Legal Review & Commentary: Failure to diagnose perforated bowel results in a $670,000 settlement
Failure to diagnose perforated bowel results in a $670,000 settlement
By Jan J. Gorrie, Esq., and Blake Delaney, Summer Associate
Buchanan Ingersoll PC,
Tampa, FL
News: A woman presented to the ED of a hospital. When told there would be a two-hour wait to be seen, she tried to drive to another hospital but had to stop and call for emergency medical assistance. She was taken by ambulance back to the first hospital where, several hours she later, she was diagnosed with a perforated bowel. Rather than immediately undergo the required emergency surgery, she agreed to be transferred to another hospital. She died shortly after arriving at the receiving facility.
Her husband and parents brought a wrongful death action against the hospital, treating physicians, and ambulance service. Prior to trial, all parties confidentially settled for $670,000.
Background: The woman presented to the ED with complaints of severe abdominal pain. After an initial evaluation by the triage nurse, she was told it would be at least two hours before the physicians would examine her. She elected to leave the hospital with her husband and drive to another hospital about 45 minutes away.
En route to the second hospital, her pain and discomfort became so severe that she and her husband stopped at friend’s house and called a rescue squad. Paramedics arrived and transported her to the closest facility, the hospital where she had been triaged earlier.
She arrived at the ED for the second time at 1:50 a.m. Vital signs revealed her to be febrile, with pulse of 88 and blood pressure at 100/60. This was the only recorded set of vital signs throughout the admission. She was placed on a gurney in a hallway and an IV was unsuccessful.
At 3:15 a.m., the ED physician evaluated her. Lab and radiology studies were performed. Flat and upright abdominal films showed a high-grade small bowel obstruction. Lab assessments revealed an elevated white blood cell count of 20,300.
According to her husband, the ED physician told him his wife had a bowel obstruction and asked where she would like to have the surgery performed. The husband said neither the ED physician nor the on-call surgeon offered or suggested the surgery be performed immediately at that hospital.
Since the patient had had prior gastric bypass surgery performed at another facility, she and her husband requested the surgery be performed there. Meanwhile, her condition deteriorated. The ED staff was unable to obtain blood pressure readings and, after several unsuccessful attempts to establish an IV line, the on-call surgeon was asked to establish a central line. The central venous access was finally established at 5:30 a.m. and an arterial blood gas was taken at 5:40 a.m. This test showed the patient was in a metabolic acidosis state.
Her care was turned over to an ambulance service for transport to the other facility at 6:30 a.m. — almost five hours after her second arrival at the ED.
During transport, no oxygen, intravenous fluids, or medications were administered and, with the exception of cardiac monitoring, her vital signs went unmonitored. The patient was awake throughout the trip until her arrival at the receiving facility, where she turned to her right side, took one gasp of breath, and arrested. Full cardiopulmonary resuscitation measures were immediately employed but, despite all efforts, she was pronounced dead at 7:43 a.m.
The decedent’s spouse and parents brought action against the providers for wrongful death. The plaintiff alleged the ED physician violated the standard of care by failing to appropriately assess and stabilize the patient prior to transport to another facility.
The plaintiff further alleged the ED staff violated the standard of care by allowing her to be transported. Similarly, the plaintiff claimed the ambulance service should not have transported a patient that was clearly not properly stabilized and that it did not provide sufficient monitoring of her condition while in transit.
The cause of death became an issue. On autopsy, a large, benign adrenal carcinoma known as a pheochromocytoma was found. The defense alleged the death was caused by a "pheo crisis" or "storm" and it further alleged that the medical chart provided by the ED physicians and others was appropriate under the circumstances.
This action resulted in a settlement among all of the defendants of $670,000.
What this means to you: EDs are mandated by EMTALA to provide triage and to stabilize a patient that presents with an emergency medical condition or is in labor.
