Monday, March 30, 2020

Case Summary: The patient underwent a colonoscopy at the defendant facility. Two days post-procedure, the plaintiff presented back at the hospital with severe abdominal pain. The ER physician there diagnosed him with an iatrogenic colon perforation. The surgeon was called and in the interim his care was turned over to a hospitalists. Neither of them reportedly followed up with the surgeon until 18 hours later, at which time the patient’s condition had gotten much worse. He was allegedly told the surgeon could not care for him because he was outside of the insurance plan. The pt had arrived at 12:00 pm and sat for 20+ hours before surgery at 9:00 a.m. the next day. By the time they opened him up, there was puss and stool. His colon was repaired shortly thereafter, but he died from an infection 12 hours after surgery.

Questions/allegations:  Was the patient's ultimate demise related to the delay between the time the patient was diagnosed with the perforation and the actual time he underwent surgery to repair the perforation? Did the hospital staff properly monitor this patient? Was it a breach in standard of care to not refer this patient to surgery immediately?


AMFS' experts reviewed this case and provided the following opinions: 

Hospitalist Expert’s findings: There was a prolonged period of hypotension from about 10 pm to 6 am with no physician having seen the patient until he was sent to the ICU. The notes from the ER MD and the first hospitalist both suggest that another hospitalist was going to see the pt in the morning. There is no follow-up documentation from either the ER MD or the hospitalists - the requested surgeon turned out not to be the surgeon on call for that insurance. There is no documentation of calling any alternative surgeon. One of the doctors gave verbal orders for the normal saline boluses, so he was apparently aware of the hypotension without specifically acting on it. There clearly is a problem in the handover process and what was documented as reported from ER regarding which surgeon would see the pt and from the first hospitalist to the second hospitalist. No one over the night escalated the surgical consult when the pt was persistently hypotensive.

Infectious Disease Expert’s findings:  The delay in surgical care adversely affected the outcome of this patient. The progression to sepsis from the known perforation, which was identified right away, clearly required sooner surgical attention. For a variety of reasons it appears the delay worsened his prognosis and he progressed with a septic picture, though each doctor documented his need for surgery. The lack of surgery is the key issue. He received appropriate antibiotics and supportive care, along the way from ER to Hospital to ICU to surgical suite and back to ICU, but needed to see a surgeon as originally noted, right away.