Medicolegal Issues

Delay in Addressing Bleeding From Dialysis Access Site


 

Reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Delay in Addressing Bleeding From Dialysis Access Site
At age 73, a woman with a 20-year history of diabetes had been using prescribed insulin injections, but not consistently. She had undergone kidney dialysis for more than 10 years and had end-stage renal failure as well as several other comorbidities, including diabetic retinopathy, glaucoma, hypertension, hepatitis B, and a history of knee surgery.

For 11 days before she was hospitalized in December 2004, the patient had experienced bleeding from the dialysis shunt access site in her right groin. This necessitated several emergency department (ED) visits leading to three hospitalizations. During the visit in question, the patient was seen by several physicians. Angioplasty and angiography were ordered in advance of anticipated removal of any occlusions from the shunt/graft site. Two days later, it was determined that the site should be examined and possibly revised, and surgery was scheduled for the following day. However, the patient experienced another bleed which led to a code blue; she did not survive.

The plaintiff alleged negligence by one of the physicians involved for failing to come to examine and treat the decedent’s shunt/graft site.

The defendant physician claimed that he had been consulted by phone by an ED physician and that he had not expected to see the decedent. When the defendant received a call two days later from one of the hospital nurses, he did not know why.

Defense also claimed that the decedent had wanted to keep the existing dialysis shunt/graft site in order to avoid a transition to peritoneal dialysis.

According to a published account, a confidential settlement was reached during trial.

“Moderate” Heart Defect Overlooked
One morning at work, a 37-year-old man experienced a lump in his throat, chest tightness, lightheadedness, and jaw pain. He contacted the defendant internist, who instructed the man to come to his office immediately. ECG results were normal, and after examining the patient, the internist determined that his symptoms had been induced by anxiety.

The next day, on the internist’s orders, the patient underwent ECG exercise stress testing, conducted by the defendant cardiologist. Results were interpreted as normal. A technetium Tc99m sestamibi nuclear scan confirmed a moderate defect in the left anterior descending chamber. Test results were mailed to the internist the following day.

The patient returned to work three days later and suffered a heart attack, collapsed, and was pronounced dead within one hour.

Plaintiffs for the decedent claimed that the internist should have diagnosed a heart attack and unstable angina and that further testing should have been performed during the initial visit to rule out a heart attack. The plaintiff also claimed that the decedent should have been sent to the ED and further argued that the nuclear test results should have been reported to the internist immediately, not mailed.

The defense maintained that no negligence was involved.

According to a published account, a jury found only the internist negligent and returned a $4 million verdict.

PSA Testing Conducted Only Once
In January 2005, a 49-year-old man presented to an internists’ group with urinary tract complaints, including frequent urination and a weak stream. He underwent a partial physical examination by the defendant internist, as well as prostate-specific antigen (PSA) testing. The patient did not follow up for the remainder of the exam, but did make an appointment five months later for follow-up and a complete acute care visit.

At that time, the patient complained of rectal bleeding. The internist performed a digital rectal exam and noted an enlargement of the prostate. He did not suggest repeat PSA testing, nor did he follow up on the man’s previous urinary tract complaints. Instead, he referred him to a -gastroenterologist.

Late in 2005, the patient called the internist to inquire about blood work, including a test for diabetes. A fasting blood glucose test was ordered. Shortly thereafter, the man saw his internist, complaining of a sore throat. The internist ordered a series of laboratory tests, including lipid panels, a thyroid-stimulating hormone test, and liver enzyme tests. A PSA was neither ordered nor discussed.

In November 2007, the man was given a diagnosis of stage IV prostate cancer with metastasis to the brain, lungs, spine, and bony extremities. He did not respond to chemotherapy or to any of several other interventions.

At the time of arbitration, two weeks before the man’s death, he claimed that more regular PSA testing should have been ordered.

The defendant claimed that the original PSA test was sufficient and that even if a diagnosis had been made in May 2005, the man’s chance of survival would have been less than 50%.

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