Legal Review & Commentary

Heparin use contributes to death: $1 million arbitration

News: A middle-aged woman presented at the emergency department with flu symptoms. She was also disoriented. After initial tests were performed — principally a spinal tap, in which blood was found — she was admitted and was eventually transferred to the intensive care unit. It was suspected that she had suffered from a heart attack, so heparin was initiated. Approximately five days later, she was noted to have bilateral paralysis and was subsequently transferred to another facility, where she was also diagnosed as having lung cancer. She sued the hospital and attending physicians for failure to properly monitor her care and treatment, specifically claiming that the continuance of heparin was contraindicated.

A confidential high/low agreement was reached with the physician, and the arbitration award against the hospital was $1 million.

Background: The plaintiff, age 58, went to the ED with a fever and flu symptoms. She was also confused, disoriented, and hypoxic. A chest X-ray revealed acute bilateral pulmonary infiltrates, indicative of pneumonia. A lumbar puncture was performed to check for meningitis. The spinal fluid obtained during the tap contained red blood cells. She was started on oxygen and admitted to the hospital.

The following day, her respiratory distress worsened, and she required intubation. She was transferred to the intensive care unit. Once in the ICU, she complained of anginal pain. A possible myocardial infarction was diagnosed, and IV heparin was ordered. The heart attack was ruled out over the next 48 hours, but the plaintiff remained intubated and on IV heparin in the ICU for approximately five days. Once she was extubated, it was noted that she had bilateral paralysis of the legs. An MRI was performed and revealed extensive blood in the intradural and epidural spaces from the lumbar to the thoracic region, caused by a spinal hematoma. The plaintiff was transferred to another hospital for treatment of what was determined to be permanent paralysis.

The plaintiff brought suit against the hospital and attending physician, claiming that the IV heparin was contraindicated because of the blood found in the spinal tap and because of questionable cardiac changes. She also claimed that the continued use of IV heparin after the myocardial infarct was ruled out contributed to the hematoma. The plaintiff maintained that daily and thorough examination should have been performed in the ICU and that the nurses failed to conduct regular neurological assessment of her extremities while in the ICU.

The defendants contended that the administration of IV heparin in a patient with a bloody or traumatic spinal tap was not contraindicated and that the formation of the spinal hematoma was abrupt and could not have been diagnosed and treated in time to avoid paralysis. The hospital maintained that the nurses did in fact conduct routine assessments.

A confidential high/low agreement was reached with the attending physician prior to arbitration. The arbitration award was for $1 million against the hospital.

The plaintiff died shortly after arbitration as a result of lung cancer diagnosed during her hospitalization for paralysis.

What this means to you: "Heparin is a medication with serious ramifications, requiring careful supervision and monitoring, which apparently did not occur," Rosenblatt says. "Nor does it appear that this patient was adequately assessed upon presentation in the emergency department. The physicians and nursing personnel providing care to this patient failed to communicate with each other, obtain an adequate history, and place proper emphasis on coexisting morbidities. The patient was reported to be a healthy adult with a sudden onset of relatively common symptoms of malice, fever, and possible pneumonia. A lumbar puncture was appropriately initiated to rule out meningitis, but the presence of red blood cells in any significant number should have triggered further investigation," she notes.

"When the patient began to complain of significant unrelieved chest pain, the possibility of a cancerous lung lesion, together with the positive red blood cells in the spinal fluid, may indicate a differential diagnosis to the suspected heart attack. Without the results of other clinically appropriate tests, it is difficult to determine which possibility initially carried the greatest weight, but the history speaks toward a serious pulmonary condition," she adds.

"The use of heparin in a potential myocardial infarction may have been appropriate, but this therapy requires careful monitoring of the patient’s prothrombin time, which is the most common way to express the clotting time of blood, particularly in a patient with red blood cells present in the spinal fluid. Once the MI was ruled out, any treatments initiated as a result of the suspected cardiac infarct should have been immediately reevaluated," says Rosenblatt.

"This raises the issue of critically ill patients who are concurrently under the treatment of several consultants, each of whom has a different medical focus. The patient’s initial presentation of pneumonia and the positive spinal tap appears lost to the potential MI. The narrative does not discuss what happened after the MI was ruled out but does indicate that the other presenting symptoms of hypoxia, potential bleeding of questionable etiology, and intractable chest pain were not adequately followed,” she explains.

"Given the continued use of IV heparin, an astute nurse or attending physician was remiss in not assessing all possible indicators of bleeding, such as lower-extremity weakness, any neurological burning sensation, or early onset of pseudo-paralysis. Among the possibilities of over-anticoagulation are a change in orientation, lethargy, and complaints of severe headache, slurred speech, bloody urine and stools, coffee-colored emesis, and other classical indicators of hemorrhage," adds Rosenblatt.

"The question arises as to what lab studies were performed over the following days, and was there any connection made to the preexisting symptoms? Did the nurses assess the patient daily, turn the patient frequently, and question the labs ordered and results obtained? In any patient receiving IV heparin, the possibility of hemorrhage is never far from reality," she notes.

"All of this leads one to believe that perhaps a full history may never have been obtained — and if it was, the information was not well circulated among the various consultants on the case. Such an oversight may have also been the underlying cause of the coumadin case," notes Rosenblatt.

"Hospitals, and particularly emergency departments and walk-in clinics, have an undeniable duty to obtain an accurate history and perform a meaningful assessment. This is not always easy, but it is necessary. Arguing that the delay to properly diagnose did not affect the outcome of either case is like arguing that failure to repair faulty brakes on one’s car did not cause an accident involving brake failure," Rosenblatt concludes.