Legal Review & Commentary

Delay in Shunt Leads to Hypoxia; $22M Verdict

News: At birth, a baby boy was diagnosed with a congenital heart defect preventing blood flow to his lungs. Two days later, a B-T shunt was placed, and the child was discharged a few days later. About two weeks after birth, the baby was brought to a local hospital hypothermic, mottled, and with low oxygen saturation levels. Seven hours after the baby was admitted, a pediatric cardiologist performed a cardiac catheterization to diagnose the issue, and eventually a replacement shunt was inserted. About seven months later, the baby was diagnosed with a stroke, and when he was 3 years old, underwent an amputation of his left leg. He also suffered developmental delays as a result of prolonged hypoxia. The jury found in favor of the plaintiff and awarded $22, 327,241.

Background: A baby boy born with a congenital heart defect, called pulmonary atresia, underwent surgery to place a Blalock-Taussig (or BT) shunt. The BT shunt is used to temporarily direct blood flow to the lungs. After discharge, the baby presented at a local hospital providing pediatric cardiology care as hypothermic, riddled with spots or patches, and with oxygen saturation levels in the 50% range, when normal ranges are between 95% and 100%. While in the emergency department, the baby was classified as a four out of four for acuity, and his oxygen levels fell into the teens, a condition also known as hypoxia.

A pediatric cardiology fellow performed an echocardiogram that uncovered slow blood flow through the shunt. Based on his findings, the physician recommended the boy for surgery. The attending physician, however, did not see the boy until 4 hours later and ultimately determined that a cardiac catheterization procedure was necessary. Following the catheterization, a pressure dressing was applied to the boy's left leg.

Following the subsequent emergency shunt replacement surgery, the boy's leg continued to be mottled and discolored due to spots and blotches. The boy was diagnosed with a stroke and eventually underwent an above-the-knee amputation of his left leg as a result of the stroke. The boy also suffered developmental delays due to prolonged hypoxia.

The boy's family sued the hospital, three physicians, and two nurses, claiming medical malpractice. The plaintiff's attorney alleged that the shunt replacement surgery should have been done shortly after presenting and that the cardiac catheterization procedure was unnecessary based on the diagnosis. In addition, the plaintiff claimed that the dressing placed on the boy's leg was extra tight and that the hospital staff failed to properly evaluate and monitor the boy's leg following the catheterization.

The defense contended that their actions fell within the standard of care and that the cardiac catheterization was necessary in order to properly diagnose the shunt occlusion. According to the defense, the echocardiogram tape was inadvertently erased and could not be produced at trial.

The boy needs assistance with everything from dressing to feeding himself. While he is able to walk with the help of a prosthetic and attend school, the boy's mother had to quit her job in order to care for him.

The jury agreed with the plaintiff and found that the hospital and staff were negligent by: failing to make a timely diagnosis of the issues regarding the shunt; improperly subjecting the boy to an unnecessary procedure; improperly applying pressure to the dressing on the boy's left leg; and failing to remove the dressing in a timely manner. The jury also found that the hospital and staff failed to monitor the boy's pulse and improperly destroyed an echocardiogram.

What This Means To You: The congenital defect of pulmonary atresia (PA) is also known as the "blue baby syndrome." Common symptoms of pulmonary atresia include cyanosis within the transitional first day of life, rapid or difficult breathing, lethargy, irritability, and pale, cool, or clammy skin. Oxygen and perhaps ventilation may be used initially to assist with respiratory function. Diagnostic studies to aid in the confirmation of PA include chest X-ray, EKG, echocardiogram, or cardiac catheterization. The Blalock-Taussig (B-T) shunt is a temporary procedure used to direct blood flow to the lungs and relieve cyanosis. Ultimately, surgical intervention will be required to improve blood flow to the lungs on a permanent basis.

In this case, the infant boy was diagnosed with PA at birth. Two days later, a B-T shunt was placed. About two weeks later, the child presented to a hospital ED with low oxygen saturation levels, mottling, and hypothermia, and was classified as 4/4 acuity. The attending physician did not evaluate the child until four hours post-echocardiogram and recommendation for surgery. Seven hours post-admission, a heart catheterization was performed. This was followed by emergency shunt replacement surgery. This case represents an issue of timeliness and failure to rescue vs. actual intervention and appropriate treatment. There was failure to either recognize adequate perfusion or the signs and symptoms of hypoxia. The interventions provided to the baby boy at birth and thereafter may have been appropriate, but the delay in intervening in a timely manner is at the heart of the matter. This brings to mind several questions: were the signs and symptoms of hypoxia properly identified and communicated? Was the acuity and severity of the situation properly communicated and understood? Was the sense of intervention urgency communicated and understood? Was follow-through monitored? Did assessment and reassessment occur? Was there adherence to an appropriate chain of communication and command? Were solutions to problem(s) identified, initiated, and monitored? Given the jury verdict in this case, I would venture to say the answer to all these questions is "no."

Low oxygen saturation rates require immediate attention and intervention. A saturation rate 45% to 50% below normal range in a child requires rapid response; an emergent response is absolutely necessary when those stats drop into the teens. With a known history of PA and B-T shunt placement, this 2-week-old infant with symptoms of hypoxia required emergent assessment and intervention. Long-term effects and damages from prolonged hypoxia not addressed in a timely manner, especially in infants, children or young adults, often leads to expensive verdicts. Consideration of life expectancy rates and the need for lifelong continued assistance with activities of daily living contribute to the verdict dollar determination.

Following the heart catheterization, this young boy continued to display signs of circulatory issues in his left leg, as evidenced by persistent mottling and discoloration. The pressure dressing on his left leg may have been improperly applied. The left leg site and dressing should have been assessed on a frequent basis for post-procedure bleeding and circulatory constriction. Evidence of monitoring left leg status post-heart cath was critical. The inability of the hospital to produce the echocardiogram that substantiated decreased blood flow through the shunt demonstrated carelessness. Absence of monitoring evidence and failure to produce films or records leaves little to defend. And regardless of all the facts presented in the case from both plaintiff and defense perspectives, there is a young boy who has suffered a stroke at a very early age, incurred developmental delays, and will live with those negative outcomes the rest of his life.

Continuous medical and clinical staff education in assessment, documentation, and communication skills is required for successful outcomes for the patients we serve and for survival in the world of litigation. The Joint Commission describes the goal of assessment in its introduction to Standard PC.01.02.01 as determining "the care, treatment, and services that will meet the patient's initial and continuing needs. Patient needs must be reassessed throughout the course of care, treatment, and services." Failure to properly assess, and reassess continuing care needs on a frequent and as-needed basis, is failure to serve our patients, their families, and our health care organizations. Failure to provide evidence of care through appropriate, clear, and concise documentation leaves us with little to no support of our efforts in providing care when faced with litigation.

Reference

1. Circuit Court of Illinois, Cook County Judicial Circuit, No 02L16398.