Failure to respond in a timely manner to a neurologic emergency

by Wayne Wenske, Senior Marketing Strategist, and
Stacey Agnew, Risk Management Representative

Presentation
On April 3, a 67-year-old woman came to Orthopedic Surgeon A’s office reporting neck pain radiating to both shoulders and increasing numbness in her fingers and legs.

Physician action
A CT scan of the cervical spine showed severe spinal cord compression from C3-C6, with level C3-C4 also showing myelomalacia. The results of the CT also suggested ossification of the posterior longitudinal ligament (OPLL). Orthopedic Surgeon A diagnosed the patient with cervical myelopathy, OPLL, and diffuse idiopathic skeletal hyperostosis (DISH). He recommended a decompressive cervical surgery posteriorly and fusion.

Upon request from the patient, Orthopedic Surgeon A referred the patient to another surgeon in his group, Orthopedic Surgeon B, for a second opinion. Orthopedic Surgeon B agreed with the diagnosis and treatment plan but added that the patient needed a decompressive procedure from C2–C7; a stabilization procedure with C2 pedicle screws; and posterior instrumentation down to T1.

Orthopedic Surgeon A agreed with the recommendations and planned to decompress the patient’s neck to include C-3 laminectomy. Because of the patient’s OPLL and DISH, Orthopedic Surgeon A determined that anterior surgery would not be possible.

On April 25, Orthopedic Surgeon A took the patient to surgery and performed a laminectomy with partial facetectomies and foraminotomies from C2-T1; posterior cervical instrumentation at every level C2-T1; and posterior instrumented fusion C2-T1. Surgery was performed with intra-operative neuromonitoring.

During surgery, the motor evoked potentials (MEP) of the patient’s left hand were lost and never returned, indicating nerve root compression or injury not from cord compression. A single drain was placed before closing.

The next morning at 9:01 a.m., Orthopedic Surgeon A saw the patient and documented that her pain was controlled, and no events occurred overnight. The patient had 5/5 strength in all extremities, was alert, oriented, and clinically stable. She was to proceed with physical and occupational therapy. Orthopedic Surgeon A ordered the removal of the surgical drain, and then traveled out of state on vacation.

At 10:19 a.m., a nurse removed the patient’s drain and recorded drainage as 260 ml over the last 24 hours.

Orthopedic Surgeon A later testified that he did not know this much fluid was drained an hour and 18 minutes after seeing the drain. During his last inspection of the drain, there was no drainage present. He also testified that the nurse told him drainage was “minimal,” during a phone check in, but he never reviewed the chart to determine the drainage amount.

On April 27, at 7:05 a.m., a nurse called Orthopedic Surgeon A’s physician assistant (PA) to report that the patient could not wiggle her toes. Within the hour, she called the PA back to inform her that the patient had resumed the ability to wiggle her toes.

At 9:51 a.m., the PA documented that the patient was able to move her hands and feet. However, she was hard to wake and appeared to be overmedicated. The patient had been given morphine intravenously overnight.

At 10:05 a.m., a physical medicine and rehabilitation physician saw the patient and documented that she was not moving her extremities and was very sleepy and lethargic, but alert and oriented. He also noted a trace right grip and normal sensation in all extremities.

He discontinued the patient’s morphine and ordered naloxone to address her lethargy. He planned to retest the patient’s extremities. If the test showed motor function impairment, he planned to obtain an MRI to check for cord compression. The physician called Orthopedic Surgeon A to tell him of the patient’s condition and his plan.

The nurse also called Orthopedic Surgeon A to inform him that the nurses were unable to move the patient from a recliner to a wheelchair for transport to MRI. After speaking with the MRI tech, Orthopedic Surgeon A ordered dexamethasone, a head CT, and that the patient be moved to the ICU for monitoring.

At 2:38 p.m., the results of a CT scan of the cervical spine were noted to be normal by the radiologist and on-call Orthopedic Surgeon C. Neither physician noted a hematoma or seroma in the films, but the radiologist noted posterior changes of the cervical spine post-op and a large amount of neural foraminal stenosis due to spurring.

At 2:45 p.m., a nurse practitioner (NP) ordered a fluid bolus and naloxone. A follow-up CT of the head without contrast was also ordered and revealed no evidence of acute intracranial process.

At approximately 5 p.m., the NP asked ICU Critical Care Specialist A to admit the patient to the ICU. During the consult, the NP stated that the patient was experiencing mental status changes and had received naloxone without improvement.

A nurse spoke with ICU Critical Care Specialist B at 7 p.m. to report the patient’s inability to move her extremities and incontinence since surgery. At 7:26 p.m., Critical Care Specialist B admitted the patient to the ICU. The patient’s mental status had improved with naloxone, but her blood pressure was low. She was given another fluid bolus.

