Commentary:
Discrepancy in diagnostic reports does not always result in an indefensible claim.
The Case:
A 34-YOBF (5’9”, 213 lbs., BMI: 31.5) was seen by her PCP for follow-up of asthma and dysmenorrhea. The patient’s medications included Ventolin®, Advair®, and Singulair®. Asthma was noted to be chronic but stable. The patient complained of heavy periods with painful cramps. After discussing potential side effects of medications, the PCP prescribed norethindrone-ethinyl estradiol (progesterone and estrogen BCP) and Tylenol® as needed for pain.
After almost one year, a family practice (FP) physician at an immediate care clinic examined the patient for swelling and pain in the left lower extremity. The patient rated the pain as 6/10 and constant with intermittent tingling, tightness, and swelling. The physician documented tightness in the left upper thigh and intermittent left hip pain. The patient was noted to be limping slightly with tenderness at her anterior thigh. Examination revealed edema of the left lower extremity with no calf or posterior tenderness. Although no injury was reported, the patient reported shoveling snow the week prior. The patient had no history of blood clots or blood disorders but was a former smoker. She reported she had smoked for five years and had ceased four years ago.
The patient’s vital signs were stable and she was diagnosed with pain in her hip and thigh. The FP ordered a lumbar spine and left hip x-ray. The studies were performed onsite and the results were normal. A STAT ultrasound of the left leg to rule out DVT was also ordered. The order requested that results be faxed and included a fax number. The FP documented as follows “Plan: Recheck in 3-4 days if not better. Sooner, if worse. Need to rule out DVT. Doppler US of left leg. If US negative, continue with Ibuprofen 2-3 tabs.”
Later that morning, the patient presented to a medical center for testing where she underwent a left duplex lower extremity ultrasound. The ultrasound tech faxed her preliminary report, which noted a normal study, to the immediate care clinic prior to lunch.
That afternoon, the defendant general surgeon reviewed the still images of the study and the ultrasound tech’s worksheet, and dictated a report as follows: “Left lower extremity Venous Doppler examination demonstrates normal spontaneous flow with normal respiratory phasicity and augmentation to compression in the common femoral and popliteal vein. Duplex imaging in the longitudinal and transverse projections in the left lower extremity demonstrates no intraluminal filling defects or noncompressibility suggestive of deep vein thrombosis in the common femoral, superficial femoral, or popliteal veins. INTERPRETATION: No evidence for deep vein thrombosis by his examination. It is however, an abnormal examination with diminished spontaneous flow and respiratory phasicity in the superficial femoral and popliteal vein. Clinical correlation required.”
The defendant general surgeon did not have access to the preliminary report by the tech.
The next morning, the defendant signed off on the report and faxed it to the ordering physician. The following day the ordering FP reviewed the report and discussed the results with the patient. The FP testified she did not understand the significance of slow flow/phasicity. The patient reported feeling the same and was instructed to follow up with a vascular surgeon. The patient wanted a second opinion, so she scheduled an appointment with her PCP the next day.
That afternoon, the patient called 911 from her home. After forced entry, EMTs found the patient in respiratory distress. She advised the EMTs of her history of asthma and her swollen leg. The patient was immediately placed on oxygen and administered nebulized albuterol. Prior to leaving her residence, she arrested; CPR was initiated and she was intubated. The patient arrived at the ER in respiratory distress with no spontaneous heartbeat, and fixed and dilated pupils. She was pronounced dead 23 minutes later. Autopsy listed the cause of death as pulmonary artery thromboembolism.
Plaintiff experts testified the defendant general surgeon had a duty to call the PCP to advise of the discrepant report because the sonographer’s preliminary read was normal and the defendant documented an abnormal study. There was a question whether the defendant had access to the preliminary report or not. The experts testified that diminished flow findings are highly suggestive of DVT. They also argued that the defendant general surgeon violated the standard of care by not being aware of the preliminary report. The policy of accessibility of the reports was also questioned.
The defense expert testified a thrombus was not visualized on the still images from the Venous Doppler ultrasound (VDUS). The expert argued that the interpreting physician cannot determine findings such as slow flow and loss of phasicity as accurately as the tech, who is using the dynamic aspect of the study. Expert testimony stated that VDUS cannot rule out a DVT, and that no single test can. Findings of slow flow and phasicity were not something that would require the defendant to make an immediate call to the ordering physician and did not fall under the Critical Results Policy for the facility.
The jury returned a defense verdict.
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