Allegation:
Patient alleges failure to properly monitor, diagnose, and treat post-operative infection, resulting in patient’s death.
The Case:
The patient, a 55 YOF (5’, 95 lbs.), had an extensive medical history including HTN, peripheral vascular disease, GERD with bleeding peptic ulcer, pancreatitis secondary to gallstones and alcoholism, smoking, and depression. Her surgical history included a Whipple procedure eight years prior due to alcohol-induced pancreatitis.
The patient complained to her PCP of bilateral lower extremity rest pain and claudication. He ordered a lower extremity arterial study, which revealed significant peripheral vascular occlusive disease with aorto-iliac segment disease, and/or common femoral disease with significant decreased flows associated with exercise. A general surgeon interpreted the study and recommended a vascular surgery consultation and intervention.
The defendant vascular surgeon evaluated the patient; his diagnosis was occlusion of the bilateral external iliac arteries, and high-grade stenosis of the proximal right superficial femoral artery. He ordered an MRA of the lower extremities, and recommended lower extremity revascularization. The MRA revealed bilateral external iliac disease with bilateral occlusions, right greater than left. The defendant surgeon requested medical clearance before proceeding with surgery.
The patient’s GI physician sent a letter saying he could not clear this patient for surgery. He noted her COPD, osteoarthritis, and advanced chronic alcoholic liver disease with ongoing alcohol and cigarette abuse. He said she had a non-healing chronic anastomotic ulcer at the gastrojejunal anastomosis of her prior Whipple procedure that had bled on numerous occasions during the past two years. He felt the proposed surgery would need to be more “life-saving” to outweigh these issues. An appointment was scheduled for the patient to meet again with the vascular surgeon.
The defendant met with the patient to discuss the opinions of her internist and GI physician. The patient said her legs were impossibly symptomatic and she desperately wanted to proceed. After a long discussion regarding risks and benefits, the defendant said he would schedule the procedure.
The bilateral retrograde iliofemoral endarterectomies, angioplasty of the bilateral common iliac arteries and superficial femoral artery, and stenting of the bilateral common iliac arteries and superficial femoral artery were successful. Other than anticipated pulmonary issues, the patient did well, ambulated in the hall, and went home on post-op day seven.
A week later, the patient called the office worried about some redness and swelling around the incision. She came in and on exam, some erythema around the incisions was noted; the surgeon did not believe the incisions were infected. The patient stated her walking was quite improved. On exam, pulses were present and non-invasive follow-up studies were ordered.
Two weeks later, the patient had a duplex scan prior to seeing the vascular surgeon. There was a 1.4 cm x 3.5 cm collection of fluid in the right groin, and a questionable smaller collection of fluid in the left groin. The vascular surgeon noted no bleeding, fluctuance, or bruit. He opened the left groin and found what appeared to be a superficial infection. He cultured the purulent drainage with a swab, gently probed the depths of the wound, and noted no additional cavities or deep space infection. He prescribed Keflex® 500 mg.
On the way home from the visit, the patient complained to her driver of pain and tingling at the left incision site. She began to bleed profusely from the wound and passed out. The driver pulled over to the side of the road and called EMS. When they arrived on the scene, the patient was in cardiac arrest. CPR was initiated and she was transported to the hospital.
On arrival, she remained in cardiac arrest with complete vascular collapse secondary to acute hemorrhage. CPR continued while multiple transfusions were given. Once a pulse returned, the patient was rushed to surgery by the vascular surgeon. The operative note indicated the hemorrhage was the result of a “left femoral artery blowout.” He also noted: “A previous vein patch and previously repaired artery was blown out with necrotic edges presumably related to infection.” The artery was repaired, cultures obtained, and a wound vac placed.
Following surgery, the patient remained in critical condition manifesting signs of anoxic encephalopathy; she remained in a vegetative state. The family elected comfort measures only and the patient died a week later.
At trial, the defendant made an excellent witness and patiently went through every decision point. He explained that on the last office exam, the deep tissues appeared intact and the patient was without fever or chills. He even discussed what a deep tissue infection would look like and said that was not what he saw. He testified the patient told him she was ambulating well and was without pain. Defense experts testified there were no symptoms or evidence of an arterial infection.
Verdict:
After a short deliberation, the jury returned a unanimous no cause verdict for the defendant vascular surgeon.
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