Legal Review & Commentary Supplement to HRM: Family awarded $10.8 million after woman dies from complications following cardiac catheterization

Family awarded $10.8 million after woman dies from complications following cardiac catheterization

News: A woman underwent routine cardiac catheterization in a hospital. Complications arose, and the patient died. The patient’s family sued and contended that the hospital and the doctor did not take sufficiently prompt or adequate actions to treat the complications. The defendants contended that all reasonable and proper steps had been taken to care for the patient, who had suffered from a rare complication that was difficult to deal with. The jury sided with the patient’s family and awarded $10.8 million. Both defendants are jointly and severally liable for 100% of the verdict.

Background: Cardiac catheterization is usually a relatively routine medical procedure used to diagnose and treat certain heart conditions. A catheter is essentially a long, thin, and flexible tube that is inserted through a blood vessel in the arm, neck, or groin and pushed through to the heart, which allows providers to perform treatments and do diagnostic tests. Although usually performed in a hospital setting by cardiologists, the patient remains awake during the procedure. It causes minimal if any pain, and rarely results in serious complications.

In this case, the patient was a woman in her mid-30s who, according to the patient’s family, had a very mild history of heart issues. The woman initially went to a doctor complaining of possible bronchitis, but tests showed possible signs of heart trouble. She underwent a cardiac catheterization procedure. The cardiac catheterization procedure initially was believed to be routine and showed her heart was healthy and clear. However, during the procedure, one of the coronary arteries (left main) was dissected. This dissection means that the inner lining of the artery was disrupted by the tip of the catheter, which resulted in the collapse of the inner lining and a significant supply of blood to the heart being cut off.

The patient’s family contended that once the patient started showing signs of severe complications post-catheterization, more than 30 minutes passed before the patient was taken for surgery. The patient’s family said the patient was near death when she arrived for surgery 20 minutes later and nearly 50 minutes after complications arose. Despite three hours of surgical efforts, the patient died. The hospital and the doctor, an interventional cardiologist who is board-certified in internal medicine/cardiovascular disease, testified that all proper and reasonable efforts had been made to care for the patient in light of what they argued was a rare complication that was difficult to deal with. On an 11-1 vote, the jury sided with the patient’s family and awarded $10.8 million dollars.

What this means to you: The facts of the case and size of the jury’s award suggest that the defense never offered a good explanation for why an interventional cardiologist waited for such a long time to identify the severity of the problem and take appropriate action (i.e., ordering immediate surgery) once the patient started showing signs of disruption to a significant blood vessel. Some evidence uncovered during the discovery phase of the case suggested that in the past, the doctor had experienced a similar but less serious situation. Thus, the doctor might erroneously have believed that the patient here had more time than she did to see whether the symptoms would subside and to bring in his partner to consult, instead of acting immediately and decisively on the theory that one could assume only the worst.

Rigorously requiring even the most prestigious doctors working at a hospital to attend conferences and participate in periodic refresher and continuing education courses might help avoid a circumstance in which a highly regarded specialist makes a fundamental error with disastrous consequences.

The case also illustrates the potential danger of subjecting patients to unnecessary medical tests and procedures. Here we have an apparently healthy woman in her mid-30s who went to the emergency department complaining primarily of symptoms of bronchitis. The doctor prescribed albuterol. The patient complained of chest pains, which is a known side effect of albuterol. Because the patient had in the past some very mild heart issues related to an irregular heartbeat, the hospital decided that a cardiac catheterization was required. During that procedure, the left main coronary artery was disrupted, and the problem was not identified and remedied quickly enough. By the time the patient reached the surgery room, not even three hours’ worth of surgical efforts could save her life. The simplistic story is that she went in with a cough, got caught in a cascading series of medical misjudgments, and died in the care of her hospital doctors. Had monitoring or less invasive measuring techniques instead of full-blown cardiac catheterization been employed, the patient very well might have survived without any further incident at all.

That said, it is also worth noting that even one of the family’s attorneys was subsequently quoted in the press as agreeing that was an isolated situation. Isolated situation or not, the jury still found the hospital and the doctor at fault and returned a very large verdict for the patient’s family.

Always expect the unexpected when performing delicate invasive procedures on critical organs. It is rare that during a routine catheterization the catheter can cause a dissection. If this happens the interventional cardiologist will try and "repair" this problem with an angioplasty or stent. How unstable the patient becomes depends on the vessel that is dissecting. The left main would have a very high mortality. While the cardiologist is working on a "bail-out" or rescue intervention and probably inserting an intra-aortic balloon pump (IABP), the on-call cardiac surgical team will be alerted and on the way in for the emergency surgery needed to repair the damage. In most hospitals, a cardiac surgical team is on-call in the event of an unexpected emergency. In cases where there is increased risk of an untoward event, such as with a patient who has left ventricular dysfunction and an ejection fraction less than 30%, the interventional cardiologist can request that the cardiac surgical team be on site.

Your hospital can prepare by taking the following steps:

• Make sure that back-up systems are in place to call in staff.
• Know how to reach people quickly. Have current phone or pager numbers easily available.
• Have emergency equipment such as your "crash cart" IABP, suction, and supplies checked daily, and have it all close by and ready for use. Make sure staff knows how to use it.
• Run drills periodically to test staff competency.
• Have policies in place that speak to expected responses in emergency situations.
• Finally, have your physicians always educate patients on what risks are involved in these types of procedures and ensure that they have documented this information in the informed consent process.

Medical staffs should also review their credentialing processes to ensure that physicians who perform high-risk procedures are credentialed carefully, maintain their board certifications, and are consistently monitored for performance issues. A tight peer review process is critical if the hospital wants to safely offer advanced medical and surgical services to the community.

As in the first case discussed above, there is also a responsibility for the cardiac catheterization team to intervene on behalf of the patient if they think there is a delay to provide emergent care. Was the catheterization lab staff aware of the surgeon’s delay? Did they "speak up"? All hospitals have a hierarchy or chain of command available to staff to use to bypass a provider who is not following a procedure or standard of care. In this case, there also was a responsibility for other team members to advocate for their patient.

The key legal question in any case like this one is whether the hospital, doctor, and staff behaved reasonably under the circumstances given the facts that were known to them at the time in light of their training, education, and institutional policies and expectations. Failing to speak up when a patient’s life hangs in the balance will rarely look reasonable, and neither will the failure to have a process to allow people a safe outlet for raising legitimate concerns. It is important for risk managers at hospitals and medical clinics to work with their in-house legal counsel and develop constructive policies along these lines. If there are no in-house legal counsel or if the in-house legal counsel for whatever reason lack the expertise to advise authoritatively on these issues, strongly consider investing in the expertise of outside counsel experienced in these areas, where an ounce of prevention can be worth well more than a pound of cure.

Finally, the facts underlying this case raise many questions. Was the procedure even necessary? Why was there a rush to perform a cardiac catheterization after a complaint of chest pain without other findings? Did she have a questionable EKG? Was a stress test done that showed ischemic changes? Certainly the stress test could have been offered first. Perhaps her chest pain came from nothing more than her active cough. Bronchitis, before treatment, can be very painful in and of itself. Another rule of risk management is to start with and rule out the simplest explanation first before exploring the more complex. It often works. Disciplined implementation of such an active risk management approach also can be beneficial in any subsequent litigation, but it is critically important to document steps taken, results obtained, and the reasoning behind decisions as the treatment process moves forward.

Reference:

11SL-CC03684, Division 5, Circuit Court of St. Louis County, MO, 21st Judicial Circuit.