Medicolegal Issues

Teen’s Condition Deteriorates After Appendectomy


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

Teen’s Condition Deteriorates After Appendectomy
The plaintiffs’ 13-year-old son underwent an appendectomy, performed by the defendant surgeon, Dr. W. The boy’s condition deteriorated after surgery when a covering physician, Dr. H., was on call. The patient was transported by air from the defendant hospital to a children’s hospital three days later. He died following surgery at the receiving hospital. At autopsy, the cause of death was found to be multiple organ failure caused by sepsis related to a necrotic bowel.

The plaintiffs claimed that Dr. W. failed to remove necrotic tissue from the bowel during the initial surgery and that neither Dr. W. nor Dr. H. determined the cause of the decedent’s deteriorating condition or its underlying diagnosis; they failed to perform a second surgery or to order timely transfer for the boy, as the transfer was claimed to have been delayed by 7.5 hours. The plaintiffs also claimed that the hospital nurses should have contacted the hospital chief of staff about the situation.

The plaintiffs argued further that the boy was near death by the time he arrived at the receiving hospital and that the surgery performed there had virtually no chance of success.

According to a published report, a $1,210,000 verdict was returned against Dr. W. and his surgical group practice.

Failure to Investigate New-Onset Abdominal Pain
Since childhood, a man had been treated with prednisone for hemolytic anemia. When he visited the defendant internist at age 62, in March 2004, his history was also significant for prostate cancer, a prostate resection, brachytherapy, and recurrent bladder outlet obstructions. He was referred to the defendant urologist, who performed a cystoscopy in April 2004. After being discharged, the decedent found he was unable to urinate.

He went to the emergency department (ED) the next day, and a Foley catheter was inserted. The man was given a diagnosis of pyelonephritis and was discharged with prescription antibiotics.

The next day, the patient returned to the hospital in acute renal failure. He was admitted by the urologist for dialysis. During the patient’s 16-day hospitalization, his internist was not informed that he had been admitted and never participated in the patient’s care. CT performed during this period suggested a problem near the right kidney, and cystoscopy was performed. When the urologist “entered” the left ureter, the patient began to urinate, and this appeared to relieve the obstruction. The right ureter and kidney were not evaluated because the urologist was unable to locate the opening to the right ureter.

In addition to his renal problems, the patient experienced Staphylococcus pneumoniae infection, atrial fibrillation, abdominal pain, and respiratory failure, necessitating his admission to the ICU. His care there was coordinated by a hospitalist and involved several specialists.

The patient’s discharge instructions included follow-up with the internist and the urologist. Accordingly, he went to see the internist, who reviewed the hospitalist’s summary of the man’s hospital stay. The discharge summary specifically stated that the patient’s obstructive nephropathy had been resolved.

At the follow-up visit with his internist, the patient was in a weakened state and appeared anemic, and the internist ordered blood work and urinalysis. In response to the man’s complaints of heart palpitations, the internist prescribed a beta-blocker.

Results from the urinalysis and urine culture were negative. The internist attributed an elevated white blood cell count to an increase in the patient’s prednisone dosing. Blood work also revealed a low hematocrit and low hemoglobin level, for which a blood transfusion was ordered. As a result, the hemato-crit and hemoglobin returned to normal values.

The patient returned to the internist five days later with new complaints of abdominal pain and a tender upper midabdomen. Further blood work was ordered, along with repeat urinalysis. Ultrasonography was scheduled for one week later.

Abnormal urinalysis results consistent with urinary tract infection were returned after office hours that day. Two days later, abnormal results were returned on the blood work.

The patient died on the day before the scheduled ultrasound. The internist did not see the results of the blood work or the urinalysis until after he learned of the decedent’s death.

Autopsy revealed a right renal abscess, 15 gallstones, a swollen liver, and other problems. The immediate cause of death was determined to be portal vein thrombosis due to pyelonephritis, which had progressed to systemic inflammatory response syndrome.

Plaintiff for the decedent claimed that the internist should have been prompted by the new finding of right upper quadrant abdominal pain to order earlier ultrasonography at another of the practice’s locations, or to refer the decedent to the ED for emergent ultrasonography.


Next Article: