Legal Review and Commentary
Failure to diagnose large pleural abscess leads to $227,500 verdict
By Blake J. Delaney, Esq., Buchanan Ingersoll & Rooney PC, Tampa, FL
News: A middle-aged woman went to the emergency department complaining of abdominal pains. After testing and evaluation indicated intestinal inflammation and a possible abdominal cyst along with diverticular disease, the hospital began the patient on a course of antibiotic therapy. Over the next three days at the hospital, the woman's health did not seem to improve. Nevertheless, her condition was characterized by her doctor as "stable," and she was discharged. After two days at home, the woman began gasping for breath and was rushed to another hospital's emergency department, where she ultimately died. An autopsy showed that the respiratory failure had been caused by a massive abscess in the woman's abdomen, itself possibly caused by diverticular disease. After a jury trial, a verdict of $227,500 was entered in favor of the decedent's husband.
Background: After experiencing abdominal pain and nausea for three days, a 55-year-old woman went to the emergency department. A trauma surgeon evaluated the woman and diagnosed her with a possible large abdominal mass or cyst. The surgeon ordered that the woman be admitted for further evaluation. The patient subsequently underwent a CT scan, the results of which showed possible diverticular disease, characterized by sacs having formed in the wall of the large intestine. Because the radiologist reviewing the CT scan also noted inflammation of the patient's distal colon and suspected that her large intestine may have been perforated, causing infection, he ordered immediate antibiotic therapy and an exploratory laparotomy to be conducted two days later to examine the patient's abdominal organs.
Later that day, the patient began feeling better, causing doctors to rethink the need for emergency surgery. But nurses noted that the woman was experiencing shortness of breath, and her blood work indicated a continuing infection. Even more, a subsequent chest X-ray indicated some difficulty with her lungs to the point that a follow-up X-ray was ordered.
On the woman's third day in the hospital, another CT scan was taken that showed increased inflammation around the woman's descending colon as well as new fluid around her stomach. The trauma surgeon concluded, however, that these changes were not significant enough to alter the patient's current course of antibiotic therapy treatment. The following day, the patient was noted to still be short of breath, her pulse oximeter readings were low, and her blood work showed a 12,600 white blood count with 82 segmentations. Nevertheless, the surgeon discharged the woman and claimed that his patient's condition was stable, even though he acknowledged a potential problem with her large intestine.
Once at home, the woman continued to endure symptoms. She was confined to a wheelchair, needed help to get into the car, couldn't walk up a few stairs at the time without a good deal of distress, and was unable to lie down without feeling as if she was drowning. Consequently, she spent the following two nights and one day sitting in a chair.
The following day, her breathing became so labored that she called 911 for emergency assistance. She was rushed to a different hospital's emergency department, where she arrived gasping for breath. Shortly thereafter, the woman's pulse was lost, and immediate resuscitation was attempted. Following partial resuscitative success, the woman was taken to the intensive care unit, where a CT scan showed her left lung becoming opaque and a rightward shift of her heart, aorta, esophagus, and trachea. A pulmonologist at the second hospital concluded that the woman had suffered respiratory failure following a massive accumulation of fluid in an abscess on her left side. Hospital personnel worked quickly to drain 1,200 cc of fluid from the abscess, estimated to be 12 cm by 15 cm. The woman was placed on a ventilator to assist her with breathing.
Two days later, an electroencephalogram showed profound and irreversible brain damage. The woman was removed from the ventilator and subsequently died, with a final diagnosis of severe anoxic encephalopathy, cardiorespiratory arrest, unilateral pleural effusion, and left pericolic abscess. An autopsy showed no specific perforation site in her large intestine, but the abscess was thought to have formed due to such a perforation.
The woman's husband sued the trauma surgeon and the first hospital for negligence, and he claimed that the defendants failed to appreciate the woman's condition before discharging her. The plaintiff claimed that by failing to recognize that the blood work upon discharge clearly indicated a vigorous infection process at work, the defendants' conduct allowed the abscess to grow to the point of infecting his wife's lungs. The plaintiff maintained that had the trauma surgeon simply kept his wife in the hospital for a longer period of time, even just for observation, her infection never would have been able to spread such that it essentially asphyxiated her.
