Was this postsurgical complication properly managed?

Facts

A 41-year-old G3P1 woman signed consent for a tubal ligation on February 17, 2010. She was diabetic and obese (5 ft, 1 in and 188 lb). Preoperative testing, which consisted of a chest x-ray, EKG and blood workup, was performed at the defendant hospital on February 26, 2010.

On March 5, 2010, the patient presented for the tubal ligation. A consent was signed authorizing resident Dr. A to perform a bilateral tubal ligation. The risks of the procedure were bleeding, blood transfusion, infection, injury to the surrounding viscera, conversion to laparotomy, failure of procedure, and ectopic pregnancy.

According to the operative note dictated and signed by Dr. A, Dr. A and Dr. B performed the procedure. A 10-mm incision was made in the infraumbilical fold and was then carried down using blunt dissection with Kelly clamps. The surgeons encountered difficulty in reaching the fascial layer “due to a very thick subcutaneous fat layer.” Attending Dr. C was called for an intraoperative consult, and introduced a Veress needle into the peritoneal cavity, confirmed placement, and then placed a trocar and sleeve. The placement was confirmed by laparoscope. The placement of a second trocar was done under direct visualization. The fallopian tubes were then fulgurated, closing them off, the instruments were removed and the field was inspected by laparoscope. The inspection was negative and the patient was closed.

The patient was transferred to the recovery room in stable condition, accompanied by Dr. A and Dr. B. While in the recovery room, the patient received Toradol at 10:55 am for complaints of pain of 10 on a scale of 1 to 10. Morphine was given at 11:45 am, which reduced her pain level to 5/10. At 1:28 pm, a nurse wrote a discharge note that documented an elevated pulse of 84 (the patient’s pulse was 60 on admission). She was discharged at 1:52 pm.

The patient re-presented to the defendant hospital’s emergency department (ED) at 8:54 pm with tachycardia (110) and complaints of “constant aching.” Her respiratory rate was normal. Her blood glucose was elevated at 261. Her hemoglobin and hematocrit were essentially the same as they had been on admission earlier that day. However, her white blood cell count was elevated at 12.1 (it had been 6.4 preoperatively) with a left shift.

A morphine IV push (10 mg) was given at 9:35 pm, on order by defendant Dr. D. By midnight, the patient was feeling better. A nurse noted that Dr. A saw the patient and recommended to see the patient in the clinic. (There is no note by Dr. A.) There is a gap in the records until Dr. D wrote a note at approximately 4:14 am on March 6, 2010. The patient may have left at midnight, according to a nurse’s note, which indicates the patient had a “steady gait." The discharge sheet with the instructions given to the patient is not contained within the medical records.

Conversations with Dr. D and Dr. A present a conflict in the events that transpired. Dr. D states he handed the chart to Dr. A for a consult even though a formal consultation request is not documented. Dr. A states she spoke to the patient, but was not asked to do a consult and did not perform one. Neither Dr. D nor Dr. A ever notified co-defendant attending Dr. C that the patient was in the ED postoperatively.

The patient returned to the hospital via ambulance on March 6 at 5:19 pm with complaints of abdominal pain. Her blood pressure was 108/70, and she was tachycardic with a pulse of 141. The triage nurse noted that the patient was unable to provide a reliable history regarding her underlying clinical condition. A family member reported that the pain worsened after the patient was discharged and that she had increased abdominal girth, weakness, lethargy, shortness of breath, and chest pain. The history was documented at 7:20 pm (although she initially presented about 2 hours earlier). Her blood glucose was 327.

An immediate bedside U/S was performed by Dr. E. The study showed free fluid throughout the lower abdomen. Dr. E called in a stat gynecological consult and requested the chief and attending to prepare the OR. Nonparty attending gynecologist Dr. F noted at 7:20 pm that the patient’s abdomen was distended with positive rebound. Her blood pressure was 85/67, heart rate 120, and respiratory rate 40. Dr. F’s impression was hemorrhagic shock.

Dr. F took the patient to the OR for an exploratory laparotomy. Upon entry into the peritoneal cavity, approximately 600 cc of copious fecal material and pus were elicited. The anesthesiologist was aware of the suspected diagnosis of septic shock secondary to fecal peritonitis. At the beginning of the ligament of Treitz, the bowel was run, revealing a small through-and-through puncture site in the small bowel exuding fecal matter. Dr. F called in an emergency surgical intraoperative consultant who performed a small bowel resection and end-to-end anastomosis. The perforation sites in the middle part of the small intestine were identified as 2 small perforations about 4 mm each in diameter and 1 cm apart from each other. There was a small through-and-through perforation of adjacent mesentery without mesenteric hematoma or bleeding noted. A segment about 5 cm long was resected from the small intestine.

