Did Patient Require Clearance for Surgery?

Reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Did Patient Require Clearance for Surgery?
A 36-year-old man was admitted to the defendant hospital with congestive heart failure and shortness of breath. CT angiography revealed cardiomegaly and several enlarged mediastinal lymph nodes. His medical history included cigarette smoking and ongoing treatment for tuberculosis and diabetes.

Echocardiography performed soon after the man's admission revealed diffuse hypokinesis consistent with cardiomyopathy and an ejection fraction of 30% to 35%. Two days later, a differential diagnosis was formed for the enlarged lymph nodes which included disseminated tuberculosis, infection (including the possibility of HIV), and neoplasm. A lymph node biopsy by way of mediastinoscopy was recommended.

The following day, the patient was seen by a cardiothoracic surgeon, who also recommended a mediastinoscopy and obtained consent from the patient for the procedure. That same day, an adenosine Cardiolite stress test was performed, with neither ischemia nor chest pain reported. The imaging portion of the study indicated several areas of prior infarction and an ejection fraction of 20%.

The following day, the man was seen by the defendant cardiologist, who added two cardiac agents to his medications. A plan was formulated to await results of a lymph node biopsy, scheduled for a few hours later, and to continue to follow the patient.

No complications occurred during the mediastinoscopy, but immediately after extubation, the man went into cardiopulmonary arrest. He was resuscitated but never regained consciousness. Two days later, he experience a second arrest and died.

Autopsy revealed triple-vessel coronary artery disease and a hemorrhagic septal infarction. The plaintiffs claimed that the decedent's presentation and coronary artery risk factors required that he not be cleared for surgery without undergoing coronary angiography. Angiography results, the plaintiff claimed, would have prompted bypass surgery and ensured the decedent's survival.

The defendant claimed that the treatment was proper, that a presurgery cardiac catheterization was not required, and that she had not been consulted to clear the decedent for surgery. The defendant further argued that the decedent's postsurgical cardiopulmonary arrest resulted from an adverse reaction to epinephrine and administration of 700 cc of IV fluid.

According to a published account, a defense verdict was returned.

Peritoneal Abscess, Colonic Rupture Missed
Sudden-onset abdominal pain brought a 69-year-old woman to the emergency department, where she was seen by a surgeon. He ordered abdominal CT, which was read by the defendant radiologist as showing free air. The next day a pelvic CT was read by the same radiologist, who concluded that the patient's colon appeared healthy. After undergoing a cholecystectomy the next day, the patient was soon released.

She returned to the hospital three days later with persistent pain, and a third CT scan showed free air. Exploratory laparotomy revealed a colonic rupture related to diverticulitis. In spite of aggressive intervention, the woman died several weeks later due to complications of sepsis.

The plaintiff alleged that the radiologist had misread the second CT, which had shown evidence of peritoneal abscess. The plaintiff claimed that a proper reading of this CT would have led to repair of the perforation before sepsis became fulminant.

The defense claimed that the reading of the pelvic CT was reasonable and that the woman's death was the result of comorbidities and complications from several previous surgeries.

A defense verdict was returned.

Infant Injured During (or After?) Cesarean Delivery
After a nonemergent cesarean delivery by a physician from a women's medical group in June 2001, the plaintiff infant was noted to be jittery and hypertonic, and stridor was developing, so she was admitted to a special care unit. Several hours later, the child's father noticed that her right hand was clenched in a fist except for the middle finger, which had a gash at the base.

He brought this to the attention of a nurse, who said it was probably just dried blood from the delivery. When she wiped the area, however, it began to bleed. The nurse then discovered a laceration, about 1.0 cm long and 0.5 cm deep, which extended into the bone of the finger. Two flexor tendons, the tendon pulleys, and a portion of the digital nerve had all been severed. Reconstructive surgery was performed two days later to reattach the tendons, rebuild the pulleys, and repair the nerve.