ICU Critical Care Specialist A later testified that she did not recall being told about the patient’s blood pressure. She assumed the patient’s blood pressure was not an issue and her mean arterial pressure (MAP) was above 70. However, between 5 and 7 p.m., the patient’s MAPs dropped to 61, 61, 59, 59, 57, and 61.

ICU Critical Care Specialist A was also not told of the decline in the patient’s condition.

At 8:38 p.m., ICU Critical Care Specialist B documented the patient was still hypotensive
despite being given fluids, and now suspected the hypotension was neurogenic. A norepinephrine bitartrate drip was started. At 9:02 p.m., a nurse reported that the patient’s hypotension had resolved. The physician told the nurse to keep the patient’s MAP over 70 and call the night staff if it dropped.

On April 28, the PA also examined the patient and found the patient unable to move her legs, had poor functioning of both arms, and pain in her shoulders. However, the patient’s BP and MAP were normal.

After being notified of the patient’s condition, Orthopedic Surgeon A ordered an MRI of the cervical spine (a STAT order that took four and a half hours to complete). The study revealed a compressive hematoma.

Orthopedic Surgeon C, the only available surgeon from Orthopedic Surgeon A’s group, started an emergency decompressive surgery at 3:18 p.m. He found a “significant egress of liquid, serosanguineous seroma/hematoma-like fluid that appeared to be under some pressure.”

On April 29, at 7:40 a.m., Orthopedic Surgeons A and C informed the patient and her family that she had suffered a spinal cord injury from a post-op fluid collection. The patient had no sensation from the nipple line down, and no meaningful use of her left hand. She did have some sensation of the dorsum of the feet. At the time, Orthopedic Surgeon A remained hopeful for neurologic recovery.

Several months later, there were no improvements in the patient’s neurological status. She had been transferred to a rehabilitation hospital where she developed several decubitus ulcers that required a few procedures to drain and repair.

The patient’s left hand is atrophied, but she retains the use of her right hand. She is incontinent of bowel and bladder and requires around the clock custodial care.

Allegations
A lawsuit was filed against the group that employed Orthopedic Surgeons A, B, and C and the PA; the group that employed Critical Care Specialists A and B; and the hospital. The plaintiffs alleged that the patient’s drain should not have been removed on the first day of post-operative recovery and that the MAPs were too low for seven days after surgery. It was also alleged that the defendants failed to adequately monitor the patient post-surgery.

Legal implications
Expert consultants for both the defense and the plaintiffs were divided on what caused the patient's condition. Some experts believed the patient's hypotension caused the neurological damage, while others felt the compressive hematoma was the root cause.

Expert consultants who reviewed the case for the plaintiff were critical of Orthopedic Surgeon A and the nurses for their poor communication about the removal of the patient’s surgical drain. They argued that this action caused the compressive hematoma and contributed to the patient’s outcome.

Another plaintiff’s expert claimed the April 27 CT scan was consistent with “overall non-specific quite recent posterior postoperative changes.” This expert believed that had an MRI been performed — as recommended by Physical Medicine and Rehabilitation Physician A — a more conclusive diagnosis could have been made 24 hours earlier.

Defense consultants were also critical of the postoperative care, specifically that the patient’s hypotension was inadequately addressed. Another defense consultant stated that the management of the patient’s hypotension was difficult, and that placing her in the ICU directly from the post anesthesia care unit (PACU) might have led to a different outcome.

Further, this consultant concluded that taking the patient to surgery to drain the hematoma and placing her in the ICU earlier may have resulted in a much better outcome.

Disposition
This case was settled on behalf of the orthopedic group and the critical care group. The hospital also settled with the patient.

Risk management considerations
It is essential for physicians to ensure that patients will be well cared for during an absence and that strong continuity of care is maintained.

Performing complex surgeries or procedures just before taking leave could be an issue if complications arise that may affect patient safety and outcomes. Having a good plan for coverage for post-operative or high-risk patients is imperative before taking a break or vacation out of town.

In this case, there were several health care professionals involved in the care of the patient. When this many providers are involved, strong communication and documentation is important to maintain quality continuity of care. Clear, contemporaneous, and accurate documentation helps to keep all providers fully informed so that treatment decisions can be made confidently and in a timely manner.

While oral communication is always important, it can also be tricky if relying on others to interpret and communicate lab results or patient conditions. Certain words can be subject to interpretation, such as the word “minimal” in this case.

Review of written information documented in the patient record to substantiate oral information helps provide clarity for medical decision making and removes questions around how information may have been interpreted. Had the physician read the chart to ascertain the exact amount of fluid coming from the drain, instead of relying on the nurse’s oral report of “minimal,” the poor outcome for this patient may have been avoided.