HCCA Annual Compliance Institute - Chicago S4: Industry Immersion Session Case Handouts, April 25, 2004 CASE 1:

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1 HCCA Annual Compliance Institute - Chicago S4: Industry Immersion Session Case Handouts, April 25, 2004 CASE 1: This case is about a 30 year old female patient who suffered chronic neck pain as a result of an auto accident in She suffered a T-5 fracture that resulted in her being hospitalized for approximately one week. Following the auto accident she began to experience neck pain and headaches. This persisted and progressed over the subsequent years. She sought treatment from an orthopedic surgeon who recommended that prior to any surgery she undergo a series of epidural steroid injections to see if that would provide her with any relief for her neck pain. She consulted with an anesthesiologist who, after taking a history from the patient, reviewing her medical records, and performing a limited physical examination, informed the patient that she would be a good candidate for the epidural steroid injections. The physician also provided the patient with a three page typewritten handout on steroid injections. (See Exhibit A) The patient who was accompanied by her husband was eager to proceed, while the husband was somewhat skeptical. The physician left the patient and her husband alone to discuss whether or not she wished to proceed. After some discussion the patient informed the physician that she did wish to proceed. The procedure was performed in the OR under fluoroscopy. At trial, the physician testified that he did not recall the procedure in that it was <redacted>years prior to the lawsuit having been filed and there was nothing in his notes that would have suggested anything untoward having occurred during the procedure. However, the patient testified that she experienced a jolt down the entire right side of her body when the needle had been inserted and that the physician had to remove and replace the epidural needle. She further testified that when the initial needle had been placed she jumped as a result of the pain that she experienced. The patient then went on to testify that when she left the hospital after her injection she was in severe pain and needed assistance in getting to her car (alleged facts that were not supported by the medical records). When she arrived at home her husband received a call from his mother advising him that his uncle had suffered a heart attack and that he and the patient needed to come to Los Angeles. The patient testified that she did not contact the doctor regarding the wisdom of traveling to Los Angeles and that she was quite uncomfortable during the trip. The following morning the patient was complaining of excruciating headaches and severe rightsided pain. She called the anesthesiologist, who called in a prescription for a medrol dose pack and asked that she call if it did not provide any relief. The following day, a Sunday, the patient again contacted the physician and informed him that she did not have any relief from the headaches and right-sided pain. In a second conversation on that same day the physician 1

2 instructed her to come to the emergency room at a San Diego hospital and that he would meet her there. The patient arrived in the ER that evening where she underwent an MRI showing a hematoma in the cervical spine area, suggesting that there may have been a puncture of the spinal cord at the C2-3 level. While in the emergency room of the hospital, which incidentally was a different facility than where the epidural steroid injection had been given, the physician wrote a note describing what the MRI findings were and elaborating on the procedure of two days prior. Plaintiff attempted to focus on this note arguing that it included things in it that were not in the operative note. The implication was that the physician was attempting to cover up his negligence. The physician continued to follow up with the patient and made arrangements for the patient to be evaluated by a neurosurgeon and a neurologist who both acknowledged that her spinal cord had been inadvertently punctured during the epidural steroid injection procedure but that the injury was minor and that she should enjoy full recovery over time. The anesthesiologist paid directly for the services of the neurosurgeon and neurologist. The physician dictated a note for the chart approximately sixteen days after the procedure outlining in detail the series of events that had transpired and offered an opinion as to a possible explanation on how the injury had occurred. He wrote: I remain uncertain what error, if any, caused the injury. The needle was too deep at some point during the procedure but I am uncertain how this occurred....the only possible explanation I can think for the set of circumstances here is that I somehow caused initial needle placement in what I felt was superficial tissue before the first fluoroscopic film was ever taken. This note was characterized at trial by the Plaintiff as an admission by the physician that he was negligent. Discussion Points: 1) Was the patient fully informed of the risks of this procedure? 2) How can this be proven in a court of law? 3) What should you advise physicians regarding informed consent? 4) Was the physician s documentation adequate in this case? Appropriate? 5) What documentation guidelines do you provide to your physicians? 6) Was it appropriate for the treating physician to pay for the neurosurgeon and neurologist s services? Is this an admission of guilt? ***************************************************************************** 2

3 CASE 2 HCCA Annual Compliance Institute - Chicago S4: Industry Immersion Session Case Handouts, April 25, 2004 The patient, a 33 year old male, was admitted to the hospital for treatment of a left kidney stone with percutaneous nephrostomy and lithotripsy. His medical history was notable for recurrent cystine stone formation. As a consequence of recurrent stone formation, he had an atrophic right kidney contributing only 5% of his total renal function. His physical examination was normal. In the pre-anesthesia questionnaire, the patient commented that he had malignant hyperthemia as a reaction to a previous general anesthetic. The patient was evaluated by the anesthesiologist at approximately 0730 on the day of surgery. The medical and surgical history was reviewed. A focused physical examination was performed. The plan was continuous lumbar epidural anesthesia with sedation. The patient gave his consent to the anesthetic plan after a discussion of the risks, benefits and complications. The patient arrived in the operating room at approximately Surgery began at The urologist inserted a rigid nephroscope and identified the stone in the left kidney. Stone fragmentation was carried out using a combination of ultrasound lithotripsy and holmium laser lithotripsy. It was not possible to remove all of the stone. The nursing record shows that irrigants used during the surgery were glycine x 3 and water x 14. Surgery ended at approximately Vital signs during surgery were normal. The patient arrived in the recovery room at At the time of admission, he was unresponsive. His vital signs were otherwise normal. The epidural catheter was removed by the anesthesiologist at At 1400 the patient remained unresponsive to stimuli, but was moving his extremities spontaneously. At 1420 he was described by the nursing staff as restless, not responding to verbal stimuli, not opening his eyes and trying to climb out of bed. The recovery room nurse contacted the anesthesiologist, who had left the hospital, and after reporting her observations, received an order for sedation, which was given between At 1440 the patient was reported as very restless. The recovery room again contacted the anesthesiologist and received an order for a narcotic. Vital signs remained normal from 1315 through approximately At 1500 the patient was again described as unresponsive and at approximately the patients blood pressure was 243/132, his heart rate was 60 and he had an oxygen saturation of %. The recovery room nurse again contacted the anesthesiologist and informed him of the hypertension and decreased mental status. Additional orders were given to the recovery room nurse by the anesthesiologist. Between 1515 and 1530 another anesthesiologist was called to the recovery room to evaluate the patient. Upon bedside evaluation, this anesthesiologist found the patient unresponsive and that he had a dilated right pupil. An intercranial event was suspected. After consulting with an attending neurosurgeon, the anesthesiologist initiated therapy for reduction and management of increased 3