Because the infant could not participate actively in physical therapy, scar tissue developed. A second surgery was performed in March 2003 to release the tendons and nerve from the scar tissue.

By age 7, the girl had very limited use of her right middle finger and will need a third surgery to release additional scar tissue. This surgery has a success rate of only 65%, and function of the patient's finger will never be completely normal. The finger is also slightly shorter than the ring and index fingers. The plaintiff alleged res ipsa loquitur ("the thing speaks for itself").

Defense for the hospital argued that the laceration occurred during the cesarean delivery and was a known risk for this procedure. A resident obstetrician testified that she remembered the baby's hands being in the surgical field and "fighting" to come out as soon as the uterus was surgically entered. This, she claimed, was "the strangest thing she had ever seen."

Defense for the women's medical group argued that the laceration could not have occurred during the surgery based on the infant's face-down position at the time of delivery. It was alleged that the laceration must have occurred after the baby was handed off to a hospital staff member.

According to a published report, a $2,756,442 verdict was returned against the hospital. The women's medical group received a defense verdict.

Failure to Treat Ascending Cholangitis
In December 2002, a 45-year-old woman presented to the hospital with right upper quadrant abdominal pain, a urinary tract infection, and a pelvic infection. She also had a history of irritable bowel syndrome. The defendant family doctor, who had provided the patient's care for 10 years, admitted her and prescribed oral antibiotics to treat the urinary tract infection and the pelvic infection. Ultrasonography and magnetic resonance cholangiopancreatography showed a 3.0- to 4.0-cm mass at the head of the pancreas, a dilated common bile duct, and gallstones.

Lab test results included elevations in bilirubin, white blood cell count, and liver enzymes. The defendant gastroenterologist was called in for a consult.

Over the next few days, the woman's abdominal pain waxed and waned and shifted in location; her temperature dropped. After four days, her bilirubin level and white blood cell count spiked, so IV antibiotics were started. Two days later, the patient arrested and coded and remained in a coma until her death in May 2003.

The plaintiff claimed that the defendants failed to diagnose and treat ascending cholangitis from the time of the patient's admission until her cardiac arrest, resulting in sepsis and death.

The defendants claimed that the decedent did not have ascending cholangitis until two days before she went into arrest, at which time the condition was properly addressed. The defendants also claimed that there were no signs or symptoms of sepsis before that time and that the decedent had refused to consent to endoscopic retrograde cholangiopancreatography (ERCP) or surgical intervention. The defendants contended that a CT-guided biopsy was not performed because of the decedent's obesity.

The plaintiff denied that an ERCP or surgical intervention had been recommended and refused, since there was no record of this in the medical chart.

A defense verdict was returned.  

Reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Did Patient Require Clearance for Surgery?
A 36-year-old man was admitted to the defendant hospital with congestive heart failure and shortness of breath. CT angiography revealed cardiomegaly and several enlarged mediastinal lymph nodes. His medical history included cigarette smoking and ongoing treatment for tuberculosis and diabetes.

Echocardiography performed soon after the man's admission revealed diffuse hypokinesis consistent with cardiomyopathy and an ejection fraction of 30% to 35%. Two days later, a differential diagnosis was formed for the enlarged lymph nodes which included disseminated tuberculosis, infection (including the possibility of HIV), and neoplasm. A lymph node biopsy by way of mediastinoscopy was recommended.

The following day, the patient was seen by a cardiothoracic surgeon, who also recommended a mediastinoscopy and obtained consent from the patient for the procedure. That same day, an adenosine Cardiolite stress test was performed, with neither ischemia nor chest pain reported. The imaging portion of the study indicated several areas of prior infarction and an ejection fraction of 20%.

The following day, the man was seen by the defendant cardiologist, who added two cardiac agents to his medications. A plan was formulated to await results of a lymph node biopsy, scheduled for a few hours later, and to continue to follow the patient.

