Confidential

Facts

In October 2004, the patient, 52, was admitted to defendant hospital for implantation of an intrathecal pump for treatment of refractory chronic back pain. After the procedure, she experienced severe post-LP headaches and contracted methicillin resistant staphylococcus infections, and was discharged to an intermediate facility, the transitional care unit (TCU) of defendant hospital.

The patient had been disabled because of this pain for several years, and had no income other than social security disability, and performed few household services.

About a week after the transfer of the patient to the TCU, though the headache and infection were coming under control, the patient began experiencing constipation, nausea and vomiting, including vomiting of undigested food, and severe abdominal pain. Aggressive treatment for constipation bore good results, but the abdominal pain, nausea and vomiting continued, the abdominal pain turning "crampy." An abdominal series showed constipation and also signs of early small bowel obstruction.

On the evening before her death, the patient experienced narcotics requiring abdominal pain and narcotics requiring nausea and vomiting. Only vomiting gave transient relief. At 4 a.m., when the patient requested her third high dose of narcotics for both pain and nausea within an eight-hour period, and when she went into early shock, with a blood pressure dropping below 100 and a pulse rate of 157, the patient covering internist was called, and told about the developments that morning, including the blood pressure, the heart rate, the need for a third shot of Demerol within eight hours, a low grade fever, and the results of the previous day's abdominal x-rays. He ordered another shot of Demerol and nothing else and went back to sleep. He did not come in to see the patient, order any tests, order an NG tube or fluid replacement nor any surgical consultation.

At 5:30 a.m., the decedent was found sitting on the floor next to her bed, with her eyes rolled up and no palpable blood pressure, with a heart rate of 160. The defendant covering the internist again did not come in to see the patient, but instead told the nurses to call the pain doctor who had put in the intrathecal pump weeks before, and to get abdominal and back CT examinations later in the day, and then went back to sleep.

The pain doctor called the nursing supervisor, who then called the defendant covering internist and advised that the patient needed to be transferred to the ICU. The covering internist ordered this transfer, and again did not come to see his patient, nor wrote any orders. At about 7 a.m., he spoke with defendant attending internist, who agreed to come to the ICU and see the patient. He arrived at 8 a.m., finding the patient to have a blood pressure varying between 60 and 100, a pulse rate of 160, and a tender and distended abdomen. He called for consultations by both a cardiologist and a surgeon. Defendant attending internist believed the surgeon was "coming right down." Surgeon stated he said he would "get there as soon as I can." Surgeon arrive one hour later, in time to see the patient throw up massive amounts of food and fluids, aspirate the vomitus and have a cardiac arrest from which she never awoke. The patient was lying flat when this episode occurred, having just had an abdominal x-ray taken.

PLAINTIFF’S CONTENTIONS:
The plaintiff contended that the combination of crampy abdominal pain, leading the patient to move from one position to another, nausea, emesis of undigested food hours after eating, development of hypotension and tachycardia and an x-ray picture of early bowel obstruction in a woman with a history of three prior abdominal surgeries required consideration of small bowel obstruction, and treatment with an NG tube, fluid replacement, keeping the patient upright or on her left side, and surgical consultation by the time of the 4 a.m. call to defendant covering internist. The defendant did virtually nothing to find the cause of the signs and symptoms that alarmed the night shift nurses enough to induce a call to him in the middle of the night from a unit where the patients normally did not have critical illnesses. The standard of care required that the covering internist come into the hospital to evaluate the patient and to take appropriate measures.

The plaintiff also contended that the loss of consciousness and drop of blood pressure while sitting up that occurred at 5:30 a.m. required the covering internist to come in to evaluate his patient, to take all prior precautions regarding small bowel obstruction that were required at 4 a.m., and also to consider cardiac and pulmonary causes of the patient’s hypotension and loss of responsiveness. Telling the nurses to call someone else without seeing his own patient violated the standard of care.

The plaintiff further contended that by the time the attending internist saw the decedent at 9 a.m., four hours had passed without diagnosis or treatment of severe small bowel obstruction, the patient had gone into frank shock. The plaintiff also contended that without decompression of the bowel by NG suction, and with the decedent being laid flat for the abdominal film, massive emesis and aspiration was foreseeable, though it would have been easily preventable with decompression of the obstruction any time during the five hours in which doctors were informed of the patient’s condition, and before the fatal episode of aspiration.

As to the hospital, the plaintiff contended that the nurses should not have laid the decedent down flat for the abdominal films. The patient should have been sitting up or lying on her left side, to avoid aspiration in this situation.

As to the covering internist, the plaintiff contended that he should have been in to see his patient at 4 a.m. and 5:30 a.m., and at the later transfer to the ICU, and should have ordered NG suction, proper positioning of the patient, fluid replacement and surgical consultation.

As to the attending internist, the plaintiff contended that though he had only one hour between initial evaluation of the decedent and her fatal aspiration, he should have ordered the insertion of an NG tube and proper positioning of the decedent.

DEFENDANT’S CONTENTIONS:
The hospital contended that the doctors were fully informed of the patient’s condition many hours before the fatal episode of emesis and aspiration. Normally, abdominal films are taken with the patient lying flat, and no contrary orders were given by the doctors on the case. But for the x-ray, the nurses kept the patient sitting up or on her left side.

The covering internist contended that the 4 a.m. call was just for a pain shot; he ordered the pain shot. It was reasonable to order more Demerol to ease the pain and possibly make the heart rate go down. The abdominal pain sounded like gastritis. The attending internist, who knew the patient well, was coming on duty in a couple of hours.

After the 5:30 a.m. call, he did the proper thing and tried to call the doctors who knew the patient well to come in and care for her.

The attending internist contended that by the time he could get in to see this patient, she was already in shock with a tender, possibly distended abdomen. It was impossible to say if there was a cardiac problem causing bowel pain, or vice versa. He called the proper consultants, the cardiologist and the surgeon, and began fluid replacement. He did not put the NG tube down because he believed that the surgeon had told him to hold off until the surgeon could come and see the decedent and surgeon then did not come for a full hour.

Damages

There were no significant economic damages in the case, though the decedent had helped her husband market his business, and his income from that business fell after her death, the husband received social security survivor’s benefits that equaled his lost earnings.

Result

Defendant hospital settled for $75,000; defendant attending internist settled for $50,000; defendant covering internist settled for $29,999.