During the resection procedure, the patient developed desaturation and diminished breath sounds of the left chest, followed by cardiac arrest. The patient coded at 8:52 pm. Cardiopulmonary resuscitation was started. A pneumothorax was suspected because of diminished breath sounds on the left side, and left chest tube thoracotomy drainage was performed. Codes were again called at 9:20 pm, 9:37 pm, and 9:49 pm. The patient did not respond to continued cardiopulmonary resuscitation. She expired at 9:59 pm. According to the autopsy, the primary cause of death was peritonitis secondary to small bowel perforations.

Allegations

The plaintiffs claimed that the defendants negligently performed the tubal ligation by only utilizing a 10-mm incision for trocar placement, causing a bowel perforation that they failed to recognize and repair in a timely manner. They further contended that the patient was not adequately evaluated on either the March 5 or March 6 return to the hospital ED, and that the failure to notify the attending ob/gyn of the patient’s return resulted in improper and premature discharge without an accurate diagnosis of perforation and sepsis. They asserted that, as a result, the patient went into septic shock and ultimately expired.

Discovery

The ED expert was unable to defend the care given in the first ED visit and found departures on the part of Dr. D and Dr. A in that a gynecological consult must be obtained on a postoperative patient 7½ hours after discharge from surgery when she presents to the ED with abdominal pain. Our expert felt this was very likely a preventable death. While an ED attending would not be expected to perform an U/S under these circumstances, a gynecologist most likely would have performed an U/S had a proper consult been obtained.

Further, the complaint of abdominal pain was not appropriately assessed. This patient had complaints of pain 10/10 with the pain medication Toradol already on board. A maximum amount of morphine permitted in one dose (10 mg) was given in an IV push, which our expert felt masked the pain. The patient was discharged with these 2 drugs on board, but the etiology of the pain was never determined. Additionally, while Dr. D reviewed the complete blood count and differential with respect to the Hgb and Hct, he missed the signs of sepsis already beginning with the left shift in the differential. Had the patient been admitted and administered antibiotics, our expert felt, she likely could have survived.

Our expert ob/gyn could not defend the care given by Dr. D or Dr. A. He found no departures in the standard of care by co-defendant attending Dr. C, although he felt that Dr. C and Dr. A exercised poor judgment in making only a 10-mm incision on this obese patient without documentation of attempting to enlarge it once problems were encountered. A closed laparotomy was then undertaken, which was when the perforation likely occurred.

With respect to the ED care, our expert found it inexplicable that defendant Dr. A participated in the surgery earlier in the day, dictated the OR note at 6 pm, and saw the patient later that evening in the ED, yet claimed she was not asked to do a consult on the patient and therefore did not examine the patient, write a note, or notify the ob/gyn attending. He also felt that Dr. D did not do anything to evaluate the cause of the abdominal pain and should have done “something,” such as abdominal x-ray, U/S, or CT-scan. Instead, he medicated her with morphine and discharged her without determining the etiology of her pain.

Outcome

The case settled prior to engaging in pretrial depositions of the parties for $1,000,000 as to the hospital, ob/gyn resident Dr. A, and ED attending Dr. D; with attending Dr. C contributing another $250,000 for her release.

Analysis

This difficult defense-a young woman dying shortly after a routine tubal ligation-was further complicated by conflicting reports about who said what to whom and when. There was disagreement between Dr. D (the ED attending), who believed he had asked ob/gyn resident Dr. A (who had assisted in the tubal ligation) to consult on and evaluate the patient, and Dr. A, who denied this and claimed to have “just said hello” in passing. In the absence of having a consult documented within the chart, Dr. D’s discharge of the patient was premature, and the failure to evaluate the patient, who had just been operated on and was now back in the hospital complaining of pain, was a departure on the part of Dr. A.

Furthermore, notification of attending Dr. C, who had operated on the patient, was warranted because a more experienced pair of eyes, ears, and hands may have recognized the signs and symptoms of post-tubal ligation bowel perforation. Rather than risk a verdict at trial, or having Dr. D and Dr. A further complicate the defense by testifying in a conflicting manner at deposition, our team decided to resolve the case before engaging in more meaningful, and potentially harmful, discovery.

Often an unwanted result balances the tightrope between known complication and departure from good practice. When the entire constellation of events, taken as a whole, however, reveals a series of missteps and mishaps surrounding that sentinel event, it becomes increasingly difficult to defend that initial complication and its aftermath as something that can occur in the absence of negligence.