Medicolegal lesson: Beyond the Scope

Complaint rebuttal and discussion:

The defendants’ theory of the case was that Mrs. AP suffered an upper GI bleed prior to arrival to the ED that stopped bleeding. While in the ED, her vital signs and general condition improved, and there was no indication for early endoscopy as she was not orthostatic and her hemoglobin was not less than 10 g/dL. Her rebleed, while regrettable, was too big to be resuscitated. ICU care would not have changed the outcome, as Mrs. AP suffered hematemesis and aspiration in the presence of her nurse with immediate physician response.

The medical chart, however, clearly supported the proposition that Mrs. AP was hemodynamically unstable from the start. The plaintiff GI expert opined that had Mrs. AP received early endoscopy with or without sclerotherapy, Mrs. AP would have been further risk stratified to the extent that NGT placement would have been considered and/or therapy would more likely than not have prevented the subsequent large-volume hematemesis and aspiration.

Conclusion:

The scientific principles confirm that Mrs. AP should have been admitted to the ICU with closer monitoring and oxygen therapy. However, the scientific principles also refute the notion that blood transfusion, NGT lavage, or early endoscopy would have made any difference in the outcome. In hindsight, these interventions may have saved Mrs. AP’s life. But taking the facts known to the providers at the time, the case is less clear. At the time of admission, Dr. Hospitalist would have been well served to call Dr. GI to confirm and document the plan of care. According to deposition testimony, Dr. Hospitalist never spoke with Dr. GI. Such a conversation regarding the criteria for early endoscopy would have gone a long way to eliminating Dr. Hospitalist from this case at the outset. Hospitalists do have the right to rely on specialists, but in the middle of the night, we are often on our own and will be held to a "reasonable physician" standard. Dr. Hospitalist had access to the patient and the medical record – Dr. GI did not. A documented discussion with Dr. GI may have provided a better defense for Dr. Hospitalist. Ultimately, despite the issues regarding causation and the prevailing scientific principles, this case was settled on behalf of the plaintiff for an undisclosed amount.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.