On June 15, an 85-year-old woman was taken by ambulance to the emergency department. She had been experiencing abdominal pain, generalized weakness, diarrhea, nausea, and vomiting for two days. Her medical history included dementia, hypertension, and a ventral hernia repair.
An abdominal CT revealed an anterior ventral hernia containing non-obstructed bowel loop. In the radiology report, there was no mention of the gallbladder.
The admitting internal medicine physician believed the patient’s right upper quadrant pain was suggestive of gallbladder disease. He ordered an ultrasound and a hepatobiliary scan, though the hepatobiliary scan was not performed.
The radiologist, a defendant in this case, interpreted the ultrasound and documented “…multiple echogenic defects within the gallbladder. The gallbladder wall is thickened at 4.6 mm.” The patient was diagnosed with cholelithiasis and cholecystitis. A consult with a general surgeon was requested.
Based on the patient’s symptoms and the results of the ultrasound, the general surgeon ordered a hepatobiliary scan with gallbladder ejection fraction to make sure the cholecystitis was not acute. He also noted the presence of a large anterior abdominal wall hernia containing non-obstructed bowel loops. The general surgeon suggested surgery only on an emergent basis.
The hepatobiliary scan revealed, “Small liver. Non-visualization of gallbladder compatible with cystic duct obstruction and acute cholecystitis. Dilated hepatic duct and CBD and ectasia of the CBD distally and protruding into the pancreatic head area. No biliary obstruction.”
After speaking with the admitting physician, the general surgeon agreed to perform surgery on June 20.
The general surgeon performed an open laparotomy and learned the patient did not have a gallbladder. The clips were in place from a previous surgery. He also noted that the abdominal wall was virtually non-existent, measuring approximately 3 mm in thickness. The general surgeon irrigated the area and removed all fluids, placed a drain, and attempted repair of the subcostal hernia.
After the surgery, the patient went on to develop leukocytosis, bandemia, and sepsis. She became incontinent and nauseated with green emesis. Studies revealed a small bowel obstruction, but the general surgeon felt that surgery to repair the obstruction was too risky. He recommended palliative management with admission to hospice.
On July 17, the patient was transferred to another facility. After refusal by a number of surgeons, the family found a surgeon to explore the patient’s incarcerated incisional hernia. That surgeon found two strangulated internal hernias within the sac, with perforation and ischemic changes. The surgeon also found an ischemic ileum that required re-section and re-anastomosis.
The patient’s condition worsened and she developed deep vein thrombosis and a C. difficile infection. She died on August 16.
A lawsuit was filed against the radiologist and the general surgeon. The plaintiffs alleged the general surgeon was negligent when he performed surgery to remove the patient’s gallbladder when there was evidence to make him question the presence of the gallbladder. They alleged the radiologist was negligent when he misinterpreted the gallbladder study.
The plaintiff’s expert was critical of the general surgeon for taking the patient to surgery after indicating he would only do so on an emergent basis. Further, documentation showed the patient had no right upper quadrant pain and a non-tender, non-distended abdomen on the day of the surgery.
The results of the patient’s labs — in particular, her liver function tests and her bilirubin — were also normal. Also documented were the results of the hepatobiliary scan, which noted non-visualization of the gallbladder. Taken together, these facts should have alerted the general surgeon to further explore the cause of the patient’s symptoms.
Defense experts who reviewed this case expressed similar criticism. Additionally, the defense of this case was compromised by documentation and communication issues. The co-defendant radiologist documented that the hepatobiliary scan was a “technically limited study.” He testified that such phraseology is typically adequate to put the referring physician on notice to not rely on the study.
The patient’s family also testified that they repeatedly asked the general surgeon to call the patient’s primary care physician to obtain the patient’s medical history. In reviewing the patient’s hospital records from two years earlier, the notes from a CT scan of the abdomen indicated the patient had a prior cholecystectomy. Neither the general surgeon nor the radiologist had seen this report.
This case was settled on behalf of the general surgeon and the radiologist.
Risk management considerations
Obtaining and recording a thorough medical history is a requirement for an adequate medical record. When a patient is unreliable — in this case due to dementia — it is particularly important to request and review medical records from previous or current health care professionals.
The surgeon initially documented that he would perform surgery only on an emergent basis. He changed his mind and took the patient to the operating room 48 hours later. Had he documented his rationale, he would have had his clinical reasoning and observations in writing. When a physician documents his or her clinical rationale, it may assist in deciding if the objective facts represent a well-reasoned plan of care.
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