No complications occurred during the mediastinoscopy, but immediately after extubation, the man went into cardiopulmonary arrest. He was resuscitated but never regained consciousness. Two days later, he experience a second arrest and died.

Autopsy revealed triple-vessel coronary artery disease and a hemorrhagic septal infarction. The plaintiffs claimed that the decedent's presentation and coronary artery risk factors required that he not be cleared for surgery without undergoing coronary angiography. Angiography results, the plaintiff claimed, would have prompted bypass surgery and ensured the decedent's survival.

The defendant claimed that the treatment was proper, that a presurgery cardiac catheterization was not required, and that she had not been consulted to clear the decedent for surgery. The defendant further argued that the decedent's postsurgical cardiopulmonary arrest resulted from an adverse reaction to epinephrine and administration of 700 cc of IV fluid.

According to a published account, a defense verdict was returned.

Peritoneal Abscess, Colonic Rupture Missed
Sudden-onset abdominal pain brought a 69-year-old woman to the emergency department, where she was seen by a surgeon. He ordered abdominal CT, which was read by the defendant radiologist as showing free air. The next day a pelvic CT was read by the same radiologist, who concluded that the patient's colon appeared healthy. After undergoing a cholecystectomy the next day, the patient was soon released.

She returned to the hospital three days later with persistent pain, and a third CT scan showed free air. Exploratory laparotomy revealed a colonic rupture related to diverticulitis. In spite of aggressive intervention, the woman died several weeks later due to complications of sepsis.

The plaintiff alleged that the radiologist had misread the second CT, which had shown evidence of peritoneal abscess. The plaintiff claimed that a proper reading of this CT would have led to repair of the perforation before sepsis became fulminant.

The defense claimed that the reading of the pelvic CT was reasonable and that the woman's death was the result of comorbidities and complications from several previous surgeries.

A defense verdict was returned.

Infant Injured During (or After?) Cesarean Delivery
After a nonemergent cesarean delivery by a physician from a women's medical group in June 2001, the plaintiff infant was noted to be jittery and hypertonic, and stridor was developing, so she was admitted to a special care unit. Several hours later, the child's father noticed that her right hand was clenched in a fist except for the middle finger, which had a gash at the base.

He brought this to the attention of a nurse, who said it was probably just dried blood from the delivery. When she wiped the area, however, it began to bleed. The nurse then discovered a laceration, about 1.0 cm long and 0.5 cm deep, which extended into the bone of the finger. Two flexor tendons, the tendon pulleys, and a portion of the digital nerve had all been severed. Reconstructive surgery was performed two days later to reattach the tendons, rebuild the pulleys, and repair the nerve.

Because the infant could not participate actively in physical therapy, scar tissue developed. A second surgery was performed in March 2003 to release the tendons and nerve from the scar tissue.

By age 7, the girl had very limited use of her right middle finger and will need a third surgery to release additional scar tissue. This surgery has a success rate of only 65%, and function of the patient's finger will never be completely normal. The finger is also slightly shorter than the ring and index fingers. The plaintiff alleged res ipsa loquitur ("the thing speaks for itself").

Defense for the hospital argued that the laceration occurred during the cesarean delivery and was a known risk for this procedure. A resident obstetrician testified that she remembered the baby's hands being in the surgical field and "fighting" to come out as soon as the uterus was surgically entered. This, she claimed, was "the strangest thing she had ever seen."

Defense for the women's medical group argued that the laceration could not have occurred during the surgery based on the infant's face-down position at the time of delivery. It was alleged that the laceration must have occurred after the baby was handed off to a hospital staff member.

According to a published report, a $2,756,442 verdict was returned against the hospital. The women's medical group received a defense verdict.

Failure to Treat Ascending Cholangitis
In December 2002, a 45-year-old woman presented to the hospital with right upper quadrant abdominal pain, a urinary tract infection, and a pelvic infection. She also had a history of irritable bowel syndrome. The defendant family doctor, who had provided the patient's care for 10 years, admitted her and prescribed oral antibiotics to treat the urinary tract infection and the pelvic infection. Ultrasonography and magnetic resonance cholangiopancreatography showed a 3.0- to 4.0-cm mass at the head of the pancreas, a dilated common bile duct, and gallstones.

