By Damian D. Capozzola, Esq.
The Law Offices of Damian D. Capozzola
Los Angeles
Jamie Terrence, RN
President and Founder, Healthcare Risk Services
Former Director of Risk Management Services
(2004-2013)
California Hospital Medical Center
Los Angeles
Elena N. Sandell, JD
UCLA School of Law, 2018
News: A 58-year-old male presented to a hospital with abdominal pain, nausea, and vomiting. He was otherwise in good health and able to perform all daily activities without assistance. A CT scan revealed several aneurysms, but two radiologists failed to detect that one had already ruptured. The patient’s condition rapidly deteriorated, and despite an emergency surgery, the patient suffered permanent paralysis.
The patient and his wife brought suit against the hospital and multiple physicians, alleging that their failure to diagnose and treat the ruptured aneurysm constituted medical malpractice. The defendants denied liability. Six days prior to the start of trial, the parties entered into a settlement agreement for a total of $20.6 million.
Background: In October 2013, a 58-year-old man was admitted to the ED with abdominal pain, nausea, and vomiting. A CT scan was performed on his abdomen, revealing several aneurysms. According to the patient, two radiologists who reviewed the scan failed to notice that one of the aneurysms was already bleeding. A vascular surgeon reviewed the scan the next morning and also failed to notice the bleeding aneurysm.
As the day progressed, the patient’s condition worsened. He experienced weakness in both legs, a severe drop in blood pressure, even more severe abdominal pain, abdominal distension, and a decrease in hemoglobin and hematocrit. The following morning, the patient’s condition had further worsened as he experienced increased weakness in his lower limbs. The attending day hospitalist, suspecting a spinal epidural abscess, ordered a routine MRI; however, it was not performed due to severely increased abdominal distension. The physician ordered an immediate X-ray, which showed a dilated large bowel. The patient was promptly transferred to a different hospital where another CT scan showed a rupture in the patient’s right common iliac artery aneurysm.
Emergency surgery was performed to fix the rupture; however, it was too late to prevent all injuries. The patient suffered bilateral fasciotomies on both legs, amputation of several toes, deep pressure ulcers, and chronic pain. He also was left permanently paralyzed. The patient requires full-time assistance and care, and is unable to work as a result of his injuries.
In 2015, the patient and his wife filed a medical malpractice action against the initial hospital and several of the individual physicians who were involved in his care. The patient alleged that the physicians did not provide him with the necessary standard of care and that their negligence caused him to be rushed into surgery, which resulted in the significant, permanent injuries.
The defendant hospital and physicians claimed that because the patient suffered from end-stage kidney disease, his life expectancy was already significantly diminished. They further asserted that the patient’s injuries were well-known complications of the surgery he required. Finally, the defendants argued that the surgery was necessary regardless of when the bleeding aneurysms were diagnosed and the patient’s injuries were no more severe as a result of the delayed diagnosis.
Six days before the trial, the parties entered into a complete settlement agreement, resolving all of the patient’s claims against the hospital and individual physicians. The hospital agreed to pay the patient $13.5 million, and the physicians collectively agreed to pay $7.1 million, for a total of $20.6 million.
What this means to you: This case serves as an example of both the importance of ensuring that information on a patient is clearly communicated among physicians and staff when multiple physicians are involved in the care of the patient, as well as the importance of timely diagnosis and prompt treatment. The sizeable settlement reached by the parties is confirmation of the significance of the patient’s injuries and the significant possibility of liability on behalf of the hospital and physicians.
In this case, from the time the patient was admitted to the ED to the time surgery was performed, the patient was seen and treated by numerous physicians. This situation, which is especially common in an ED setting, can lead to difficulties in patient information being communicated correctly and increased times in diagnosis. In fact, among other things, the patient alleged that three different physicians revised his initial CT scan and that all three failed to notice that one of the aneurysms in his abdomen was already bleeding at the time. Also, the physician who treated the patient the next morning had not previously examined the patient and did not properly assess the speed at which the patient’s condition was worsening. This is evidenced by the fact that the doctor, according to the plaintiff, ordered a routine MRI rather than a stat MRI, which would have been appropriate given the patient’s newly developed symptoms.
Further, the scheduled routine MRI was never performed because within 12 hours, the patient’s condition had become so severe that he had to be transported to another hospital to undergo emergency surgery. Had a single physician adequately monitored the patient’s condition or had the information been communicated more accurately among the multiple physicians, the gravity of the patient’s condition may have been noticed earlier, and a stat MRI would have been performed.
Physicians rely on quantitative and qualitative data they receive from nurses who are with patients for eight to 12 hours at a time. While one or more physicians on any case spend minutes with patients, nurses have the ability to observe trends in a patient’s condition over time. Significant changes in a patient’s condition must be reported to physicians rapidly and consistently until interventions are performed to address urgent conditions. A drop in blood pressure accompanied by a drop in hemoglobin and hematocrit levels are textbook signs of bleeding and possible hemorrhaging. Abdominal distention gives care providers a clue as to the area of bleeding.
This patient’s body was providing signals about what was happening, but none of the physicians or staff involved recognized and reported them. The nurse assigned to this patient had a responsibility to notify the physicians about these critical changes and to follow up, using the chain of command if necessary, until appropriate actions were taken — in this case, emergency vascular surgery. All of these factors certainly affected the patient’s course of treatment, and under different circumstances, it is plausible that the rupture of the aneurysm in his right common iliac artery could have been prevented and injuries reduced.
Regardless of the events, it is important to keep in mind that the initial delay in reaching a proper diagnosis and developing an effective course of treatment was most likely due to the fact that all three physicians who analyzed the plaintiff’s CT scan failed to notice bleeding was already present. While this may not have entirely prevented the complications that subsequently developed, it may have resulted in the hospital staff checking in on the patient more frequently or noticing changes in his health more promptly. Since this matter settled prior to a finding of liability by a jury, it is difficult to evaluate the arguments and defenses raised by the parties.
Given the patient’s significant and permanent injuries, and the delays by the physicians, a jury may well have determined that the physicians failed to provide care consistent with the appropriate standard. However, the physicians and hospital had plausible defenses concerning causation: If the patient would have suffered the same injuries regardless of the delay, then the injuries were merely an unfortunate unavoidable consequence of the patient’s condition, and there was no negligence.
Medical malpractice trials are inherently risky and difficult to predict, as the patient and care providers must have appreciated. These inherent risks and difficulties — as well as the costs of trial — encourage parties to settle matters before trial to greater control the potential for recovery, from a patient’s perspective, and to control the amount of a verdict, from a care provider’s perspective. Settlement discussions take place at all stages of litigation, even after trial has started. In this case, the parties had prepared for trial and thoroughly evaluated their claims and defenses, as well as the opposing side’s claims and defenses, and determined that settlement was in all the parties’ interests. This is a regular occurrence in litigation, and physicians and hospitals should consult with counsel to evaluate and determine whether settlement is appropriate for a specific case.
REFERENCE
Announced on Feb. 19, 2019; action in the Circuit Court of Cook County, Illinois, Case Number 2015-L-010132.
This case serves as an example of both the importance of ensuring that information on a patient is clearly communicated among physicians and staff when multiple physicians are involved in the care of the patient, as well as the importance of timely diagnosis and prompt treatment.
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