Allegation:
Plaintiff alleged the physician was inadequately trained in the use of Dilaudid®, which led to the patient's death.
The Case:
At 8:00 a.m., a 33 YOM (5’9”, 230 lbs.), presented to the ED with complaints of 7/10 RLQ pain, decreased intake, and nausea. Vital signs were BP 146/86, P 95, R 18, T 97.4, with SaO2 96%. The patient described the pain as a sharp/dull throb. He had taken Advair® and Lortab® the night before. At 8:15 a.m., the ED physician saw the patient and ordered IV normal saline, Zosyn®, Demerol®, and Zofran®. The ED physician also ordered labs, x-rays, and an ultrasound. Abdominal and chest x-rays were negative, and the ultrasound revealed “abdominal-hypoechoic areas left kidney for which CT is recommended.”
At 10:03 a.m., the abdominal CT showed an enlarged appendix with thickened walls and periappendiceal inflammatory changes. There was a 2 cm calcification within the appendix with a 2 cc fluid collection medially. The impression was appendicitis with suspected appendiceal abscess. The patient again received Demerol and Zofran with improvement in pain and nausea.
A general surgeon was contacted, and the patient was admitted by the defendant family physician. The patient gave consent for a laparoscopic appendectomy although the general surgeon did not see the patient on the day of admission. Surgery was set for the next morning. Demerol was changed to morphine sulphate 2-4 mg IV q3h prn. Later, the RN called the defendant family physician and asked if morphine sulphate could be changed to Dilaudid due to ineffective pain control. Dilaudid 2-4 mg IV q3h prn was ordered. The patient received 4 mg at 6:35 p.m. and 11:03 p.m. The patient was stable overnight with pain well-controlled with Dilaudid, which was also given at 2:57 a.m.
The surgeon evaluated the patient at 6:00 a.m., and the patient was taken to pre-op. At 7:00 a.m., the laparoscopic appendectomy began. The appendix was gangrenous with necrotic serosa and was removed. The patient’s RLQ was copiously irrigated, and a drain was placed in the right gutter. The patient tolerated the procedure well and returned to the PACU. His BP was stable with HR 110-120. Pain was initially rated 6/10 and he was given morphine sulphate 4 mg, Demerol 25 mg, and Phenergan® 25 mg, thromboembolism deterrent stockings and sequential compression devices were applied. Within 25 minutes, his pain reduced to 2/10, and he was transported to the floor.
Soon after the patient arrived in his room, the defendant family medicine physician discontinued the morphine and added Dilaudid 2-4 mg q3h prn pain. The patient did well walking in the hall following his surgery. Vital signs remained stable; the patient was awake and alert, and ambulated in the hall several times. He received Dilaudid three times that day and three times that night. The last dose of Dilaudid he received was at 4:54 a.m.
The surgeon came in for rounds at 6:45 a.m., and he found the patient cold and unresponsive. A code was called. Despite resuscitative efforts for 35 minutes, the patient was pronounced dead.
An autopsy revealed cirrhosis of the liver, cardiomegaly, and pulmonary thromboembolism. The appendectomy site showed no evidence of perforation or necrosis; however, a 2 cm necrotic appendiceal tip was found adherent and hidden within the wall of the ascending colon. Pathology on the surgical submission denoted necrotizing appendicitis. The patient’s heart had concentric left ventricular hypertrophy and moderate atherosclerosis. Toxicology was not requested. The pathologist believed the patient may have suffered from hypertrophic subaortic stenosis. There was no evidence the patient died from a Dilaudid overdose.
The plaintiff alleged that the patient died from a Dilaudid overdose that the defendant family physician improperly prescribed. In addition, the plaintiff claimed there were two violations of hospital policies: the pharmacy did not contact the ordering physician to discuss and verify, or clarify, a questionable prescription for Dilaudid, and the hospital’s nurses were not trained about the effects of Dilaudid.
A pharmacist and a family medicine physician were the plaintiff’s experts. The expert pharmacist testified the Dilaudid ordered was a high dose, but on cross examination, he admitted he was unfamiliar with most of the characteristics of the drug. The expert family medicine physician testified that he agreed with all allegations against the defendant family medicine physician.
Six defense experts testified and were well-received by the jury. The expert pathologist’s opinion was sudden cardiac death, due to the patient’s enlarged heart and an absence of facts to support any other cause of death. The expert pathologist did not believe Dilaudid played a role since there were no signs of problems with speech or ambulation. An expert board certified cardiologist testified the patient’s hypertrophied heart indicated advanced heart disease which likely led to sudden cardiac death.
An expert family practitioner stated the care given by the defendant was appropriate and within the standard of care. He said the Dilaudid order was acceptable and did not cause the patient’s death based on his activity level, mental status, and vital signs. A defense expert pharmacologist also testified Dilaudid did not cause the death and the dosing was reasonable. A second expert family practice physician, also board certified in emergency medicine, did not believe the death could be related to Dilaudid. This expert based that belief on the fact the patient tolerated the medication well for two days with no effect on his activity level or vital signs. There is no evidence to indicate the patient ever experienced respiratory depression.
Verdict:
The jury returned a verdict in favor of the defense.
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