Medical Malpractice Insights: Are you smarter than a general surgeon on the phone at 1 AM?

Author: Chuck Pilcher, MD, FACEP (Editor, Med Mal Insights) // Editors: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Welcome to this month’s case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians, and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights


Are you smarter than a general surgeon on the phone?

 It’s 1:00 AM. It’s your patient. It’s time to trust your gut – and the patient’s bleeding gut.

Facts: A 20-year-old female undergoes a laparoscopic appendectomy and is discharged the same day. Nine hours later she returns to the ED due to weakness leading to an episode of syncope at home. Her hemoglobin, which was 12.0 pre-op, is now 9.0. On orthostatic testing, her pulse rises to 156, but her BP is stable. Her abdomen is tender in all quadrants with minimal rebound. At 1:00 AM, the ED doc contacts the patient’s surgeon, who reassures him that the 3 point drop in Hgb is merely from “hemodilution” due to the 3 liters of IV NS she received during surgery. She is discharged from the ED but returns 30 hours later with worsening weakness and near syncope. Her Hgb is now 6.0. She is taken back to the OR, where a midline incision is needed to locate and control an arterial bleed from a LUQ mesenteric artery. She recovers but is unhappy with the midline (keloid) scar and seeks legal advice regarding the bleeding complication and the first post-op ED visit.

Plaintiff: My Hgb dropped 3 points in 9 hours after surgery. I had orthostatic tachycardia from bleeding into my gut. My surgeon should never have cut that artery in the OR, but in the ED, I was your patient. You suspected the problem and should have gotten an ultrasound or CT scan so my surgeon couldn’t talk you into sending me home just because he didn’t want to get out of bed. Calling my findings “hemodilution” is baloney. Hemodilution never causes that much drop in Hgb and doesn’t last for 9 hours. Besides, if I had enough IV fluid to drop my Hgb 3 points, I would not have had orthostatic tachycardia. If you (the ED doc) had done the right thing 30 hours earlier, my bleeding could have been stopped laparoscopically. But no, it got so bad that I had to be opened up and now have this ugly scar down the middle of my belly.

Defense: Yes, maybe I should have trusted my gut and done more, but the surgeon is responsible for cutting your mesenteric artery, not me. Besides, hemodilution is a reasonable explanation. It can last more than 8 hours. The source of your bleeding was hard to locate, and we probably couldn’t have avoided the midline incision – which, by the way, saved your life. And while we’ve been arguing about this for over a year, you’ve formed keloids even at your laparoscopic puncture wounds, so the bad scars are not our fault.

Result: After expert review by a neutral third party, no lawsuit was filed. Even if negligence were acknowledged, a different outcome was not assured, i.e., causation could not be proven. Despite that, there are things we can learn.

Takeaways:

  • An anemic post-op patient who faints and has abnormal orthostatic VS should be taken seriously (and yes, the utility of orthostatic VS is controversial).
  • Hemodilution is real but negligible and typically self-corrects in < 8 hours. (See Reference below.)
  • Always consider the worst possibility. Don’t assume the best.
  • An ultrasound or CT scan before calling the surgeon may be appropriate, but one of these imaging modalities is recommended before discharge.  Discussing the optimal imaging plan with a surgeon can be helpful.
  • Trusting a tired surgeon for reassurance over a phone call at 1:00 AM without further workup is ill-advised. This is your patient. Trust you gut.
  • Hemorrhage after laparoscopic appendectomy is a known complication, not malpractice.

 

Reference: Dilution and redistribution effects of rapid 2-litre infusions of 0.9% (w/v) saline and 5% (w/v) dextrose on haematological parameters and serum biochemistry in normal subjects: a double-blind crossover study. Lobo DN et al. Clin Sci (Lond). 2001 Aug;101(2):173-9. https://www.ncbi.nlm.nih.gov/pubmed/11473492

 

“The best preparation for tomorrow is to do today’s work superbly well.”

Sir William Osler

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