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News: A woman’s physician sent her to the emergency department (ED) with severe abdominal pain. He admitted her for observation and discharged her two days later advising that she seek psychological counseling. The patient was readmitted the next day for emergency surgery to remove her obstructed small intestine. A settlement with the hospital and physicians was for $125,000.
Background: Shortly after relocating to Southern California, a 55-year-old homemaker and mother of one sought the help of a family practitioner for severe localized abdominal pain. After speaking with the physician on the phone and describing her history of reconstructive bowel surgery six years prior, the doctor said, "You probably have to go to the bathroom," and told her that if the pain persisted for an hour, she should go to the ED.
An hour later and still in pain, she went to an ED where she was met by her physician. Following the physician’s examination, he stated that she probably had a nervous stomach and irritable bowel syndrome. The physician ordered a barium enema and admitted her to the hospital for observation. Shortly after being admitted, the patient began to projectile vomit. The physician prescribed Compazine but shared with the patient that he believed she "had caused the condition herself" and that she needed psychological counseling.
During the evening, nurses inserted a gastric tube to alleviate the uncontrollable vomiting and the woman experienced some relief once the tube was inserted. The family physician still believed that the symptoms were psychosomatic. However, a consulting physician thought that the patient might have stomach cancer. A gastrointestinal endoscopy was performed. The results indicated that a CT scan be performed and the small bowel be examined. However, no further tests were performed and she was discharged from the hospital.
Immediately upon arriving home, the patient began to projectile vomit in 10- to 15-minute intervals. Throughout the night, she took Compazine and Xanax when she could, but continued to throw up. Early the morning, she began to have difficulty breathing and her lips had turned blue. At 6 a.m., her family called 911. She was taken to the hospital and readmitted. She then had lost control of her bowel function and was unable to stand or walk. A CT scan was ordered by the consulting physician and performed the next morning. It revealed adhesions causing bowel obstruction of the small intestine. She was experiencing acute renal failure was taken immediately to surgery.
As a result of the necrosis, the patient experienced permanent loss of approximately five feet of her small intestine and suffered postoperative emotional distress.
The plaintiff alleged that due to the prima facie evidence of her medical experience, the family physician failed to realize the full extent of her underlying condition. The fact that she shared with the physician her medical history, including the reconstructive surgery, should have been a red flag for a diagnosis of potential adhesions. The plaintiff maintained that the physician fell below the standard of care for not ordering the diagnostic tests prior to discharge.
The defendant primary care physician argued that the care and treatment rendered to the patient complied with the standard of care and that he appropriately relied upon the consulting physicians’ opinions as to the need to order additional tests. While the consulting physicians did admit that discharging the patient prior to having the additional tests performed did fail below the standard of care, but that they did not have any knowledge of her discharge and that it was the primary care, admitting physician’s responsibility to have ordered the tests. Regardless, all of the defendants maintained that plaintiff would have needed the same surgery anyway, even if the obstruction had been diagnosed 36 hours earlier. Ultimately, the hospital and consulting physicians were dismissed from the case and the family practitioner settled for $125,000 with the plaintiff.
What this means to you: This woman began her exchange with her family practitioner by describing her history of reconstructive bowel surgery, yet the practitioner dismissed her significant medical history and told her she "had caused the condition herself."
"Listen to your patients. Not all patients have the same tolerance for pain," notes Cheryl A. Whiteman, risk manager of Cigna Healthcare of Florida Inc. in Tampa.* "While the family practitioner’s calling in consulting physicians was appropriate, his failure to follow their advice became problematic to his defense. It would be interesting to review the documentation in this case. It is prudent for the physicians to utilize different diagnoses so that anyone reviewing the record would understand which conditions were being considered as well as which one were ruled out as the result of the tests performed, consultants’ conclusions, and the patient’s evolving condition. Essentially, one wonders how the physician justified this patient’s discharge in light of the facts presented.
"Based on the findings when the patient was readmitted with projectile vomiting, difficulty breathing, and acute renal failure as a result of bowel obstruction with necrosis, it would seem that he family practitioner and the referral physicians would have better served their patient had additional testing been performed during the first admission. Before assuming a psychological overlay, physical pathology must be considered, particularly as it relates to the patient’s medical history, which in this instance should have raised a red flag. And, if the medical history did not raise the flag with the family practitioner, he should have at least shared the history with the referral physicians even if he discounted it himself," adds Whiteman.
"Under the facts of this particular case, the hospital was dismissed, but the lesson remains — listen to your patients. This is not only true for the treating physicians but all medical personnel. You never know when you may hold the key piece of information to facilitate the arrival at the appropriate diagnosis," concludes Whiteman.
*These comments do not necessarily reflect those of Cigna Healthcare of Florida Inc.
• Anonymous Patient and Husband v. Anonymous Obstetrician/Gynecologist and Anonymous Hospital, Indiana.