A 44-year-old man came to see a urologist to discuss having a vasectomy. The urologist counseled the patient about the procedure, and the patient signed a preoperative consent form that listed the loss of a testicle as a possible surgical complication.
The vasectomy was performed on October 1 under local anesthesia. The operative report mentioned a standard vasectomy procedure with minimal bleeding and no complications. The patient was discharged with instructions to rest and apply ice. He was prescribed hydrocodone for pain.
The pathology report stated the tissue removed was normal anatomical, completely transected vas deferens from both the right and left side with no vascular structures being removed.
At 6 p.m. on October 2, the urologist received an after-hours phone call from the patient. The patient reported increased pain and swelling. The urologist advised the patient to continue taking his pain medication and to rest and apply ice. This phone call was not documented in the medical record.
The patient followed these instructions, but called the urologist on the evening of October 4 . According to the patient, he told the urologist that he was still experiencing significant pain while taking the hydrocodone and that his scrotum had swelled to the size of an eggplant. The patient testified that the urologist told him to continue with ice and rest, and to go to the emergency department (ED) if his temperature exceeded 101 degrees.
This phone call was not documented in the medical record and the urologist later disputed that the patient told him his scrotum was the size of an eggplant.
At 6 p.m. on October 5, the urologist met the patient at the ED. A testicular ultrasound found that there was no vascular flow to the testicle. The urologist informed the patient that the infarcted testicle would have to be removed.
On October 6, the urologist performed an orchiectomy. The urologist explored the testicle, and found no evidence of blood flow and a modest amount of hematoma. He described nothing remarkable about the anatomy and described the testicle as appearing grossly dead. The pathology report stated that the left testicle was hemorrhagically necrotic and inflamed but no thrombus was identified.
The patient was seen two weeks after the surgery. The urologist noted that there was no sign of a wound infection and that the patient was walking satisfactorily.
A lawsuit was filed against the urologist. The allegations included failure to respond to the patient’s reports of significant pain and swelling. Had the urologist responded in a more timely manner, the patient’s testicle could have been saved. The patient sought damages for pain and suffering and physical disfigurement.
The plaintiff’s expert did not criticize the urologist’s performance of the vasectomy or the orchiectomy, but did focus on the delay in recognizing the complications. The plaintiff’s urology expert testified that when the patient called at 6 p.m., October 2 reporting pain, swelling, and discoloration, the patient should have been directed to the ED. Had the patient been seen in the ED, the testicle might have been preserved.
Defense experts were supportive of the urologist’s actions. The patient’s symptoms of pain, swelling, and discoloration commonly occur after a vasectomy. Further, the potential intraoperative events — vascular injury or hematoma development — are known complications of vasectomies. These complications were not caused by substandard care by the urologist.
The urologist confirmed that he did not document any of the after-hours phone calls from the patient in the medical record. Therefore, the content of these telephone calls was contested. However, the urologist testified that even if the patient had come to the office at the first phone call, he likely would not have evacuated the hematoma. The majority of the time, he observes the hematoma and it generally goes away without the need for surgery.
It was also noted by the defense that when the patient came to the ED, neither the urologist nor the nurses described dramatic swelling of the scrotum. The ED ultrasound report described a hematoma, but it did not describe the swelling as significant.
This case was taken to trial and the jury returned a verdict in favor of the defendant.
Risk management considerations
The events from the case offer the opportunity to identify a weakness in the medical record. Had the after-hours phone calls been documented with a factual description of the patient’s symptoms, the case may not have been filed.
Physicians who do not document phone calls from patients have incomplete records. If the patient experiences a bad outcome and subsequently files a lawsuit, relying on memory at a later date may compromise the physician’s defense. Including calls in the medical record will be part of a comprehensive diary and reflects prudent risk management. This content can serve a physician and staff as well as subsequent caregivers in providing well-informed care.
In addition, Texas Medical Board rules state, “an adequate medical record” should “include a summary or documentation memorializing communications transmitted or received by the physician about which a medical decision is made regarding the patient.” (1) Documentation options may include message pads, use of answering service logs to prompt documentation into the record, direct entry into the EMR, or notes scanned into an electronic medical record.
1.Texas Medical Board. Texas Medical Board Rules Chapter 165 Medical Records. Available at https://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=3&ti=22&pt=9. Accessed August 31, 2021.
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