Allegation
Failure to timely and appropriately diagnose and treat sepsis, resulting in kidney and respiratory failure and the ultimate the death of a 62 YOF.
Case Details
A 62 YOF was admitted for repair of abdominal wall defect, incarcerated hernia, and lysis of adhesions. Her extensive medical history included abdominal pain, anemia, and multiple malignancies. She previously had a colon resection with an anastomotic leak requiring revision surgery. During the second surgery, the surgeon excised a section of abdominal wall skin and soft tissue.
Post surgery, the patient experienced respiratory depression that required Narcan. She initially showed signs of improvement, but her condition later deteriorated, and she experienced abdominal pain, low blood pressure, and elevated creatinine levels, indicating potential complications. By the third postoperative day, she had shortness of breath, malaise, and concerning vital signs. She had significant drainage from her close suction drain, with venous blood draining from the left and right abdominal drains and ecchymosis throughout the abdomen. Also, the patient’s urinary output postoperatively was critical, given the increased fluid intake and her creatinine levels rising to 3.7. Her hemoglobin dropped from 11.5 to 7.2, and she remained drowsy and unresponsive, even after receiving two units of packed red blood cells. That evening, severe metabolic acidosis and worsening hypoxia were observed, leading to her transfer to the ICU. Despite multiple attempts, the respiratory therapist was unable to obtain arterial blood gases, and fluid overload became a concern due to extensive fluid administration. Lasix was administered, and an arterial line was requested. The patient was intubated, and care was handed over to the on-site ICU physician.
In the ICU, the defendant critical care physician conducted a telemedicine consult, noting increased shortness of breath and declining kidney function. A chest X-ray showed low lung volumes and basilar atelectasis but no pulmonary edema or pneumothorax. Vital signs indicated a temperature of 97.0°F, heart rate of 126, and blood pressure of 128/50. The physician’s assessment indicated worsening acute kidney injury, prompting a plan to avoid nephrotoxins, continue ketorolac tromethamine, adjust medications for renal impairment, recommend a nephrology consult, and order a renal ultrasound. Sepsis Protocol was marked N/A. Close monitoring and further evaluation were necessary to address her deteriorating condition. Importantly, even though orders were placed during the telehealth video visit, some of those orders were later overridden by the in-person treating surgeon, highlighting a challenge of telemedicine—the physician is not always aware if the given orders are implemented.
Later in the evening, the ICU physician responded to reports of hypotension and tachycardia by ordering norepinephrine bitartrate to support blood pressure. The patient’s condition continued to deteriorate overnight, with worsening metabolic acidosis and signs of sepsis. An exploratory laparotomy was suggested, but the patient was hemodynamically unstable.
Morning lab results indicated persistent acidosis and low calcium levels, prompting the administration of bicarbonate and calcium gluconate. During monitoring, the patient developed bradycardia, which progressed to cardiopulmonary arrest. Despite the aggressive treatments, the patient experienced intermittent asystole. Her condition worsened, and after discussions with the family, and the knowledge that the patient wished to be resuscitated only if there was a meaningful chance of recovery, the decision was made to cease resuscitation efforts. The patient experienced recurrent asystole and was pronounced dead soon thereafter.
Expert Testimony
The plaintiff’s expert testified that the defendant critical care physician deviated from the standard of care by failing to timely diagnose sepsis, recognize its source, and communicate effectively with the surgeon. The expert further opined that these alleged failures contributed to the patient’s death. In contrast, the defense expert stated that the critical care physician acted appropriately, conducting a thorough review and ordering necessary diagnostics upon arrival. The physician expressed concern about potential fluid overload after administering Lasix and instructed the nurse to hold feeds and arrange for a chest X-ray. However, there was no further communication with the physician regarding the patient’s condition.
Resolution
The case settled. Experts suggested that antibiotics should have been ordered aggressively for sepsis during the initial evaluation.
Risk Reduction Strategies
Medical professionals can help enhance patient safety and reduce liability with the following strategies:
- Ensure the patient’s condition can be adequately evaluated with available telehealth equipment, determining if a critical care assessment is feasible remotely.
- Effective communication and handoff between on-site and remote clinicians are vital to ensuring patient safety and maintaining the standard of care. By establishing clear, structured communication channels and utilizing standardized handoff protocols, both parties can share essential patient information accurately and promptly. This coordination helps prevent errors, ensure continuity of care, and align both teams on patient needs and care plans.
- Thoroughly document virtual encounters as you would for in-person visits, including communications with consulting physicians and follow-up recommendations.
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