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By Damian D. Capozzola, Esq.
The Law Offices of Damian D. Capozzola
Los Angeles, CA
Jamie Terrence, RN
President and Founder, Healthcare Risk Services
Former Director of Risk Management Services
California Hospital Medical Center
Los Angeles, CA
Morgan Lynch, 2018 JD Candidate
Pepperdine University School of Law
News: In early 2012, a young woman sought care at a hospital for the treatment of an anemic disorder. She underwent a surgical removal of her spleen to treat the disorder. During postoperative recovery, the patient suffered from stomach pain and fever. These symptoms were caused by an undiscovered blood clot in her system that was restricting blood flow to her intestines. The patient returned to the ED several times before any treatment was provided, but at that point it was too late and the clot could not be broken apart, limiting her functionality.
The patient sued the hospital and several physicians, arguing that they were negligent in failing to timely diagnose her blood clot. The case proceeded to a trial that lasted several days and resulted in a verdict in favor of the patient for more than $6 million. That amount is subject to the state’s tort reform laws and will therefore be reduced.
Background: In March 2012, a 23-year-old nursing school student was admitted to a hospital for the removal of her spleen to treat an anemic disorder. After the surgery, the patient experienced stomach pain and a fever and stayed in the hospital for an extended period. A CT scan was performed, but the treating physicians failed to recognize the portal vein thrombosis. The patient was admitted to the ED twice before she was ultimately diagnosed with the clot on April 15, 2012.
The physician who eventually discovered the blood clot used several methods to treat the clot, but none were effective because it was “too old.” Due to the medical complications, the patient was forced to temporarily drop out of nursing school but did complete her degree and secured employment at a hospital. However, the blood clot remains in her system, and the related complications forced her to switch to part-time employment status.
The patient filed suit in March 2014 against four doctors and the hospital, but the patient dismissed the hospital from the lawsuit several months later. A confidential settlement was reached with one of the doctors in 2017.
The case proceeded to a jury trial against three doctors: a surgeon, a radiologist, and a general surgeon who performed the splenectomy. The jury deliberated for two days and returned a verdict in favor of the plaintiff. The award totaled $6 million, including past medical expenses, future medical expenses, loss of earning capacity, past physical pain and mental anguish, future physical pain and mental anguish, past physical impairment, and future physical impairment. However, this amount will be significantly reduced due to the state’s tort reform act.
As to additional specific findings, the jury determined that the surgeon and the radiologist were negligent in their failure to diagnose and treat the patient’s portal vein thrombosis, a blood clot in the vein that brings blood from the intestines to the liver. The jury found the general surgeon who performed the splenectomy to have acted within the appropriate standard of care.
The jury also found the patient 10% negligent after hearing evidence she had refused to be administered a prophylactic blood thinner after the clot was discovered. She agreed to be administered three other blood-thinning medications, but none were successful in breaking up the clot. As a result, the clot remained in the patient’s system.
What this means to you: This case highlights the necessity of timely and accurate diagnoses. Portal vein thrombosis is a blockage or narrowing of the portal vein by a blood clot. The portal vein is the blood vessel that transports blood from the intestines to the liver. Most people with portal vein thrombosis have no symptoms, but some individuals experience the accumulation of fluid in the abdomen, an enlargement of the spleen, and severe bleeding in the esophagus. The spleen is enlarged because of increased pressure in the portal vein caused by its blockage or narrowing. This increase in pressure in turn causes an increase in spleen size, or splenomegaly. The blockage or narrowing of the portal vein also causes esophageal varicose, a dilation and twisting of the esophageal veins as well as the veins in the stomach, called the gastric varices. As a result, these veins can bleed considerably in some patients.
With this knowledge, physicians can diagnose portal vein thrombosis with patients who experience bleeding in varicose veins in the esophagus or the stomach, an enlarged spleen, and/or conditions that create a risk of developing portal vein thrombosis, such as umbilical cord infection in newborns or acute appendicitis. Further, physicians can use blood tests to determine the functionality level of the patient’s liver as well as whether the liver has been damaged. However, since these tests do not always reveal portal vein thrombosis, physicians who receive normal results should use Doppler ultrasonography. This can reveal a restriction or obstruction of blood flow in a patient’s portal vein. In some patients, it may be necessary to conduct MRI or CT scans to reveal the patient’s blood flow.
Timely and accurate diagnosis is only the first step, and must be followed by appropriate treatment to conform to the standard of care. If a patient is diagnosed with portal vein thrombosis, the treatment depends on several factors: the rapidity with which the disorder develops, the age of the patient, and the comorbidity of other disorders such as portal hypertension and bleeding from varicose veins. If the clot causes vein blockage suddenly, physicians typically will use thrombolysis. This procedure involves the use of a drug that dissolves clots, such as tissue plasminogen activator. If instead the blockage develops slowly over time, physicians use an anticoagulant, such as heparin, to prevent clots from emerging or increasing in size. This method is not used when clots suddenly develop because anticoagulants will not dissolve existing clots.
Physicians often will treat portal hypertension and bleeding from the esophagus simultaneously with the thrombosis treatment, and there are multiple techniques available to treat esophageal bleeding. Ultimately, the methods for treatment must conform to the applicable standards of care in order to protect from claims of malpractice; when multiple different appropriate treatment options exist, physicians should discuss these with the patient along with advantages and disadvantages of each method, and document it as further protection from a claim by the patient that he or she was insufficiently advised to make an informed decision.
Finally, what was critical in this case was the failure of the surgeon and subsequent ED physicians and staff to recognize, acknowledge, and diagnose postoperative complications. Stomach pain and fever are symptomatic of the body responding to something abnormal. When this occurs in a healthy person, that person may seek medical attention if symptoms persist. When a patient who has just undergone major surgery presents with these symptoms, it is the duty of healthcare practitioners to use appropriate investigative resources to uncover the source of the problem. If no definitive diagnoses can be made, experts should be consulted. A medical professional who instead chooses the path of least resistance by sending an injured or suffering patient home with analgesics rather than addressing and curing the root of the problem is more likely to be subsequently pursued for failing to provide appropriate care. Diagnosis and treatment must be prompt as this case demonstrates that certain conditions evolve over time, subsequently precluding or reducing treatment options. In that case, a medical provider’s delay in proper diagnosis or proper treatment not only may constitute negligence, but it may increase the harm suffered by the patient and increase the resulting damages in any litigation.
Decided on Feb. 15, 2018, in the 234th District Court in Harris County, Texas; case number 201417076.
Financial Disclosure: Author Greg Freeman, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Terrey L. Hatcher and Nurse Planner Maureen Archambault report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Consulting Editor Arnold Mackles, MD, MBA, LHRM, discloses that he is an author and advisory board member for The Sullivan Group and that he is owner, stockholder, presenter, author, and consultant for Innovative Healthcare Compliance Group.