Lab test results included elevations in bilirubin, white blood cell count, and liver enzymes. The defendant gastroenterologist was called in for a consult.

Over the next few days, the woman's abdominal pain waxed and waned and shifted in location; her temperature dropped. After four days, her bilirubin level and white blood cell count spiked, so IV antibiotics were started. Two days later, the patient arrested and coded and remained in a coma until her death in May 2003.

The plaintiff claimed that the defendants failed to diagnose and treat ascending cholangitis from the time of the patient's admission until her cardiac arrest, resulting in sepsis and death.

The defendants claimed that the decedent did not have ascending cholangitis until two days before she went into arrest, at which time the condition was properly addressed. The defendants also claimed that there were no signs or symptoms of sepsis before that time and that the decedent had refused to consent to endoscopic retrograde cholangiopancreatography (ERCP) or surgical intervention. The defendants contended that a CT-guided biopsy was not performed because of the decedent's obesity.

The plaintiff denied that an ERCP or surgical intervention had been recommended and refused, since there was no record of this in the medical chart.

A defense verdict was returned.  

Reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Did Patient Require Clearance for Surgery?
A 36-year-old man was admitted to the defendant hospital with congestive heart failure and shortness of breath. CT angiography revealed cardiomegaly and several enlarged mediastinal lymph nodes. His medical history included cigarette smoking and ongoing treatment for tuberculosis and diabetes.

Echocardiography performed soon after the man's admission revealed diffuse hypokinesis consistent with cardiomyopathy and an ejection fraction of 30% to 35%. Two days later, a differential diagnosis was formed for the enlarged lymph nodes which included disseminated tuberculosis, infection (including the possibility of HIV), and neoplasm. A lymph node biopsy by way of mediastinoscopy was recommended.

The following day, the patient was seen by a cardiothoracic surgeon, who also recommended a mediastinoscopy and obtained consent from the patient for the procedure. That same day, an adenosine Cardiolite stress test was performed, with neither ischemia nor chest pain reported. The imaging portion of the study indicated several areas of prior infarction and an ejection fraction of 20%.

The following day, the man was seen by the defendant cardiologist, who added two cardiac agents to his medications. A plan was formulated to await results of a lymph node biopsy, scheduled for a few hours later, and to continue to follow the patient.

No complications occurred during the mediastinoscopy, but immediately after extubation, the man went into cardiopulmonary arrest. He was resuscitated but never regained consciousness. Two days later, he experience a second arrest and died.

Autopsy revealed triple-vessel coronary artery disease and a hemorrhagic septal infarction. The plaintiffs claimed that the decedent's presentation and coronary artery risk factors required that he not be cleared for surgery without undergoing coronary angiography. Angiography results, the plaintiff claimed, would have prompted bypass surgery and ensured the decedent's survival.

The defendant claimed that the treatment was proper, that a presurgery cardiac catheterization was not required, and that she had not been consulted to clear the decedent for surgery. The defendant further argued that the decedent's postsurgical cardiopulmonary arrest resulted from an adverse reaction to epinephrine and administration of 700 cc of IV fluid.

According to a published account, a defense verdict was returned.

Peritoneal Abscess, Colonic Rupture Missed
Sudden-onset abdominal pain brought a 69-year-old woman to the emergency department, where she was seen by a surgeon. He ordered abdominal CT, which was read by the defendant radiologist as showing free air. The next day a pelvic CT was read by the same radiologist, who concluded that the patient's colon appeared healthy. After undergoing a cholecystectomy the next day, the patient was soon released.

She returned to the hospital three days later with persistent pain, and a third CT scan showed free air. Exploratory laparotomy revealed a colonic rupture related to diverticulitis. In spite of aggressive intervention, the woman died several weeks later due to complications of sepsis.

