Legal Review & Commentary
Aneurysm overlooked: $2.1 million verdict
News: A man went to the hospital after experiencing severe headaches. A physician's assistant (PA) diagnosed the man as suffering from a spinal headache, and a blood patch was performed to repair the hole where the spinal fluid was thought to be leaking out. Following the blood patch, the man was discharged home by a physician who did not make any notes in the chart or examine the patient. The man returned to the hospital later that night, and he soon thereafter lost consciousness and became comatose. Doctors eventually determined that the man had suffered a ruptured pseudoaneurysm of the vertebral artery, and surgery was performed to stop the bleeding. The man, who learned he would be wheelchair-bound and severely aphasic for the rest of his life, sued the hospital and the discharging physician for negligence. Shortly after the trial started, the parties settled for $2.1 million.
Background: A 62-year-old salesman underwent a hernia repair under epidural anesthesia. Over the course of the next few days, the man experienced persistent severe headaches. He called his hernia repair surgeon, who told him to go to the ED and who in turn called the ED to alert them that a man would be coming in with a possible spinal headache.
When the man arrived at the ED, a physician's assistant determined that he was having a spinal headache. The PA then spoke to the attending ED physician, who agreed with that determination, even though he never personally examined the patient. The PA then called an anesthesiologist to perform a blood patch to repair a hole where the spinal fluid was thought to be leaking out. Because the anesthesiologist was ending her shift, another anesthesiologist performed the procedure. Following the blood patch, the man was discharged by a physician who did not make any notes in the chart or examine the patient.
The man's headaches continued when he went home, and so he returned to the ED that same night. The attending doctor at the hospital examined the patient and again thought that the man was having a spinal headache. He called the anesthesiologist to perform a second blood patch, but the anesthesiologist refused and said the man needed a neurologist. An hour later, the man lost consciousness and became comatose. A CT scan showed a subarachnoid hemorrhage, and a drain was inserted.
The man was transferred to another hospital the following morning. An angiogram at the second hospital showed a ruptured pseudoaneurysm of the vertebral artery, and surgery a "coiling" was successfully performed to stop the bleeding. The patient remained in a coma for several weeks, and after he came out of the coma, doctors determined that the man would be wheelchair-bound and severely aphasic for the rest of his life.
The man sued the doctors, nurses, and PA who treated him at the first hospital, claiming that they failed to diagnose and treat a pseudoaneurysm, resulting in its rupture. The claims against all of the physicians, except for the physician who had discharged the patient, were eventually dropped.
As for damages, the man maintained that he and his wife were planning to move to Florida, but that he was going to work for several years more at his $72,000-per-year job. He consequently claimed loss of income and fringe benefits for five years, as well as past and future medical expenses and past and future pain and suffering.
The remaining defendants the first hospital and the discharging physician claimed that it was not negligence to treat the man for spinal headaches. They also claimed that even if he was having a bleeding aneurysm at the first ED visit, it was not clear that intervention was indicated. The defendants finally argued that even if the coiling procedure had been timely performed, the man's condition would not have been significantly different.
Following jury selection but before opening statements, the case settled for $2.1 million. The discharging physician's insurance carriers paid $1.85 million, and the hospital paid $300,000.
What this means to you: "In most, if not all states, a physician assistant is not an independent practitioner and is licensed to practice only under the direction of a sponsoring physician," says Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, consultant/principal of The Kicklighter Group in Tamarac, FL. The defense of this case was that it was not negligent to treat the patient for a spinal headache. The question, however, whether the physician's assistant was qualified to make that diagnosis without the physician reassessing the patient personally? It appears that, other than the initial evaluation by the physician's assistant, no physician examined that patient on the first visit.
"Documentation can save you or sink you," she says. As risk managers, we have emphasized the need for legible, complete, and pertinent document as an ongoing campaign. Documentation by all caregivers is the method of communication used most frequently to communicate the status, evaluations and results of the critical thinking of the various caregivers based on this information and data. Incomplete information and data (read: failure to document) lead to incorrect critical thinking conclusions and next steps to care for the patient.
This regrettable situation could have been avoided through better communication. It appears that the "change-of-shift" malady played a large part in the situation. The first anesthesiologist who was contacted to perform the blood patch was leaving at the end of her shift, and the task shifted to the incoming anesthesiologist. It is unclear whether either of the anesthesiologists examined the patient personally, and also unclear whether the information given by the PA to the outgoing anesthesiologist was given to the incoming anesthesiologist.
Further, it is unclear whether the anesthesiologist who eventually performed the blood patch conducted an examination of the patient or reviewed the record to independently determine if the blood patch was the proper treatment. For the discharging physician not to have evaluated the patient prior to discharge and documented that evaluation is unacceptable. In view of the lack of discharge documentation, we cannot confirm whether there was a post-procedure, pre-discharge evaluation. "Handoff" communication between caregivers and at shift change is critical. In fact, it is an area that The Joint Commission assesses in its surveys.
"Lessons should be learned from this scenario," says Kicklighter. To that end, risk management should facilitate a root-cause analysis in that type of situation to identify why this happened and to initiate and facilitate preventive processes. Education of staff regarding legible, complete, and pertinent documentation also is a must in the follow-up of that type of case as well.
Reference
- Case No. 2146/03, Nassau County (NY) Supreme Court.
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