Legal Review & Commentary

Perforated intestine during lap case precedes death, $2.5 million settlement

By Leslie E. Mathews, Esq., MHA

Buchanan Ingersoll & Rooney PC

Tampa, FL

Barbara Reding, RN, LHCRM, PLNC

Central Florida Health Alliance

Leesburg, FL

News: A 45-year-old woman underwent surgery at a local university hospital to remove a cyst on her ovary. During the operation, surgeons found dense adhesions, and the patient experienced increased pain and pressure in her abdomen following surgery. By the time the medical staff diagnosed her with a perforated bowel, the patient was in critical medical condition due to sepsis. In preparation for a second surgery, the patient suffered a heart attack resulting in severe brain damage. The patient was removed from a ventilator and died when it was determined she had no meaningful brain function. The hospital and patient's family settled a wrongful death suit for $2.5 million.

Background: A 45-year-old legally blind woman underwent surgery at a local university hospital to remove a cyst on her ovary that was causing chronic pelvic pain. During the operation, surgeons found dense adhesions requiring a difficult dissection of the bowel. Following the surgery, the patient experienced increased pain and pressure in her abdomen overnight. The next day it was recorded that the patient was tachycardic, tachypneic, nauseated, and had a bloody emesis. The nurse also reported that the patient's abdomen was tender to the touch and distended.

Two days after her surgery, the patient's blood pressure dropped to dangerously low levels. At that time, a surgical consult was ordered. The surgeon immediately determined that the patient had a hole in her large and small intestines. Before the hospital staff could prepare her for a second surgery, the patient suffered a heart attack, leaving her with severe brain damage. The cardiac arrest left her ventilator dependent with no meaningful brain function. The ventilator was removed, and she died four days after her initial surgery.

The personal representative of the patient's estate brought an amended complaint against the university medical center and four of the physicians who oversaw her care at the hospital. The plaintiff sued the hospital as the doctors' employer. The plaintiff alleged that the surgeons who completed the initial surgery were negligent in injuring the terminal ileum mesentery during surgery, perforating the anterior wall of the lower sigmoid colon, failing to appropriately follow the patient in the recovery room, and failing to communicate to the postoperative caregivers the high likelihood of bowel injury. The plaintiff claimed that the other physicians on staff at the hospital failed to assume the patient had a bowel or urinary tract injury, failed to recognize and treat symptoms of sepsis, and failed to insist the patient be returned to the operating room for surgery.

The plaintiff's counsel argued that the medical team considered other possible causes of the patient's postoperative symptoms, instead of considering organ perforation, which is a better known complication of the surgery. For example, physicians called to examine the patient ordered an arterial blood gas test and a ventilation/perfusion lung scan to rule out a pulmonary embolus. A CT scan of the patient's abdomen, performed the day after her surgery, showed fluid around the liver and spleen in the posterior cul de sac, as well as possible bowel obstruction.

The plaintiff also argued that the patient should have been examined by a doctor the day after her surgery, colon perforations are known complications of the type of surgery performed, the tests did not rule out a perforation, and tests showing a decrease in white blood cells were a sign of sepsis and should have prompted diagnosis and treatment of an infection. They argued that the delay in diagnosing the infection gave it time to spread and cause brain swelling, which resulted in the patient's death.

The plaintiff sought survival damages for the patient's conscious pain and suffering prior to her death, as well as wrongful death damages for loss of consortium. A settlement agreement was reached between the hospital and the plaintiff for $2.5 million. The patient's estate received $1.85 million for damages, the estate's personal representative received $20,039 for funeral and burial expenses, and the patient's sister received $1,038 for funeral and burial expenses. The remaining funds were paid out to a creditor and the plaintiff's attorney.

What this means for you: It is seen on almost every procedural consent form as alluded to in this case study: Intestinal perforation is a known, highly recognized complication of laparoscopic procedures, and it is addressed as such as part of the informed consent process. Common signs and symptoms of bowel perforation are severe abdominal pain (including a distended, firm, and/or "board-like" abdomen), chills, fever, nausea, vomiting, and fluid or air in the abdomen as noted on X-rays or CT scans. Signs and symptoms of septic shock also include a rapid heart rate, low blood pressure, rapid breathing, low or absent urine output, reduction in the white blood cell count and restlessness, agitation, lethargy, and confusion. Septic shock and intestinal perforation are medical emergencies, and timely assessment and intervention are critical. Intestinal perforation in and of itself is often successfully resolved through surgical intervention and antibiotic therapy. Septic shock has a high death rate, associated with rapid deterioration and organ failure, and it requires mechanical ventilation, medications, IV fluids, oxygen, and possibly surgery. With either diagnosis, early detection, diligent monitoring, and medical intervention must occur in an expedient manner.

In addition to the tragic outcome of this case, it is difficult to comprehend why a post-laparoscopy patient suffered for two days prior to a surgical consult being initiated. This female was symptomatic post-procedure. She continued to deteriorate over the next 24 hours. Where was the nursing intervention (monitoring and reporting) during that time? Where was the medical intervention in response? Ruling out a pulmonary embolus (PE) post-procedure might make some sense only after the severe abdominal pain has been addressed. While a rapid heart rate and shortness of breath are common symptoms of PE and septic shock, abdominal pain, nausea, and vomiting are not common signs and symptoms of PE. The risk of intestinal perforation following a laparoscopy is not uncommon or unexpected and, therefore, should be a primary consideration when signs and symptoms of perforation and septic shock are present in a patient post-procedure.

Knowledge of the patient's medical history and the procedure performed are of great benefit in assessing any patient post any procedure. In this case, knowing that dense adhesions were discovered during the laparoscopy and those adhesions required a "difficult dissection of the bowel" would have placed nursing personnel and attending physicians on high alert for the possibility of bowel perforation, requiring diligent monitoring for same. Knowing the patient had experienced chronic pelvic pain prior to the laparoscopy would provide a baseline for evaluating the patient's post-laparoscopic pain and would serve to alert clinical personnel that the post-laparoscopic pain was different and more intense. Unfortunately, in the "rush" of providing healthcare, nurses and physicians often do not have or take the opportunity to read the chart, do not know their patients' history and baselines, and therefore increase the risk of failure to monitor, assess and treat. This situation increases the risk of negative outcomes for the patient and financial risk for the healthcare providers.

The plaintiff's complaints regarding the care and treatment of the patient in this case are sound with the exception of negligence on the part of the surgeons in perforating the intestines. The plaintiff's counsel acknowledged the known and common complication of perforation associated with the laparoscopy, especially in light of the dense adhesions and difficult bowel dissection for this patient. The negligence in this case occurred in the follow-up, in timely assessment and diagnosis, and in the subsequent delay of critical intervention. The response in this case to a medical emergency resulted in failure to rescue a 45-year-old woman, which led to her untimely death.

The hospital should have conducted a thorough and effective root cause analysis that included the physicians. The opportunities to learn from this case and other similar cases and to adapt care processes in light of what is learned will serve to minimize risks in the future for patients and providers.

Reference:

Circuit Court of Illinois, Cook County Judicial Circuit, Case No. 10 L 2270