Commentary
Despite the defendant internist’s testimony, the lack of documentation in the record complicated the defense and ultimately resulted in settlement.
Case Details
The patient was a 70-YOWF (5’8”, 204 lb), with a medical history significant for A-fib, congestive heart failure with automatic defibrillator, and aortic aneurysm. She was discharged from the hospital following treatment for a subarachnoid hemorrhage. Because she had an indwelling PEG tube and was on ventilator support via tracheostomy, she was transferred to a transitional care facility for rehabilitation and attempted ventilator weaning.
The defendant internist recommended continuing ventilator support with admission to the ICU, as well as continuing tube feedings, offering speech therapy/physical therapy/occupational therapy, and sequential compression device for DVT prophylaxis. Admitting diagnoses were respiratory failure, subarachnoid hemorrhage, and A-fib. The patient remained fairly stable throughout the admission although attempts to wean her off the ventilator were unsuccessful.
On the 19th day of admission, the defendant internist noted leakage at the PEG insertion site and ordered a STAT kidney, ureter, bladder (KUB), and Gastrografin study. The radiology results indicated the PEG tube was likely in the stomach. Feedings were held for 29 minutes pending the radiology results.
The defendant internist’s written order to hold the PEG tube feedings was entered late, and he testified he likely gave a verbal order at the time. Similarly, there was no written order to restart feedings. The defendant internist testified he likely gave a verbal order to the nurses to restart feedings if the Gastrografin results showed tube placement in the stomach.
During the late night and early morning of the following day, the patient became hypotensive and required vasopressor agents (norepinephrine and vasopressin) ordered via telephone by the covering physician. Nursing notes made during the early morning indicate that correct PEG tube placement was verified at this time.
The next day, the patient underwent a CT of the abdomen and head. The defendant internist testified he ordered this study STAT, although the records contain no written order. The CT revealed the PEG tube was in the subcutaneous tissues with considerable extravasation of feeding fluid outside of the stomach. The internist, along with a critical care specialist (co-defendant), were made aware of the CT results and requested emergent transfer of the patient to a nearby hospital.
The medical record was devoid of any notes made contemporaneously with the event regarding the decision to transfer the patient. The record does contain a notation made by the nursing staff that suggests the defendant internist and co-defendant critical care specialist were notified of the abdominal CT results that showed the PEG tube was no longer in the stomach. This note, however, was entered approximately 12 hours after the defendant internist ordered the CT scan STAT.
The defendant internist immediately contacted the hospital requesting emergent patient transfer. An order from the defendant internist states that a bed was obtained, and the patient was transferred via ambulance in stable condition. His discharge summary on the patient was not dictated until 27 days later.
During the patient’s initial evaluation at the hospital, the physician noted she gently pulled on the PEG tube and it instantly dislodged; she noted, too, that the bumper was at approximately 2 centimeters. She immediately placed a 16-French Foley and ordered a KUB with Gastrografin contrast to confirm placement. Diagnosis of PEG tube malfunction was made and the plan was to consult surgery.
The patient remained at the hospital for an additional 15 days during which time she underwent three different surgeries and was treated for sepsis.
After her hospital stay, the patient was transferred to a long-term acute care (LTAC) facility. The patient continued to be ventilator-dependent with a tracheostomy tube and was fed via NG tube.
The patient died 52 days after transferring to the LTAC facility due to respiratory failure and intracranial hemorrhage.
Expert Testimony
The plaintiff’s expert witness stated the defendant internist breached the standard of care by failing to monitor the fluid input and output of the patient while she was under his care. The witness also testified the internist failed to follow up on the results of the CT scan until almost 33 hours after the STAT scan was ordered.
The defendant’s expert witness stated that ordering a Gastrografin study was appropriate when it was initially determined the PEG tube appeared to have a leak. He went on to state it was reasonable to rely on the radiology interpretation of the Gastrografin study that the tube was likely in the stomach and that feedings could resume. Further, transfer of the patient was appropriately arranged once the CT scan showed the PEG tube was dislodged. The expert witness felt it was unclear as to when the results of the STAT CT that indicated the PEG tube was not in the stomach was communicated to the defendant internist. He indicated those times would need to be clarified.
Resolution
The suit was eventually settled.
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