A 29-year-old man was brought to the emergency department (ED) of a regional medical center. The patient’s chief symptom was bilateral leg weakness. He had a history of poorly controlled hypertension, chronic headaches, chronic fatigue, post-traumatic stress disorder, bipolar depression, and irritable bowel syndrome.
Lab studies revealed an extremely low potassium level (1.3 mEq/L). The ED physician contacted the on-call internal medicine physician who ordered the patient’s admission and potassium replacement.
The internal medicine physician saw the patient the next morning. The physician ordered a repeat potassium study, and requested a nephrology consult to help determine the cause of the patient’s hypokalemia.
The nephrologist ordered several diagnostic studies and ultimately diagnosed the patient with a rare condition known as thyrotoxicosis. The nephrologist consulted an endocrinologist to assess for hyperthyroidism and to assume the management of the patient’s endocrine disorder. The endocrinologist made the diagnosis of thyrotoxic hypokalemic periodic paralysis (TPP), a rare condition characterized by recurrent episodes of motor weakness associated with hyperthyroidism. The nephrologist and the endocrinologist felt the patient could be treated on an outpatient basis.
The internal medicine physician discharged the patient with the following instructions: follow up with the endocrinologist in one month for a thyroid scan; see the nephrologist within two weeks; and, call the internal medicine physician’s office to schedule an appointment immediately after arriving home.
The patient was discharged on a high-potassium, low-sodium diet and was given information on this diet. The nephrologist prescribed the beta-blocker propranolol for treatment of the thyrotoxicosis. It was later discovered that this prescription was filled, but the medication was not taken by the patient.
Three days after his discharge, the patient was brought back to the ED by ambulance. Seven hours before becoming ill, he had eaten a large, carbohydrate-rich meal. His potassium level on admission was 1.3 mEq/L. While in the ED, the patient suffered cardiac arrhythmias. Resuscitative efforts lasted more than one hour but were unsuccessful.
An autopsy was performed and the pathologist concluded the patient died as a result of TPP, precipitated by a high-carbohydrate meal.
Lawsuits were filed against the internal medicine physician, the nephrologist, and the endocrinologist. The allegations included:
- failure to timely evaluate, diagnose, and treat the patient’s hyperthyroidism and thyrotoxicosis;
- negligence in deferring treatment of hyperthyroidism for two weeks after discharge;
- failure to prescribe the appropriate medication and diet before discharge; and
- failure to provide the counseling and treatment to prevent further drop in potassium level before discharge.
Defense consultants were supportive of the care given by all three physicians. The physicians successfully diagnosed and treated a very rare medical condition, one that many physicians may never see.
According to nephrology and endocrinology experts, the patient did not need long-term potassium supplementation once he left the hospital because his potassium level stabilized following replacement therapy. Propranolol, which reduces the frequency and severity of TPP attacks, was prescribed appropriately. All the experts reviewing this case, including the plaintiff’s experts, agreed that if the patient had taken propranolol as prescribed, he would not have suffered a fatal attack of TPP.
The main allegations against the physicians involved the discharge instructions and the failure to instruct the patient to follow a low-carbohydrate diet. The patient’s wife claimed that the propranolol was not taken because there was confusion over the reason for its prescription, and that they had not been given a physician’s number to call with any questions.
The nephrologist’s discharge summary clearly indicated that the patient understood why propranolol was being prescribed. The discharge instruction sheet, signed by the patient, listed phone numbers for all three physicians, but none of the physicians were ever contacted. The patient also failed to make the follow-up appointments as instructed at discharge.
During the investigation of this claim, it was also discovered that the plaintiff did not follow the low-sodium diet. The patient’s wife testified that he consumed 12 soft drinks daily after leaving the hospital. The meal the patient consumed before his death consisted of a fast-food hamburger and fries.
Regarding the failure to counsel the patient about a low-carbohydrate diet, the plaintiff’s internal medicine expert claimed that any physician treating a patient for TPP must advise the patient to reduce carbohydrate intake. Further, the standard of care would require a physician to tell the patient that a high carbohydrate load could increase the risk of an attack of TPP.
Conversely, the defense endocrinology expert stated the standard of care does not require a discussion of precipitating factors because most cases of TPP attacks are idiopathic. Additionally, if the patient had taken the propranolol as prescribed, it would have prevented the fatal attack of TPP, even in light of the high consumption of carbohydrates. It was also unlikely that the patient would have followed a low-carbohydrate diet because he failed to follow the low-sodium diet.
The cases against the internal medicine physician and the nephrologist were closed without indemnity payment. The case against the endocrinologist (who was not a TMLT policyholder) was settled before trial.
Risk management considerations
An on-call physician and two consultants responded in a timely manner to care for a patient admitted from the ED. A critical potassium level was corrected, the proper diagnosis of a rare disorder was made, and the appropriate medication was prescribed. The death of the patient occurred as the result of his failure to take propranolol.
To receive two CME credits and the TMLT risk management discount (TMLT policyholders only) for reading this and other similar case studies, please visit http://tmlt.inreachce.com.