"By virtue of this federal statute, there is an established standard of care regarding the management of any patient that presents to an emergency department. This is the prevailing issue regarding this case," notes Cheryl Whiteman, RN, MSN, HCRM, clinical risk manager at BayCare Health System in Clearwater, FL.
In her first ED visit, the patient made a decision to leave after being told by the triage nurse that she would not be seen for at least two hours, despite the chief complaint of severe abdominal pain.
"It could be argued that if conditions truly prevented an examination by a physician," says Whiteman, "it may have been prudent for the nurse to share findings with the physician. Rather than allowing the patient to leave without being evaluated by a physician, perhaps verbal orders could have been given for preliminary blood work and/or X-rays to at least begin a diagnostic work-up.
"When the patient was returned to the emergency department by ambulance, as a result of worsening symptoms, a first and only set of vital signs were recorded, making it difficult to determine if she exhibited signs of deterioration and certainly eliminating a defense argument that she was being monitored. It took approximately 1½ hours to obtain test results. That perhaps could have been obtained when she first presented, probably two to three hours earlier," she adds.
Communication in the health arena is critical and seems to have been lacking in this instance.
"Based on the radiology studies, the physician was working with a diagnosis of a small bowel obstruction, apparently corroborated by the on-call surgeon. It seems unlikely that the patient and her husband were appropriately apprised of the risks in attempting transfer to another facility for surgery. Despite having had previous surgery at that facility, risks for the transfer of a patient with a bowel obstruction and a delay in surgery are significant, and it appears that neither the patient nor her husband had a clue as to the serious nature of her condition," says Whiteman.
"As if the communication breakdown was not enough, another delay in treatment occurred in administering fluids as the staff was unable to establish an IV line. Fluid administration did not begin for approximately two hours after a diagnosis was made. Despite arterial blood gases clearly indicating metabolic acidosis, this patient was placed into an ambulance for transport an hour later. As the metabolic acidosis was not addressed, this patient was clearly not stable for transport, thus breaching EMTALA requirements and the standard of care. Likewise, there is no defense for transporting a patient in extremis without monitoring vital signs, administering oxygen, fluids, and appropriate medication," adds Whiteman.
"An autopsy determined that this patient had pheochromocytoma. While abdominal pain is a symptom of such an adrenal tumor, there was no mention of a history of more common symptoms, including hypertension, headache, rapid heart rate and palpitations. In fact, in the absence of documented vital signs throughout her ordeal, it is impossible to determine if this patient displayed extreme symptoms of pheochromocytoma, which can include acute hypertension, ventricular fibrillation, myocardial infarction, and cerebrovascular accident. Regardless of her presentation, had the surgeon proceeded with abdominal surgery for the diagnosed small bowel obstruction, there may have been the possibility of discovering the tumor and perhaps the patient would have had an increased chance of survival. Despite the preoperative diagnosis, multiple delays in diagnosis apnd treatment, failure to stabilize, and transporting an unstable patient leaves little defense for this case," she explains.
"A thorough root-cause analysis is warranted to address serious issues. Staffing needs to be reviewed to determine why there were so many delays in care and treatment. Basic management of the emergency department patient with an acute abdomen as well as the patient in acidosis needs to be taught or reviewed, along with the basics of vital signs. Documentation needs to be addressed urgently. Extensive education in regard to following EMTALA regulations and providing informed consent in regard to transfer is required. The risk manager would also be prudent to initiate an ongoing monitoring system with the emergency department to evaluate the effectiveness of the education and to ensure that the desired improvements are achieved and maintained," concludes Whiteman.
A woman presented to the ED of a hospital. When told there would be a two-hour wait to be seen, she tried to drive to another hospital but had to stop and call for emergency medical assistance. She was taken by ambulance back to the first hospital where, several hours she later, she was diagnosed with a perforated bowel. Rather than immediately undergo the required emergency surgery, she agreed to be transferred to another hospital. She died shortly after arriving at the receiving facility.
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