The plaintiff alleged that the radiologist had misread the second CT, which had shown evidence of peritoneal abscess. The plaintiff claimed that a proper reading of this CT would have led to repair of the perforation before sepsis became fulminant.

The defense claimed that the reading of the pelvic CT was reasonable and that the woman's death was the result of comorbidities and complications from several previous surgeries.

A defense verdict was returned.

Infant Injured During (or After?) Cesarean Delivery
After a nonemergent cesarean delivery by a physician from a women's medical group in June 2001, the plaintiff infant was noted to be jittery and hypertonic, and stridor was developing, so she was admitted to a special care unit. Several hours later, the child's father noticed that her right hand was clenched in a fist except for the middle finger, which had a gash at the base.

He brought this to the attention of a nurse, who said it was probably just dried blood from the delivery. When she wiped the area, however, it began to bleed. The nurse then discovered a laceration, about 1.0 cm long and 0.5 cm deep, which extended into the bone of the finger. Two flexor tendons, the tendon pulleys, and a portion of the digital nerve had all been severed. Reconstructive surgery was performed two days later to reattach the tendons, rebuild the pulleys, and repair the nerve.

Because the infant could not participate actively in physical therapy, scar tissue developed. A second surgery was performed in March 2003 to release the tendons and nerve from the scar tissue.

By age 7, the girl had very limited use of her right middle finger and will need a third surgery to release additional scar tissue. This surgery has a success rate of only 65%, and function of the patient's finger will never be completely normal. The finger is also slightly shorter than the ring and index fingers. The plaintiff alleged res ipsa loquitur ("the thing speaks for itself").

Defense for the hospital argued that the laceration occurred during the cesarean delivery and was a known risk for this procedure. A resident obstetrician testified that she remembered the baby's hands being in the surgical field and "fighting" to come out as soon as the uterus was surgically entered. This, she claimed, was "the strangest thing she had ever seen."

Defense for the women's medical group argued that the laceration could not have occurred during the surgery based on the infant's face-down position at the time of delivery. It was alleged that the laceration must have occurred after the baby was handed off to a hospital staff member.

According to a published report, a $2,756,442 verdict was returned against the hospital. The women's medical group received a defense verdict.

Failure to Treat Ascending Cholangitis
In December 2002, a 45-year-old woman presented to the hospital with right upper quadrant abdominal pain, a urinary tract infection, and a pelvic infection. She also had a history of irritable bowel syndrome. The defendant family doctor, who had provided the patient's care for 10 years, admitted her and prescribed oral antibiotics to treat the urinary tract infection and the pelvic infection. Ultrasonography and magnetic resonance cholangiopancreatography showed a 3.0- to 4.0-cm mass at the head of the pancreas, a dilated common bile duct, and gallstones.

Lab test results included elevations in bilirubin, white blood cell count, and liver enzymes. The defendant gastroenterologist was called in for a consult.

Over the next few days, the woman's abdominal pain waxed and waned and shifted in location; her temperature dropped. After four days, her bilirubin level and white blood cell count spiked, so IV antibiotics were started. Two days later, the patient arrested and coded and remained in a coma until her death in May 2003.

The plaintiff claimed that the defendants failed to diagnose and treat ascending cholangitis from the time of the patient's admission until her cardiac arrest, resulting in sepsis and death.

The defendants claimed that the decedent did not have ascending cholangitis until two days before she went into arrest, at which time the condition was properly addressed. The defendants also claimed that there were no signs or symptoms of sepsis before that time and that the decedent had refused to consent to endoscopic retrograde cholangiopancreatography (ERCP) or surgical intervention. The defendants contended that a CT-guided biopsy was not performed because of the decedent's obesity.

The plaintiff denied that an ERCP or surgical intervention had been recommended and refused, since there was no record of this in the medical chart.

A defense verdict was returned.