Failure to monitor patient following bariatric surgery

Presentation
A 22-year-old, morbidly obese woman came to a bariatric surgical center for a sleeve gastrectomy procedure. In the weeks leading up to surgery, the patient completed extensive preoperative diagnostic testing and education, including instructions for taking multivitamins.  

Physician action
A general surgeon performed the sleeve gastrectomy. The patient’s postoperative course was complicated by her inability to maintain hydration and adequate nutrition. These symptoms persisted for two weeks after surgery. 

The general surgeon ordered an upper gastrointestinal series (UGI) to identify any structural causes for the patient’s symptoms. The results were normal. Nutrition and vitamin levels were not checked. Eleven days later, the patient was seen for dysphagia. The UGI was repeated, and still no structural abnormalities were found. Again, nutrition and vitamin levels were not checked.

Four days later, the patient’s mother contacted the bariatric center and reported to a nurse that the patient was still having problems and unable to drink her prescribed protein drinks or take her multivitamin. The patient’s mother asked if the patient could switch to a gummy vitamin in the hope that it would be easier for the patient to ingest. The patient’s mother later testified that the nurse said gummy multivitamins would be fine. However, the bariatric center’s Patient Education Manual stated that gummy vitamins should not be used.

The nurse was unaware of this provision because the manual had been recently updated with this restriction. There was no documentation that the general surgeon was consulted about the change in vitamins or the patient’s inability to keep the protein shakes down.  

Three days later, the patient’s mother reported to a nurse at the bariatric center that her daughter had continued nausea, vomiting, and diarrhea and was experiencing double vision. The nurse reported that she informed the general surgeon who said that symptoms should go away within three months.  

Two days later, the patient came to the emergency department (ED) of a nearby hospital with complaints of blurry double vision. She was instructed to follow up with the general surgeon and discharged. The next day, the mother called the bariatric center to report her daughter’s double vision. The surgeon scheduled an upper endoscopy (EGD) for the following day. The EGD did not reveal any cause for nausea or vomiting. Nutrition and vitamin levels were not checked.  

Over the next week, the patient repeatedly called the bariatric center reporting nausea, vomiting, and blurry double vision. The surgeon prescribed anti-nausea and anti-diarrhea medication. A few days later, the patient was having difficulty standing and walking. The surgeon ordered additional labs that came back normal. Nutrition and vitamin levels were not checked.  

Two days later, the patient returned to the ED and was seen by a neurologist. The patient was diagnosed with Wernicke’s encephalopathy and treated for thiamine deficiency. Shortly thereafter, the patient developed permanent blindness in both eyes and an ataxic gait.  

Allegations
A lawsuit was filed against the general surgeon and the bariatric center alleging:

• failure to evaluate thiamine deficiency as a cause of the patient’s symptoms;
• failure to treat the patient’s symptoms of nausea, vomiting, visual disturbances, and/or motor difficulties/impairments with thiamine supplementation;
• failure to test the patient’s vitamin levels postoperatively in compliance with the bariatric center’s manual and in response to the patient’s postoperative symptoms; and
• failure to inform the patient that the prescribed multivitamins must contain thiamine.

Legal implications
Consultants who reviewed the case were not supportive of the general surgeon. They felt that her actions fell below the standard of care by not monitoring the patient postoperatively for nausea, vomiting, and symptoms of dehydration or vitamin deficiency. 

To support their allegations against the bariatric center, the plaintiffs pointed to the center’s Patient Education Manual that stated, “…the patient’s nutritional status after surgery is vitally important because vitamin deficiency can cause illness, weakness, and death…the Bariatric Center will monitor the postoperative nutritional status of the patient and draw lab work to monitor the patient’s lab values.” None of these labs were drawn.

Disposition
This case was settled on behalf of the general surgeon and the bariatric center. The liability issues, coupled with the permanent nature of the patient’s injury, led to the decision to settle this case.

Risk management considerations
Nutritional deficiencies are well-known complications following bariatric weight loss surgery. “Wernicke-Korsakoff Syndrome is the best known complication of thiamine (vitamin B1) deficiency. The term refers to two different syndromes, each representing a different stage of the disease. Wernicke encephalopathy (WE) is an acute syndrome requiring emergent treatment to prevent death and neurologic morbidity. Korsakoff syndrome (KS) refers to a chronic neurologic condition that usually occurs as a consequence of WE.” (1)

A high index of clinical suspicion is required when treating patients with a history of bariatric surgery presenting to any health care provider with symptoms suggestive of WE. In this case, there were several instances where a breakdown in communication and patient care occurred. 

Patient care breakdown
Not ordering nutritional studies, per the center’s Patient Education Manual, when the patient reported neurological symptoms was a breakdown in patient care. Other cases have been documented in which the appropriate lab work was ordered, but not completed. Developing and consistently following procedures for monitoring and acting on test results helps to prevent overlooking troubling test results.

Communication breakdown
Effective communication between staff members and physicians is critical. The general surgeon in this case denied knowing about the change in vitamins and would not have authorized it. 

Written policies and procedures regarding patient triage and communication among clinical staff is an important tool that can help ensure each person understands their responsibilities. 

Patient phone call documentation is recommended, including any instructions given to the patient. It is important to document these phone calls as over time it may become difficult to remember what was discussed and what instructions were given. In addition to aiding continuing quality care, this documentation can become valuable in defending a medical liability claim.  

Written policy and procedures
When training manuals and patient education materials are updated, it is important to communicate these changes to staff members and ensure they are properly trained and compliant. Have staff members sign and date the manual as acknowledgement that they have read and understand the changes. 

Source

1. UpToDate. Wernicke encephalopathy. Available at http://www.uptodate.com/contents/wernicke-encephalopathy. Accessed December 1, 2016.