News: In early 2011, a middle-aged woman presented to an ED, complaining of nausea and vomiting over the previous four days. X-rays showed a bowel obstruction. Due to her dehydration and low urine output, she was given three liters of normal saline and taken to surgery. During the four- to five-hour surgery, the patient continued to produce low urine output. To promote urine output, saline fluid was regularly administered, for a total of 6,900 mL, with only 95 mL of urine output. The surgery successfully addressed her bowel obstruction and diverticulosis by removing three-quarters of her large bowel.

Following the surgery, the patient continued to receive aggressive fluid. She experienced increased respiratory depression as fluid entered her lungs and abdomen. That resulted in abdominal compartment syndrome and organ failure. The patient was put on a ventilator and became acidotic. The medical staff thought she was septic and performed another surgery to see if she was suffering from a dead bowel. It was determined that the surgical connections were intact. However, during the procedure, she went into cardiac arrest and suffered hypoxic-ischemic encephalopathy. She remained unconscious until her death on March 23, 2011. The subsequent lawsuit resulted in a verdict of $1.7 million for the plaintiff.

Background: On Jan. 12, 2011, a 54-year-old woman arrived at the ED complaining of nausea and vomiting over four days. Analysis of X-rays revealed a bowel obstruction. She was also suffering from dehydration and low urine output, so she received three liters of normal saline and taken to surgery. The patient continued to produce a low urine output during the surgery, which lasted roughly four to five hours. Saline fluid was regularly administered, eventually totaling 6,900 mL, but with only 95 mL of urine output. Surgeons removed three-quarters of her large bowel and successfully addressed the bowel obstruction and diverticulosis.

Significant amounts of fluid were administered postoperatively in the ICU. Over the next two days, her condition deteriorated, leading to increased respiratory depression as fluid entered her lungs and abdomen due to excess saline solution, which in turn caused abdominal compartment syndrome and organ failure. She went on a ventilator, and still became acidotic. This resulted in another surgery on Jan. 14 to see if she was suffering from a dead bowel. The surgery revealed that the surgical connections were intact, but the patient went into cardiac arrest during the surgery and suffered hypoxic-ischemic encephalopathy. She remained unconscious until her death on March 23, 2011.

The woman’s estate sued the hospital, hospital owner, umbrella entities, and the surgeon, alleging they were negligent in excessively administering saline fluid and in failing to consult with a nephrologist. The estate also sued a resident doctor, a vascular surgeon who took part in the second surgery and that surgeon’s practice, the managing resident, and another resident who took part in the initial surgery. The first surgeon settled for an undisclosed amount. He and all other defendants, save for the hospital, were dismissed prior to trial. Thus, the case proceeded against the hospital only.

At trial, the plaintiff’s expert in critical care opined that, given the patient’s significantly low urine output during the surgery relative to the high-saline input, the hospital’s medical staff should have consulted with a nephrologist. According to the expert, it is not unusual to use aggressive amounts of fluid during surgery on a dehydrated patient. However, surgeons must be cognizant of the patient’s urine output in relation to the administered fluid. The fact that the patient’s urine output was 95 mL and the fluid input was 6,900 mL was a major red flag that the medical staff overlooked.

However, the hospital’s expert in critical care surgery opined that the amount of fluids administered was not overabundant or overly aggressive because it was necessary to address possible sepsis and to maintain her cardiac output and blood pressure. He also stated that the medical staff properly monitored her vitals and lab work following the surgery, and opined that she had become septic. The hospital’s expert in general surgery also testified that the medical staff adhered to the standard of care in their fluid administration. The expert stated that the woman was seriously ill with an obstructed bowel and diverticulosis and the amount of fluids given to her allowed her to remain alive. Had the fluids been discontinued, her blood pressure would have dropped.

After the conclusion of the five-day trial, the jury deliberated for one-and-a-half hours before awarding the plaintiff more than $1.7 million for past medical costs, pain and suffering, and loss of past and future companionship.

What this means to you: Neglecting a postoperative patient can cost healthcare professionals and hospitals a great deal. Hospitals have an ongoing duty to their patients. For most, it goes without saying that patients are under the care of hospitals until they are discharged. However, it bears repeating for some, and the reminder can be helpful to reduce the number of medical malpractice cases. Hospitals should periodically remind their nurses and physicians of their duties to ensure they are properly ingrained in the professionals’ minds.

This case also shows the importance of carefully monitoring patients and their symptoms. Once the medical staff recognized that the patient’s urine output was abnormally low relative to the fluid input, they should have re-evaluated her input. Patients receiving intravenous fluids require frequent assessment to reduce risks of over- or under-administration, electrolyte imbalance, and other complications. The risks associated with cases like this are so high that failure to properly monitor a patient can easily result in a malpractice suit. Therefore, it is imperative that hospitals articulate the importance of patient monitoring to medical professionals.

What happened here arose from the failures of both treating physicians and nurses to go back to the basics of fluid balance, which is learned by both in their first year of their respective training. Urine output must be closely monitored at all times for patients receiving supplemental fluids. It is expected that a dehydrated patient will initially exhibit a lower output than input as the body redistributes lost fluid. However, there should be a steady increase in output as the body’s need is satisfied. If, as in this case, there is no recovery of output, the first thought should have been renal failure, often a temporary and very reversible consequence of dehydration. A nephrologist’s consultation and intervention would have had a significant effect, and perhaps a life-saving one, on this case.

While it is true septic patients may require more aggressive fluid delivery, the staff determined in this case that the patient was not septic; thus, fluid levels should have been kept lower. The estate’s general surgery expert noted that the excessive amount of fluid was inappropriate given the patient’s vital signs and other parameters of cardiac output and cardiac function. Such relatively high fluid levels should not have gone unchecked.

When medical professionals are unsure about patient treatment, they should be directed to consult specialists. The estate’s expert in nephrology contended that a nephrologist should have been contacted immediately, so the physician could administer diuretics to streamline the fluids in the patient’s body or dialysis to jump-start the kidneys. In doing so, according to the estate’s expert in general surgery, the woman’s condition would have improved steadily. This would have prevented organ failure and the second surgery, which caused her cardiac arrest. To avoid litigation, hospitals must ensure that specialists are available for consultation.

According to the counsel for the estate, the patient also experienced pain prior to passing. Rather than discover the cause of the pain, the medical staff stopped at the administration of pain medication. If the patient’s discomfort was caused by the surgery rather than a medical condition, pain medication would have been appropriate, but here the staff negligently overlooked the root of the patient’s pain. Pain medication certainly is a useful tool, but blind administration creates more problems than solutions. Pain management is a basic patient right regardless of the patient’s condition or level of consciousness. There are multiple signs of pain recognizable by trained caregivers that indicate an unconscious patient is uncomfortable. Grimacing, high pulse rate, and high blood pressure are a few of them. Pain is expected and must be treated following a major surgery, especially after opening the abdomen. It should have been addressed earlier.

This case also shows the jury value of objective pain and suffering. The patient was unconscious until she passed, but winced and was given pain medication. The plaintiff’s counsel used this to appeal to the jury’s empathy. The jury clearly felt moved by the patient’s suffering, evidenced by the $500,000 pain and suffering award.

REFERENCE

Wayne County, Circuit Court, Case No. 14-004174-NH, November 1, 2016.