Legal Review & Commentary

Failure to treat volvulus: $2.9 million settlement

News: A 5-year-old awoke in the middle of the night with intense stomach pains and was driven to an emergency department (ED). The ED physician’s preliminary diagnosis was a probable bowel obstruction. The child was seen by his family practitioner and admitted to the hospital. A surgical consult was not requested until the next morning. Surgery was provided to address the obstruction. The boy died 14 months later from complications of having a shortened bowel. The boy’s family settled with the hospital, nurses, and ED physician for $2.9 million. Trial is set for the case against the family doctor and the doctor’s medical clinic.

Background: A 5-year-old child awoke screaming and holding his stomach. His father immediately drove him to an ED, and the child began vomiting bile. At the ED, the boy’s blood pressure dropped sharply. The ED physician examined the child and ordered lab tests and X-rays in order to more completely assess his condition. In part based on the patient’s vomiting of bile, the ED physician diagnosed the child as having "probable bowel obstruction." The physician phoned the child’s family doctor, who came to the ED and examined the child at 2:15 a.m. The family doctor admitted the child to the hospital and went home.

At 2:55 a.m., the child was taken to a room in the hospital, and nurses took his vital signs. His temperature was 93.3° F and his blood pressure was 71/36. Concerned with the results, a nurse phoned the family practitioner at 4:30 a.m. and again at 6 a.m. At 6 a.m., the nurse also received two critical lab values for the patient: glucose and venous blood readings indicating the patient was acidotic. The family doctor cut the child’s fluids and came to the hospital to order the child be moved to intensive care. When the next shift of nurses arrived at 7 a.m., the new nurse responsible for monitoring the boy saw the seriousness of his condition. She called the family physician, but he was performing a circumcision at another hospital. The nurse phoned the doctor again at 8:04 a.m. after discovering the child’s blood pressure was 42/15 and his heart rate was 187.

The family doctor finally arrived at the hospital around 8:30 a.m. and immediately ordered a surgical consult. Surgery commenced at 9:50 a.m., more than nine hours after the child’s arrival at the ED. As the ED physician had suspected, the boy had a bowel obstruction — volvulus of the colon. The family doctor had listed a generic bowel obstruction and a volvulus as two possible diagnoses on his differential diagnosis checklist, but he had believed the child might have been diabetic or was in diabetic ketoacidosis, even though lab results had ruled those conditions out.

Because of the delay in calling for a surgical consult and the subsequent surgery, most of the boy’s small intestine and colon tissue had died. They were removed during the surgery. After surgery, the child was transferred to a children’s hospital, where he spent 89 days of his remaining 14 months as an inpatient. He died from the complications of his shortened bowel.

The child’s estate and his mother filed suit for negligence against the hospital, nurses, ED physician, family doctor, and the family doctor’s medical clinic. The plaintiffs recognized that the ED doctor made the correct diagnosis of the decedent’s bowel obstruction, but they pointed out that both the family physician and the ED doctor failed to promptly call for a surgical consultation.

The plaintiffs alleged that the ED nurse also failed to use the chain of command to obtain proper treatment after realizing that the child needed a surgical consult, and they argued that the night-shift floor nurse was too inexperienced to recognize the child’s declining condition.

Using the decedent’s medical records, the boy’s mother outlined details of the extensive pain and suffering endured by her son over the last 14 months of his life. A $2.9 million settlement was reached with some of the defendants, including the hospital. The case remains set for trial against the family practitioner and his employer.

What this means to you: This case reinforces the basic notion that all health care providers have a responsibility to assure that their patients are receiving appropriate care in a timely manner.

"An examination by another physician or a transfer of care to another physician does not absolve the original physician of responsibility, nor does a change of shift relieve the first treating nurse of responsibility for the patient’s initial care," says Cheryl Whiteman, clinical risk manager, BayCare Health System in Clearwater, FL.

Indeed, this case is a classic example of how individual negligent acts can compound due to an out-of-sight-out-of-mind mentality. Initially, the ED physician provided appropriate treatment when the boy was rushed into the hospital. He identified the urgency of the young patient’s condition, diagnosed the boy’s condition as a probable bowel obstruction, and phoned the child’s family physician.

"However, as this condition is always of an urgent nature, the emergency room physician should not have accepted the primary care physician’s plan to simply admit the child to the hospital. At the very least, the emergency room physician should have questioned the primary care physician as to why a surgical consult wasn’t ordered," says Whiteman.

By allowing the child to be transferred to the intensive care unit, the ED physician may have missed his opportunity to intervene.

"It certainly would have behooved the emergency room physician to obtain the surgical consult while the child was still under the jurisdiction of the emergency room," Whiteman says.

Even if the ED physician felt that he could not order a surgical consult himself, he could have utilized the chain of command to make sure the boy received appropriate treatment.

"The emergency room physician could have contacted his medical director to obtain assistance in getting a surgical evaluation," Whiteman says.

In addition, the ED nurse also had the option of notifying a supervisor of the boy’s urgent condition. "As plaintiffs’ attorney pointed out, the emergency room nurse had a similar responsibility to enlist the supervisor’s assistance in obtaining a surgical consult. At the very least had the supervisor been made aware of the situation, he or she could have assisted the floor nurse in monitoring the child’s condition and seeking appropriate medical attention much earlier," says Whiteman.

In addition to the errors committed in the ED, the nurse caring for the child on the floor could have been more proactive. "The concern that prompted the two nighttime calls to the primary care physician should have escalated upon receiving lab values indicative of acidosis," she states.

Again, in the absence of immediate action from the primary care physician, this nurse could have activated the chain of command by notifying a supervisor. "The supervisor, in turn, could have taken the situation to an administrator and/or the family physician’s section or department chair in order to obtain orders responsive to the condition, including a surgical consult," notes Whiteman.

Finally, the family practitioner would be hard-pressed to explain his lack of action considering that a young patient of his was facing a life-threatening situation. "From the beginning, a surgical consult should have been obtained at the time the differential diagnosis was established," says Whiteman. "He should have noticed that the lab results ruled out the differential diagnosis of diabetes, which in turn escalated the probable diagnosis to a surgical abdomen. Merely transferring this patient to a critical care unit instead of dealing with the cause of the symptoms would undoubtedly be found negligent in any court.

"To prevent similar breakdowns in the future, a risk manager should ensure that the facility has a strong chain of command policy," advises Whiteman.

Reference

• McHenry County (IL) Circuit Court, Case No. 00 L 187.