By Damian D. Capozzola, Esq.
The Law Offices of Damian D. Capozzola
Los Angeles
Jamie Terrence, RN
President and Founder, are Risk Services
Former Director of Risk Management Services
(2004-2013)
California Hospital Medical Center
Los Angeles
Morgan Lynch, 2018 JD Candidate
Pepperdine University School of Law
Malibu, CA
News: In late 2007, a man presented to a hospital with diarrhea. He was taken to surgery a week later, where he was administered Levophed, a vasopressor medication. After the surgery, the treating physicians switched the patient’s medication to Neo-Synephrine.
Because of the poor blood circulation due to the vasopressors, the patient’s hand and toes became gangrenous and required amputation. The patient subsequently filed suit for breaching the standard of care. The crux of the patient’s legal argument was that the high doses of vasopressors caused his gangrenous extremities. At trial, a battle of experts ensued, and the jury delivered a verdict in favor of the plaintiff for $10.4 million.
Background: On Sept. 4, 2007, a man presented to a hospital after experiencing diarrhea for several days. The man was admitted and taken to surgery 11 days later to remove his toxic megacolon. During surgery, the medical staff administered the vasopressor medication, Levophed, to correct a drop in the patient’s blood pressure.
Postoperatively, a consulting cardiologist ordered the medical staff to wean the patient off of Levophed and administer Neo-Synephrine if his systolic blood pressure dropped below 100. The vasopressors caused poor perfusion, and as a result, the plaintiff’s left hand and all his toes became gangrenous and required amputation.
The patient-plaintiff and his (now) ex-wife filed suit against the hospital and several of its nurses. The defendants were accused of breaching the standard of care. The plaintiff sought recovery of compensatory damages for medical expenses, lost income, and damages for disfigurement and other non-economic recovery.
At trial, the plaintiff argued that from Sept. 15 to Sept. 17, the hospital’s ICU nurses neglected to perform dynamic response testing on the arterial line that was used to evaluate plaintiff’s blood pressure. As a result, he argued, the evaluation was falsely reading systolic blood pressures below 100 when his true blood pressures were higher. Therefore, the nursing staff gave the patient the maximum doses of vasopressors when his blood pressure was close to, if not, normal. This excess administration of vasopressors resulted in vasoconstriction in the patient’s blood vessels and poor perfusion to his extremities, causing them to become ischemic, necrotic, and eventually gangrenous. The plaintiff’s counsel maintained that the patient went to the hospital to cure his abdominal problem, but was left without a hand or toes, without any explanation from his doctors.
The defense argued that the plaintiff was in septic shock with five system multi-organ failure and the poor perfusion was the result of a coagulopathy cascade caused by the sepsis and the body’s native shunting of blood to vital organs for survival. The defense further asserted that the plaintiff would have died without the high doses of vasopressors.
Just before the verdict was read, parties reached a high-low agreement ensuring recovery of at least $3.5 million but capping liability at $12 million. In the end, the parties’ agreed range proved correct, as the jury deliberated for 2.5 hours before returning a verdict for $10.4 million. The breakdown of the award was as follows: $2 million for disfigurement, $1 million for loss of normal life past, $1 million for normal life future, $2 million for past pain and suffering, and $4 million for future pain and suffering. The patient’s ex-wife also received $25,000 for value of services and $25,000 for society, companionship, and relations. The available information suggests the hospital ultimately absorbed the liability.
What this means to you: The plaintiff attorney’s theme about the plaintiff leaving the hospital missing a hand and toes without an explanation from the doctors was apparently very powerful. Hospitals must be transparent. Patients have a right to know everything that is happening to them and why. Their questions deserve our best answers. If a patient believes the physicians, nurses, and hospital are doing everything in their power to provide the best care, informing them of concurrent risks and benefits of treatments, and are forthcoming with information both positive and negative, they are less likely to litigate. Gone are the days of pretending bad things don’t happen in hospitals. One Google search on a patient’s cellphone will reveal that not to be so.
To avoid angry, litigious patients in circumstances such as those presented in this case, if appropriate, hospitals should provide a genuine apology for the catastrophic result. Many jurisdictions have “I’m Sorry” laws, which are designed to encourage open communications following an adverse result and which were implemented in response to the rising number of medical malpractice suits. It is important to note that the information communicated to the patient should not include an admission of legal fault, but should contain statements that express condolences, sympathy, and empathy. The various protections offered by the “I’m Sorry” laws should be researched carefully to ensure hospitals do not apologize themselves into legal fault, but injured patients may be less inclined to pursue a legal claim if they feel the hospital and medical professionals treated them with respect and candor in light of a traumatizing experience.
However, to avoid adverse results and prevent the need for apologies as much as possible, hospitals should ensure that nurses get proper instructions and consult experts early in treatment for all procedures. To this end, it is important to provide medical professionals with repeatable guidelines. The benefit of implementing these guidelines is twofold. First, it prevents deviation from the standard of care by medical professionals. To serve this purpose, the guidelines must conform to the industry standard of care. Second, repeatable rules for medical professionals show juries that hospitals are truly concerned about the safety of their patients. It is easy to criticize juries as irrational or unpredictable, but most juries do reach verdicts grounded in the evidence. A system from which defense counsel can argue only can strengthen the case.
The fact that the nurses in this case failed to notice the patient’s gangrenous symptoms for two days brings to light a need for routine physical symptom monitoring in the aforementioned guidelines. For example, the Academy of Medical-Surgical Nurses has indicated the following practices given by hospitals in response to the question, “What is the EBP standard for assessment of the postoperative patient after discharge from PACU, [and] how often should these assessments occur?”
- Every 1 hr. x 4, then every 4 hr. x 24 hr., then per MD order — this is the standard.
- Upon arrival to the unit, in 1 hr., then every 4 hr. for 24 hr., then every 6 hr. throughout stay.
- Within 15 minutes of arrival to unit, in 30 minutes, then every 1 hr. x 2 or until stable, and every 4 hr. for 24 hr., then every 6 hr. for remainder of stay.
Each of these practices, if implemented by the nurses in this case, could have caught the patient’s gangrenous hand and toes within the two-day period in which he exhibited the symptoms.
Nurses have a responsibility to understand the side effects of all medications they administer, especially high-risk vasoactive medications. The physician also must observe his or her patient for symptoms of well-known adverse reactions to medications such as the loss of peripheral circulation caused by vasopressors. Both nurses and doctors must look beyond the technology, the monitor, and the computer, and focus their eyes and place their hands on the patient. A simple check of peripheral pulses or noting temperature and color changes in the patient’s extremities might have led to a change in the dosing of the vasoactive drugs. Finally, monitoring a patient’s cardiac functioning via an arterial line is a highly specialized skill that requires additional training even for ICU nurses. The hospital must ensure that staff required to monitor patients using A-line data are competent to do so.
Finally, it is important to note the dangers of overmedicating and failure to test. Some people avoid hospitals and physicians out of fear of overmedication and tragic experiences like the plaintiff’s in this case. Of course, that is detrimental to the health of those individuals. To remedy this situation, medical facilities may consider implementing a campaign to the public to demonstrate they understand that concern and that they have taken measures to prevent overmedication or incorrect medication. Certainly, hospitals and medical professionals should re-evaluate a patient’s symptoms frequently after a change in medication. Many experts contend that Americans are overmedicated, and hospitals and medical professionals should help combat this problem.
REFERENCE
- Decided on October 15, 2015 at the Circuit Court of Illinois, Cook County Judicial Circuit; Case No. 09L1448.
Failure to monitor adverse drug events in a patient led to gangrene and amputation of hand and toes.
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