News: In August 2012, a middle-aged man suffered a knee injury. He sought treatment and was released from a hospital with a splint. He sought surgery for his injury and met with another physician for presurgery consultation. During the consultation, a Doppler test was performed that returned a normal result. The patient was cleared for surgery, and returned to the hospital for the procedure.

The patient complained to the surgeon of continued pain, swelling, and a heating sensation in his leg. No additional Doppler test was administered. The patient was anesthetized for the surgery, and a blood clot detached from his leg and traveled to his lung, causing a pulmonary embolism. The patient was declared brain dead and ultimately died. The patient’s estate successfully argued in litigation that the presurgery procedures were negligent and that he should have received a second Doppler test. The subsequent lawsuit yielded a $5.5 million verdict.

Background: A 44-year-old electrical engineer suffered a knee injury on Aug. 7, 2012. He initially sought treatment at an emergency room, and was released with a splint on his leg. The patient presented to a different hospital on Aug. 9, and the treating physician referred the patient to a surgeon who also worked at the hospital. Surgery was scheduled for Aug. 16.

After the visit, the patient called the physician complaining that his splinted left knee, calf, and leg felt hot. The physician sent approval for the patient to undergo Doppler imaging of his left leg at a hospital. The Doppler was performed on Aug. 10 and the results were sent to the physician. The imaging was negative for any abnormalities in the leg.

On the morning of Aug. 13, the patient presented to the second hospital and was cleared for the Aug. 16 surgery to repair ruptured ligaments in his knee. The patient was anesthetized, and soon after suffered a pulmonary embolism when a deep vein thrombosis in his left leg detached and traveled to his lung. He suffered pulmonary arrest, coded, and was declared brain dead within hours of arriving for surgery.

The presurgical clearance was performed by a nurse practitioner, and the patient had a consultation with the surgeon who was scheduled to perform the surgery. The patient allegedly reported that he had continuing pain, swelling, and heat sensation in his left leg. Relying on the Doppler performed a few days earlier, the surgeon told the patient that the symptoms were related to the knee trauma he suffered. No additional Doppler imaging was ordered or performed despite the patient’s continued symptoms.

The patient was declared brain dead on Aug. 16, 2012, and died Aug. 19, 2012. He remained unconscious through the final four days of his life and was survived by his wife and two daughters.

The patient’s estate filed suit against the physicians, nurse practitioner, the hospital, and its faculty practice. The estate claimed that the various defendants were negligent in failing to order a second Doppler image of the patient’s left leg. The estate alleged this second test was necessary because the patient’s symptoms — continued pain, swelling, and perceived heat — were consistent with a deep vein thrombosis. Moreover, the estate argued that the first Doppler image was taken too close in proximity to the injury to reveal the deep vein thrombosis, as they typically take time to grow and develop after injury.

The defense argued that the patient’s signs and symptoms did not change after the Doppler on Aug. 10 and, therefore, there was no reason to order a second Doppler prior to performing surgery. The defense further argued that the nurse practitioner was not allowed to order a Doppler, knew the surgeon would see the patient during the same visit, and could rely on the surgeon to order the necessary presurgical tests.

Before trial, the physicians and nurse practitioner were dismissed from the case. A trial ultimately proceeded against the second hospital and its faculty practice. After an 11-day trial, a verdict was delivered in favor of the estate against the hospital faculty practice, awarding more than $5.5 million for personal injury and wrongful death.

What this means to you: This case illustrates the need for communication in the healthcare industry. In this case, a breakdown in communication occurred interhospital, intrahospital, and between patient and medical professional. Preparing a satisfactory medical record does a great deal for solving the inter- and intrahospital issues. It is important for medical records to be clear enough that any medical professional who picks up a patient’s file can determine exactly what steps have been taken and potentially what the next steps should be. If that practice is followed, the practice of medicine will be significantly more efficient when patients are transferred between hospitals and departments within hospitals.

Another lesson from this case is the importance of adequate and thorough presurgery procedures. Many presurgery procedures include interviews with the surgeon and other physicians knowledgeable in the various systems of the body likely to be affected by the surgery, such as a cardiologist for patients with a history of heart complications or a hematologist for patients with symptoms of blood clots or a family history of blood clots. Presurgery examinations also typically involve various tests. Some tests should be required for all patients scheduled for particular surgeries, such as complete blood count tests, X-rays, and ECGs. Specific factors may trigger the need for certain tests, such as the patient’s age, particularly difficult surgeries, and other health risks. Finally, many presurgery interviews are conducted at least a month in advance of operation. As a result, a thorough presurgery procedure should include a follow-up closer to the operation. Regardless of the tests and physician consultations used, hospitals should make an effort to establish hospitalwide minimums.

The ultimately fatal condition in this case, deep vein thrombosis, has several symptoms and risk factors that healthcare professionals should be familiar with to avoid substantial injury to patients and potential malpractice claims. While it is possible for deep vein thrombosis to not be accompanied by symptoms, swelling in one or both legs, pain or tenderness in the legs, warm skin on the legs, skin discoloration, visible veins, and tired legs all are potential symptoms that should prompt medical professionals to check for deep vein thrombosis. By analyzing both risk factors and symptoms, medical professionals can more readily diagnose and treat a deep vein thrombosis and prevent pulmonary embolisms.

Radiological misreads are common in healthcare for multiple reasons. Preliminary reads often are performed by technicians who are licensed to take measurements of the various organs and/or anomalies seen in the films or on the screens and document them for a radiologist to review. Unfortunately, it is common for a technician to include a diagnostic term, and a busy radiologist may accept this and proceed to use it in the final report without independent validation. This poses a danger to hospitals and radiologists, as acceptance without review may constitute a failure to provide the applicable standard of care.

Another common reason for a misread is the subjectivity often expressed in a radiologist’s interpretation of a result. A common example is differentiation between a tumor, fatty cyst, or other type of lesion. In cases where a patient’s symptoms warrant a study that is initially interpreted as negative, if the same symptoms persist or worsen, a re-read of the original study should be made. If the review continues as negative, a prudent physician often orders a repeat of the study. By documenting all of this in the patient’s record, the provider reduces the risk of future involvement in any subsequent litigation.

Many states have enacted laws that limit the scope of work that can be performed by nurse practitioners — for example, many states limit nurse practitioners’ ability to prescribe medicine. Many large states (such as California, Texas, and Florida) require physician oversight to prescribe, diagnose, and treat patients. However, other states have enacted laws that afford nurse practitioners full prescriptive authority, permitting them to prescribe, diagnose, and treat patients without the supervision of a physician. It is vital that hospitals are familiar with their state’s laws, and make them clear to their nurse practitioners as well as physicians. Violations of such laws, including permitting unauthorized nurse practitioners to prescribe medicine, open the door to penalties and malpractice liability.

REFERENCE

Decided on Jan. 23, 2018 in Cook County Circuit Court, Illinois; case No. 2014-L-006816.