climb stairs, and write, and to regain her strength. She also suffered permanent kidney damage and underwent a kidney transplant from a cadaver donor approximately 1 year after the delivery.

She is expected to require at least 2 more kidney transplants in her life and will require care and medication to monitor her kidney function and possible rejection.

The woman sued those involved with the delivery and postpartum management, alleging that she had suffered a uterine scar rupture and the obstetrician was negligent in not diagnosing and treating it with a hysterectomy earlier.

The hysterectomy operative report noted a uterine scar “defect” from the prior cesarean section, and the patient argued that the medical records referred to a uterine scar “rupture” or “dehiscence” interchangeably as the source of the bleeding and hemorrhagic shock.

The defense argued that this injury was a prior uterine scar “dehiscence,” not a complete rupture, and that the conservative measures were proper.

The verdict

A $4 million verdict was returned, which was reduced to $2 million under the state cap.

Ms. Collins is an attorney specializing in medical malpractice in Long Beach, California. She welcomes feedback on this column via email to dawncfree@gmail.com.