4 intercranial pressure. The attending anesthesiologist arrived back at the hospital at approximately The patient was transported to radiology where he underwent a head CT at The study showed diffuse cerebral edema. Serum chemistry values were done at 1559 which showed sodium of 116 (normal ), potassium 4.1 and osmolality of 249 (normal ). Appropriate medications were administered to lower the serum sodium levels. A neurology consultation was performed the following day. By clinical criteria, the patient s condition was consistent with brain death. A formal declaration of brain death was made at 1245 and life support measures were withdrawn. The cause of death was brain injury from acute cerebral edema. The cause of the cerebral edema was acute hyponatremia (low sodium). The cause of the hyponatremia was absorption of free water from the irrigation solutions used during the percutaneous nephrostomy and lithotripsy performed between 1025 and 1310 on the day of the procedure. Expert review of the case included the following points: 1. Water should never be used as an irrigant in this procedure as it dilutes the sodium and can lead to hyponatremia. Apparently, the hospital was out of glycine, which is why the urologist used part glycine and part water. 2. Ins and outs should be measured in these procedures. This was not done, as it was not part of the hospital s process. Discussion Points There were a number of things that went wrong in this case as a result of action or inaction by all three parties involved: The hospital, the urologist, and the anesthesiologist. 1) Should any risk management or compliance policies be implemented as a result of this case? If so, by whom the hospital? The urology group? The anesthesiology group? 2) Are there any risks to developing policies and procedures? 3) What is the best way to educate physicians in a group of these types of events? 4) What are the alternatives to writing policies and still ensuring good patient care? ****************************************************************************** CASE 3 At the time of admission to the hospital the patient was a 28 year old former Marine with a long history of insulin dependent diabetes. He was admitted to the hospital for the purpose of undergoing a second surgery to his left eye. At the time 4

5 HCCA Annual Compliance Institute - Chicago S4: Industry Immersion Session Case Handouts, April 25, 2004 of the surgery he was on disability from his employer due to his significantly reduced vision. Upon arrival at the hospital he went through the admissions process, which included a comprehensive evaluation by the admissions nurse. Upon completion of this evaluation and shortly before the scheduled surgery, the patient was transported to the operating room suite where he was introduced to the anesthesiologist fresh out of residency and on the third day of his rotation at this particular facility. The young anesthesiologist discussed with the patient his anesthesia plan and informed him of the various risks associated with that plan. In addition, the anesthesiologist reviewed the patient s medical chart that had accompanied the patient to the OR which consisted primarily of an H&P dictated the day before by the surgeon, and the Perioperative Casetrac that the admitting nurse had filled out. During discovery (deposition) the anesthesiologist testified that the Patient Profile, a part of the Perioperative Casetrac, which is filled out by the patient and contains valuable information such as what medications the patient was taking and when he last took any medication, was missing from the chart. The surgery, an elective left vitrectomy and lensectomy, was originally scheduled to last approximately 2-2 ½ hours but in fact lasted almost 4 hours. During the pre anesthesia evaluation the anesthesiologist asked the patient what medications he was taking. The patient initially indicated he was not taking any meds. However, upon further questioning, the patient informed the anesthesiologist that he noted that his blood sugar level was slightly elevated that morning so he took some insulin. Unfortunately, the anesthesiologist failed to get any of the specifics (i.e., how much insulin had he taken, and when he took it, how long had he been taking insulin, etc.). The surgical procedure was uneventful from an anesthetic perspective. However, about half way into the surgical procedure, the anesthesiologist thought it might be prudent to check the patient s blood sugar and asked the circulating nurse for a glucometer. He was advised by the nurse that the glucometer was in the recovery room and that they did not have a glucometer in the OR. Unfortunately, the discussion about the glucometer ended there. The anesthesiologist did not tell the nurse to get the glucometer from the recovery room, which was probably at most 15 yards from the OR. At the conclusion of the surgery the patient was taken to the recovery room by the anesthesiologist, a report given to the recovery room staff, and an order given to do a check of the patient s blood sugar level. The anesthesiologist then left the patient to get ready for his next case. While he was attending to his other patient, the recovery room nurse reported to him that the test results showed a blood/sugar 5

6 of 34 mg/dl (normal is 75 mg/dl to 165 mg/dl.). The anesthesiologist was surprised by the test result and ordered it be taken again - similar reading - dangerously low. At this point, it was finally recognized that the patient was hypoglycemic and remedial action was taken to increase the blood/sugar levels. Unfortunately, it was too little and clearly too late. The patient suffered from hypoglycemic encephalopathy - he was brain damaged. The case ultimately settled for a significant amount of money. Discussion Points 1) What risk management/compliance issues are raised as a result of the facts of this case? 2) Could the anesthesia group have avoided this situation through certain practices/policies? 3) How does the attorney defend an indefensible case? 6