Failure to follow up on coronary artery perforation results in $5.68 million verdict from jury
By Damian D. Capozzola, Esq.
Law Offices of Damian D. Capozzola
Jamie Terrence, RN
Director of Risk Management Services
California Hospital Medical Center
Tim Laquer, 2015 JD Candidate
Pepperdine University School of Law
News: A patient, age 49, was admitted with an acute myocardial infarction and rushed to a cardiac catheterization lab for a cardiac catheterization and angioplasty. A physician perforated a small coronary artery during the angioplasty but did not adequately treat the patient after being notified of her declining vital signs. After the patient coded, she was revived but was pronounced brain dead due to cerebral anoxia, and subsequently taken off life support by family two days later. The patient's surviving son brought suit alleging that the physician failed to take prompt action and that this delay caused the patient's injury.The defendant physician denied liability.The jury awarded $5.68 million in damages.
Background: In this matter, the patient had an acute myocardial infarction. She was promptly taken to a cardiac catheterization lab. A physician and staff promptly performed a cardiac catheterization and angioplasty. During the angioplasty, a small coronary artery was perforated. This is one of the many known risks of this procedure. Perforation of a cardiac artery is dangerous and requires close monitoring because it can result in cardiac tamponade, an emergent condition in which blood fills the pericardium, increasing pressure and decreasing efficiency of the heart. If tamponade is left untreated, it can lead to heart failure, shock, and death.
The physician was aware of the perforation asit was discovered before the patient left the cath lab. The hospital staff was advised as well, and the patient was monitored after the angioplasty. Shortly after leaving the lab, the patient's blood pressure dropped, which is indicative of a possible tamponade. Nursing staff notified the physician of this development at 2 a.m. The physician assumed this situation was presumptive tamponade, but he was about to begin treating another emergent patient. The physician had an unexplained 30-minute delay, as he did not begin treating the other patient until about 2:30 a.m. and did not find another physician to take care of the tamponade patient. Because the original patient received no immediate treatment for the tamponade, she coded at 4 a.m. When physicians finally arrived to care for her, they relieved the tamponade by draining the excess blood through pericardiocentesis. This action allowed the heart to resume functioning, but the damage was already done: The patient was brain dead from oxygen deprivation.
The patient's surviving son brought suit and claimed that the physician should have taken immediate action at 2 a.m. when the signs of tamponade were evident. At that time, the physician could have confirmed and treated the tamponade himself, or gotten another physician to treat the condition. Indeed, the primary issue in this case readily was conceded by the physician: Both the physician and the plaintiff's expert physicians admitted that the patient's perforation and signs of tamponade required immediate care. Testimony and reports during the trial brought out that the nurses attempted to persuade the physician to treat the patient or call in another physician. They were rebuked by the physician, who delayed without reason and made no calls. The physician himself admitted that the patient presumptively had tamponade, but his defense was that the hospital's call schedule was a recipe for disaster: the two competing groups of cardiologists created dynamics that didn't allow much calling between the groups. After two and one-half hours of deliberation, the jury found the physician liable and the hospital not liable. The verdict of $5.68 million subsequently was reduced based on statutory limits.
What this means to you: Emergent conditions such as tamponade require treatment quickly. In this case, by the time the tamponade was recognized and treated, it was too late. Had a physician performed the pericardiocentesis procedure sooner, the patient's life would have been saved. Failing to treat an emergent condition can be extremely dangerous to patients and easily can create liability for a physician when other reasonable physicians in the same situation would have recognized the need for, and actually performed, treatment. If members of the medical staff know there is a critical condition that might result in serious injury or death, something must be done immediately. Waiting is not only not an option, it might be considered reckless behavior. Multiple emergent patients might prevent a physician from dealing with all of them simultaneously, and this alone will not result in liability. However, given this situation, the physician must take steps to ensure that all patients are being adequately treated. Each physician should have a plan in place that adequately provides him or her with enough coverage to accomplish this step.
Also playing a significant role in the events here are the inherent risks of cardiac catheterization, which patients must be thoroughly informed of prior to the procedure. Perforation is a known risk of angioplasty, and tamponade is a known risk of perforation. The physician was aware of these facts and knew that the patient's artery was perforated. When a situation arises that has possible heightened risks, physicians must be particularly cautious and monitor the patient, and they must be ready to respond if any of these risks develop. Evidence at trial revealed that this physician had patients with perforations before, but they had resolved uneventfully.This situation might not always be the case, and physicians cannot rely on the best outcome happening every time. In fact, the longer one practices, the more likely it is that one will see a multitude of outcomes and many of those will be far from the best. Physicians should plan for the worse, rather than hope for the best. A keen awareness of the possible risks allows the physician to prepare for them and immediately intervene to mitigate those risks.
According to the physician, another important issue in this case related to call schedules. The physician claimed the hospital was at fault because the call schedule was a disaster. The hospital allowed two cardiologist groups to handle scheduling, and the two competed against each other rather than working together to fulfill patient needs. The physician blamed this situation as the reason for being unable to find another physician to cover his original tamponade patient.
Call schedules are particularly important for emergency situations, because physicians must have the option of calling another physician when multiple or large-scale emergencies happen. One physician simply cannot perform two surgeries at the same time. Hospitals should try to ensure that clinical areas have sufficient physician coverage at all times. If not, hospital administrators need to approach their medical staffs and insist that schedules be adjusted. In most cases, hospitals' boards of directors ultimately are responsible for credentialing the medical staff.Physicians with inadequate time-off coverage might be impacted negatively during the credentialing review process. The politics between competing physicians or physician groups must not be allowed to impact patient care.
Also of interest was that during deliberations, members of the jury asked a question regarding the damages award. The phrasing of the question suggested the jury was considering finding the hospital partially liable based on its scheduling problems. Ultimately, however, the jury believed that the physician individually was more culpable than the hospital, likely because of the unexplained 30-minute delay and his failure to even attempt to contact a replacement. However, while the jury did not hold the hospital responsible in this instance, hospitals do need to train their nursing staff to go up the chain-of-command when they realize that a patient is in need of immediate critical care and they are not able to get a physician to respond. The physician could have used the chain of command as well. The house supervisor, administrator on call, or some senior hospital representative should have been contacted by the physician or nursing staff so that the chiefof staff or other senior medical staff leader could intervene. Had this contact been done, the hospital's scheduling practices would not have been at issue. Relatedly, it is in a hospital's interest to supplement training in chain-of-command issues with written policies and documentation that all relevant staff personnel have received copies of the written policies as well as parallel verbal training. In any event, if a call scheduling issue creates problems for a physician, the physician still might be responsible to patients to respond to them in a timely manner and, if otherwise preoccupied, the physician must make reasonable efforts to find a replacement. Doing nothing, or waiting and hoping for a condition to resolve itself, is insufficient and might result in liability.
- Case No. 53C06-0812-CT-03249.Monroe Circuit Court, IN.Oct. 1, 2013.