Commentary:
The defendant family medicine physician assessed and responded to this elderly patient’s medical needs by ordering a blood transfusion. Plaintiff’s experts were critical of the response to the alleged blood transfusion reaction. Despite the allegations and plaintiff’s experts’ testimony, the jury found in favor of the defendant physician.
The Case:
An 80 YOWF (4’8”, 97 lbs.) presented in the late afternoon to the ED via ambulance complaining of chest pain, shortness of breath, constipation with nausea, and weakness. Vital signs on arrival were T 98.9°F, P 106, R 26, BP 85/45, and 02 sat on room air of 94 percent. The patient’s history included chest pain, anemia with thrombocytopenia, and lymphoma. Pale conjunctiva was noted; otherwise the patient’s history and physical exam were unremarkable. An EKG found sinus rhythm without acute ST-T wave changes. Laboratory testing included CBC, CMP, and Troponin. The ED physician was notified of labs: Hgb 7 (11.4-15.4), platelets 30 (130-470), WBC 3.4 (4-11), glucose 125 (74-106), sodium 128 (137-145), potassium 4.2 (3.6-5.2), chloride 96 (96-108), and C02 27 (21-32).
The patient was admitted to the services of the defendant family medicine physician with the ED impression of chest pain, anemia with thrombocytopenia, and a history of lymphoma. The defendant physician saw the patient the following day and ordered an urgent consult with a rheumatologist. The rheumatologist ordered a battery of tests including haptoglobin, retic count, direct Coombs, complement 3 and 4, cryoglobulin, ANCA, cANCA, and a CBC with peripheral smear. The rheumatologist recommended a blood transfusion and the patient provided written consent. Two units of PRBCs were typed and crossed with an order to transfuse one unit when ready.
The first unit of PRBCs was initiated at 14:15 with pre-transfusion temperature of 97°F and a BP of 92/56. Two hours after the start of the transfusion, the patient reported feeling cold, but denied pain. The nurse noted the patient experiencing chills, an altered mental status, and difficulty breathing [this note was charted approximately 5 hours after the transfusion was started]. However, documentation stated the patient’s respirations were regular and unlabored, but with diminished breath sounds. The patient was not oriented to place and was lethargic, which was attributed to the prior administration of morphine. Vital signs were T 96.7°F, P 110, R 20, and BP 145/82. The nurse notified the defendant physician of the change in patient status, and he ordered a nebulizer treatment with the transfusion to continue. Narcan® was ordered to address potential over-sedation and was administered shortly thereafter.
At 17:15, the defendant physician was at the patient’s bedside. The vital signs were T 101.3°F, P 122,R 20, and BP 125/73. Following physician examination, the transfusion was stopped at 17:30, and Tylenol® PO was ordered for fever. The rheumatologist came to the bedside and in the course of discussing the potential administration of IV steroids, the patient began to experience seizures. Neither the defendant physician, rheumatologist, nor a phone-consulted neurologist believed the seizure activity to be related to the transfusion. Unfortunately, the patient’s mental status deteriorated quickly, and her respiratory status became compromised. BiPAP was initiated with stat orders of Keppra® 500 mg IV, Ativan® 2mg IV, and Tylenol suppositories q4h prn for fever.
The treatment did not yield an improvement in the patient’s condition. Following a discussion regarding the patient’s condition with the family, a DNR order was written. The patient died at 21:25 of respiratory failure. The blood bank analysis determined the patient had an antibody to a low-frequency antigen; due to several factors, the blood bank was unable to determine if that was clinically significant. An autopsy was performed; cause of death was hypertensive and atherosclerotic cardiovascular disease, COPD, lymphoma, and possible transfusion reaction.
The estate brought suit against the defendant family medicine physician alleging negligent care and treatment of a blood transfusion resulting in death. The opinion of the plaintiff’s experts included a lack of recognition and appropriate treatment of CHF in the ED. The plaintiff’s experts were also critical of the defendant physician for continuing the blood transfusion—despite notification by the nursing staff of a change in condition, and fluid overload as a result of blood transfusion. The defense experts believed the plaintiff was significantly ill upon arrival to the ED and was likely suffering from advanced thrombotic thrombocytopenic purpura (TTP), which caused her death. They testified the patient’s signs and symptoms were not consistent with a transfusion reaction.
The Medical Review Panel reviewed this claim and rendered a unanimous decision in favor of the defendant family medicine physician. The defendant physician was anxious about going to trial, but presented well with preparation. A jury trial commenced, ultimately delivering a verdict in favor of the defendant family medicine physician.
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