Allegation:
The defendant general surgeon failed to order a CTA to evaluate an abdominal process, which resulted in the patient's death due to mesentery ischemic bowel infarction.
The Case:
The patient, a 59 YOM (5’11”, 243 lbs.), presented to the hospital with lower right quadrant and periumbilical stabbing pain for five days with nausea and diarrhea, without vomiting. He noted normal bowel movements. The pain migrated periumbilically throughout the week. He had a history of aortic valve replacement, HTN, COPD, GERD, and removal of tonsils and adenoids. He was also a three-ppd smoker. His medications included Coumadin®, Cozaar®, Effexor®, albuterol, Lasix®, Lopressor®, K-Dur®, Protonix®, and oxygen 2L/min as needed for SOB.
Two days prior, the patient had an abdominal/pelvic CT that was unremarkable. A repeat abdominal/pelvic CT demonstrated small bowel inflammation, possibly related to inflammatory bowel disease (IBD). The patient denied a history of IBD. His last colonoscopy was five years ago and showed benign polyps. His WBC was 19 (4.9-10.9). The patient was admitted to the hospital.
The following day, the patient was transferred to a different hospital for possible appendicitis or ruptured appendix. His abdominal pain was a constant, dull pain with no radiation. A surgical resident saw the patient and examined his abdomen noting it was soft, tender periumbilically, distended, and tympanic. His WBC was 16 with a left shift. The resident’s review of the CT noted transmural inflammation in the area of the ileocecal region, but the appendix was normal. The impression was ileus.
The next day, a gastroenterologist reviewed the CT, and noted the ileum was edematous and thickened, which was more consistent with ischemia rather than IBD. His impression was mesenteric insufficiency, and the need to rule out embolic versus thrombotic versus nonexclusive mesenteric ischemia; he suggested cardiac evaluation of the mechanical valve. A KUB showed the contrast made it through the small bowel into the colon, making a bowel obstruction less likely.
A cardiology consult was performed the same day. The physician noted the patient had dyspnea and hypoxia, and placed him on BiPAP. The patient had a productive cough and evidence of pneumonia was present on chest x-ray. The cardiologist believed the pneumonia, not CHF, was causing the dyspnea and recommended increasing the Lopressor and continuing low dose Lasix. An echo was ordered, IV antibiotics were continued, and Cozaar was to be restarted when feasible. As to the valve, he recommended continuing Coumadin.
Later in the day, pulmonology noted increasing dyspnea the day before with an increasing cough. The patient denied sputum production, hemoptysis, and wheezing. His dyspnea improved, although he continued to have abdominal discomfort/distension and was unable to take a deep breath. On exam, he had diminished breath sounds at the bases, but no wheezing rhonchi or crackles. The patient’s abdomen was obese and distended with minimal tenderness. His ABGs were pH 7.42 (7.35-7.45), pCO2 36 (35-45), and pO2 70 (80-100). The venous ABG sample was pH7.39, pCO2 45, and pO2 41. His WBC was 14 and the SED rate was 92 (0-20). His INR was 3.2 (0.8-1.1).
A chest x-ray showed small lung volumes with suboptimal inspiratory effort, bibasilar atelectasis, bibasilar infiltrates, and right upper lobe infiltrate. The pulmonologist’s impression was pulmonary edema/CHF, COPD, bronchitis, potential pneumonia, hypoxemia secondary to pneumonia/atelectasis, improving with bronchodilators, antibiotics, and diuretics.
The defendant surgeon and the surgical resident followed the patient for five days, signing off on the fifth day. Daily abdominal exams revealed soft, non-distended abdomen and no pain. The patient had bowel movements. His WBC continued to improve. He did not have a fever and was not tachycardic.
The patient’s condition continued to deteriorate. Six days after the defendant surgeon’s sign-off, the patient’s family chose to take him off further support and authorized a DNR. This decision was made against the advice of his treating physicians who thought other measures were still available. Without support measures, he died the following day.
The patient’s expert witness stated the defendant surgeon was negligent in failing to follow the gastroenterologist’s treatment plan. He disagreed with the assessment that the patient improved over time, and claimed the pain medication was masking the patient’s pain, resulting in a premature signing off.
Defense experts were supportive, stating the defendant surgeon met the standard of care required. Except for a likely ileus, the patient’s abdominal status was benign at the time of signing off. One of the experts stated that if this was a significant mesenteric ischemia with an infarcted bowel, the patient would have experienced a catastrophic event which would have been apparent to anyone.
Verdict:
At trial, the jury returned a unanimous verdict in favor of the defendant surgeon.
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