In their defense, the surgeon and the hospital insisted that administering the antibiotic therapy was all that should have been done for the woman and that the woman was not suffering from a lung infection when she presented to the hospital. The defendants also faulted the woman's failure to communicate fully and honestly regarding her condition — such as when she claimed she was feeling much better — as a major contributing factor to her damages. The defendants further deflected blame by faulting the ambulance service for its handling of the woman while taking her to the second hospital.
Leading up to trial, the plaintiff's final offer was $500,000, which the defendants failed to accept. A jury ultimately returned a verdict in favor of the plaintiff, finding the trauma surgeon to be 65% percent negligent and the plaintiff to be 35% at fault. The jury awarded a gross award of $350,000, representing $150,000 for pain and suffering and $200,000 for the husband's claim of loss of society and companionship. The award was reduced to $227,500 to account for the decedent's comparative negligence.
What this means to you: This case is unusual in that it appears that the emergency department's initial treatment of the decedent was appropriate. A trauma surgeon correctly diagnosed the woman with a possible large abdominal mass, ordered a CT scan, and admitted the woman and started her on IV antibiotic therapy with a plan to perform exploratory surgery. "Unfortunately, once admitted, appropriate care became compromised," says Ellen L. Barton, JD, CPCU, a risk management consultant in Phoenix, MD. "When the patient stated that she was feeling better, the physicians hesitated to execute the plan."
One of the major issues underlying this scenario is the lack of communication between the patient and the health care providers, and between the providers themselves. For example, Barton points out that the communication between the nurses and physicians was compromised. Although the nurses noted that the patient was experiencing shortness of breath and her blood work indicated a continuing infection, it does not appear that this information was appropriately communicated to the attending physicians. And even more, despite the test results and the continuing complaints from the patient regarding shortness of breath, the trauma surgeon then made a disastrous decision to discharge the patient.
"How he could have viewed this patient as stable is puzzling," says Barton. But Barton is quick to recognize that the information available in this scenario does not detail what other circumstances may have been at work, including "payer pressure to discharge." And finally, Barton notes the question that is raised by the facts as to what kind of discharge instructions the patient was given. "The fact that she spent two nights and one day unable to leave a wheelchair indicates that the patient's condition was not only not improving, but was, in fact, deteriorating. The patient should have been given instructions to return to the hospital if her symptoms did not improve or got worse within hours … not days."
Barton suggests that this case puts a much-needed focus on communication in the health care setting and on the discharge planning process. The practitioners in this scenario, for example, could have improved their treatment in at least four ways. First, while the patient may have indicated that she was feeling better, the physicians had access to test results and observations from nursing staff that indicated that the patient still was compromised. Second, the nurses had an obligation to communicate concerns directly to the attending physicians and to intervene, if necessary. Third, even though the discharge planning process begins at admission, it involves a continuous evaluation of the patient, test results, nursing observations, and physician assessment. In this case, it appears that the process did not work as it should have. And fourth, this case emphasizes the need for personalized discharge instructions. Specifically, Barton notes, the patient must be provided with clear and understandable instructions that allow the patient to look for certain symptoms or conditions and then take appropriate actions on them. Also, health care facilities have to be aware of the "unspoken" communication that the very fact of discharge indicates to patients that they are better. "Otherwise," Barton questions, "Why would they still be discharged?"
Of course, as Barton is quick to point out, there is no question in this case that the patient did not act in her own best interest. She inappropriately delayed seeking further medical treatment, which contributed to her eventual death. Nevertheless, communication among her health care providers and with the woman herself undoubtedly would have increased her chances of survival.
"Although patients clearly have a role in their own health care, they are not professionals," Barton says. "That fact needs to be recognized in not only caring for them, but in asking patients to help care for themselves."
Reference
• Milwaukee County (WI) Circuit Court, Case No. 98 CV 007325.
A middle-aged woman went to the emergency department complaining of abdominal pains. After testing and evaluation indicated intestinal inflammation and a possible abdominal cyst along with diverticular disease, the hospital began the patient on a course of antibiotic therapy.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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