Legal Review & Commentary: Post-surgical bleeding leads to brain damage
Legal Review & Commentary
Post-surgical bleeding leads to brain damage
News: A gynecologist went to examine the woman after two separate reports of the woman's abnormally low blood pressure were made. The physician noted that the woman was drowsy and unresponsive. The woman was given epinephrine, and a blood test was administered. A second test revealed that she was suffering from severe metabolic acidosis. The woman underwent exploratory surgery, and it was discovered that two blood vessels were bleeding as a result of her prior surgery. The damage to the vessels was repaired, but the woman was comatose and suffered permanent brain damage. The parties negotiated a settlement of $9 million.
Background: A woman underwent a laparoscopic-assisted vaginal hysterectomy. She was extubated at 2:05 p.m. At 2:30 p.m., she was given a painkiller and her respiration was assisted by an oxygen mask. At about 3:15 p.m., the woman's blood pressure began to decrease, to a level of 110/40 mm/Hg. Her pulse rate was 60 bpm.
At 5:45 p.m., a hospital employee made a notation that the woman's blood pressure had declined to an abnormally low level of 86/51 mm/Hg. Her pulse at that time had increased to 65 bpm and her abdomen was distended. However, the hospital employee noted that she was resting comfortably, and no action was taken at that time.
A nurse contacted a gynecologist at 6 p.m., reporting the woman's abnormally low blood pressure, but again no action was taken until 8 p.m., when a second report was made. At 8:40 p.m., a gynecologist examined the woman, noting that she was drowsy and unresponsive. The woman was given a dose of epinephrine, and a blood test was administered. The blood test revealed that her blood's hemoglobin level was dangerously low. Doctors noted that her clotting time was prolonged. Another test was administered, which demonstrated that she was suffering from severe metabolic acidosis.
The woman underwent exploratory surgery, and it was discovered that two blood vessels were bleeding as a result of the hysterectomy. The damage to the blood vessels was repaired, but the woman was comatose and suffered permanent brain damage. As a result of the several hours of unaddressed internal bleeding, the woman suffered hypotension, hypovolemic shock, severe metabolic acidosis, and sinus tachycardia. The woman further developed congestive heart failure and respiratory failure. The woman suffers from hemiparesis, incontinence and an overactive bladder, depression, twitching of her face, fatigue, emotional distress, and disinhibition syndrome.
The plaintiffs filed suit for medical malpractice, alleging that the physicians failed to timely diagnose the woman's bleeding and that the hospital was vicariously liable for the woman's injuries. Counsel for plaintiff contended that the doctors and nurses should have realized that the decreasing blood pressure and declining condition were symptoms of internal bleeding. They further claimed that there was a three-hour time lapse before any action was taken and that prompt diagnosis and treatment would have prevented the woman's injuries. Counsel for the defense conceded liability. The parties negotiated a $9 million settlement.
What this case means to you: A laparoscopic assisted vaginal hysterectomy (LAVH) involves the use of a small telescopic device that is inserted into the abdomen through a small incision. It allows light into the abdominal cavity, thus enabling the physician to see inside the cavity using a special computer screen for visualization of the pelvic organs. The uterus is then removed vaginally. This procedure still is a hysterectomy, which is a major surgery regardless of how it is performed and sometimes requires a hospital stay for a few days.
In this case, the woman underwent the LAVH in the afternoon and was extubated at 2:05 p.m. At 2:30 p.m., the patient was assessed for pain and provided pain medication as well as oxygen. It appears that the patient began to experience changes in her vital signs around 3:15 p.m. She was noted to have a decreased blood pressure to 110/40 mm/Hg and a pulse of 60 beats per minute. No action on the part of the nurse was initiated.
The role and responsibility of the nurse is to assess the patient to detect complications at an early stage. The goal is to prevent postoperative complications. The Joint Commission in its introduction of the Standard PC. 01.02.01 states, "The goal of assessment is to determine the care, treatment, and services that will meet the patient's initial and continuing needs. Patient needs must be reassessed throughout the course of care, treatment, and services." This includes data gathering, analyzing the data collected, and making decisions based on the analysis of the data. In this case, the nurse did not communicate the change in the patient's condition to the physician, nor does it appear that the change was communicated to a supervisor or colleague.
At 5:45 p.m., the patient was again demonstrating a change in her vital signs, and it was noted that her blood pressure had dropped to 86/51 mm/Hg with a pulse of 65 beats per minute. While the information was recorded in the medical record, and the patient was assessed as resting comfortably, no action on the part of the nurse was taken.
At 6 p.m., the gynecologist was informed of the changes in the patient's condition. It appears that no new orders were obtained from the physician. At 8 p.m., the physician was once again notified that the patient's condition was worsening, and at 8:40 p.m., the physician visited the patient and performed an examination.
It appears that the nurse did not assess and reassess this patient appropriately. The patient began experiencing a change in condition at 3:15 p.m.; however, no action was taken to notify the physician for approximately three hours. The physician did not see the patient or give additional treatment orders for two hours and 40 minutes. The patient already was obtunded by that point and most likely had been bleeding internally for several hours.
The Joint Commission rationale for the Standard, LD. 03.04.01 states, "Effective communication is essential among individuals and groups within the hospital, and between the hospital and external parties. Poor communication often contributes to adverse events and can compromise safety and quality of care, treatment, and services. Effective communication is timely, accurate, and usable by the audience."
According to The Joint Commission Sentinel Event No. 12 Operative and Postoperative Complications issued in February 2000, experts emphasized that communication between physicians and other health care providers is important in preventing complications. In 2008, The Joint Commission received 63 Sentinel Event Reports ass ociated with operative and postoperative complications. It was No. 6 in the 2008 Top 10 Sentinel Events list.
In conclusion, this incident may have been prevented through early and appropriate assessment, communication, diagnosis, and treatment of this woman. There were obvious signs of potential internal bleeding. The nurse should have communicated sooner and with more urgency to the physician, and the physician should have responded in an expeditious manner. Given the delay in treatment and the injuries sustained by the patient, it was wise for the defense counsel to concede and settle this case.
Reference
Case No. No. 12293/06, Supreme Court, Eleventh Judicial District, Queens County, NY.
A woman underwent a laparoscopic-assisted vaginal hysterectomy. Following the procedure, she was administered a painkiller, and her respiration was assisted by an oxygen mask. A couple of hours after the surgery, her blood pressure and pulse rate began to decline. Later, a hospital employee noted that the woman's blood pressure was abnormally low, but that her pulse had increased and her abdomen was distended. However, no action was taken.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.