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Medicolegal review has the opportunity to become the morbidity and mortality conference of the modern era. The more we share in our collective failures, the less likely we are to repeat those same mistakes.
CR was a 69-year-old man who presented to the hospital for an elective total knee revision. He had a past medical history of obesity, hypertension, and chronic obstructive pulmonary disease (COPD).
Two weeks prior to the surgery, he received preoperative clearance from his primary care physician. CR had a morning surgery that went well and was without complication. He was transferred to the postanesthesia care unit in good condition with normal oxygen saturations on 2L of oxygen by nasal cannula. His postoperative orders included a routine hospitalist consultation for “medical management,” along with orders for daily low-molecular weight heparin for deep vein thrombosis (DVT) prophylaxis. CR arrived to the orthopedic floor later that afternoon. He did well overnight, and the next morning, he began working with physical therapy. After doing some exercises in the bed, CR had his oxygen removed so that he could ambulate. While up with the physical therapist, CR reported feeling “dizzy.” A chair was brought up behind him so that he could sit down. His oxygen saturation was 88%. CR was placed back on 2L of oxygen, but as he transferred from the chair to the bed his oxygen saturation fell further to 81%. CR had his oxygen increased to 3L and over the next half-hour, his oxygen saturation came up and stayed above 92%.
Dr. Hospitalist met CR about an hour after he worked with physical therapy. CR was without complaints at the time of the evaluation and had good oxygen saturations on 3L of oxygen. Dr. Hospitalist documented that CR denied chest pain, cough, or sputum production. On auscultation, CR had a scattered wheeze. Dr. Hospitalist dictated that his differential diagnosis included pulmonary embolism (PE). He ordered bronchodilator aerosols, a chest radiograph, a troponin and a brain natriuretic peptide (BNP) level. The chest radiograph was performed that afternoon and interpreted as “no acute process,” with no evidence for atelectasis.
Overnight, CR remained on oxygen via nasal cannula. The following morning his nurse noted that CR had bilateral edema in his legs. The labs ordered by Dr. Hospitalist the previous day were now in the chart – the troponin was 0.07 ng/mL (normal < 0.04 ng/ml) and the BNP was 205 pg/mL.
At 11 a.m., CR was again seen by physical therapy. While ambulating in his room, CR began to feel “dizzy” despite the use of oxygen, and he passed out falling to his knees. The therapist and several nurses got him back to a chair and increased his oxygen. He spontaneously regained consciousness, but within a few minutes CR passed out a second time and lost his pulse. Dr. Hospitalist and the surgeon responded to the code. He was unable to be resuscitated and was pronounced dead. An autopsy was performed and determined the cause of death to be massive saddle pulmonary embolism (PE).
Complaint:
A complaint was filed against the hospital, the surgeon, and Dr. Hospitalist for failure to prevent DVT, failure to diagnose PE, and failure to treat PE. The complaint alleged that had the standard of care been followed, CR would not have died postoperatively and would otherwise have had a normal life expectancy.
Scientific principles:
Orthopedic surgery patients are known to be at high risk for venous thromboembolism. In the absence of prophylaxis, postoperative PE is common and often a fatal disease. Nonetheless, even without prophylaxis, mortality from PE can be reduced by prompt diagnosis and therapy. Unfortunately, the clinical presentation of PE is variable and nonspecific; thus, diagnostic testing is necessary before confirming or excluding the diagnosis of PE. The diagnostic approach includes algorithms designed to efficiently diagnose PE while simultaneously avoiding unnecessary testing and minimizing the risk of missing clinically important cases. While there is consensus regarding the need for algorithms, there is no agreed-upon best approach.
Complaint rebuttal and discussion:
The defense responded that the first item in the complaint was baseless as the surgeon ordered both mechanical and low-molecular weight heparin prophylaxis for DVT. The plaintiff experts agreed and the surgeon was dismissed from the case prior to trial. The focus of the case was now on Dr. Hospitalist and his failure to diagnose and treat PE.
Dr. Hospitalist defended himself by arguing that CR suffered a sudden fatal PE on the day of his death despite appropriate prophylaxis and that the “dizziness” the prior day was unrelated. The defense explained that the day prior to his death, CR was simply orthostatic from his postanesthesia state, combined with opiate analgesics, and any hypoxia was from CR’s preexisting COPD.
Plaintiff experts replied that CR had virtually no symptoms for a COPD exacerbation (i.e., no cough, no sputum production), and there was no explanation for the elevated troponin other than PE. Plaintiff experts further alleged that Dr. Hospitalist failed to incorporate an algorithm, such as the modified Wells’ Criteria, into his diagnostic approach for PE. Had he done so, Dr. Hospitalist would have recognized that CR had a high enough clinical probability for PE to warrant empiric treatment and confirmatory testing. The defense responded that the use of the modified Wells’ Criteria was nothing but an arcane “academic” exercise that did not match real clinical practice.
Conclusion:
Acute pulmonary embolism is a well-known postoperative pulmonary complication. The diagnosis must be considered in any surgical patient that has postoperative shortness of breath or unexplained hypoxia. The importance of using an algorithm to determine the need for testing and treatment cannot be understated. In this case, the PE diagnosis was considered but no algorithm was used. The jury in this case deliberated for more than a day, but ultimately returned a full defense verdict.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read past columns at eHospitalist news.com/Lessons.
Medicolegal review has the opportunity to become the morbidity and mortality conference of the modern era. The more we share in our collective failures, the less likely we are to repeat those same mistakes.
CR was a 69-year-old man who presented to the hospital for an elective total knee revision. He had a past medical history of obesity, hypertension, and chronic obstructive pulmonary disease (COPD).
Two weeks prior to the surgery, he received preoperative clearance from his primary care physician. CR had a morning surgery that went well and was without complication. He was transferred to the postanesthesia care unit in good condition with normal oxygen saturations on 2L of oxygen by nasal cannula. His postoperative orders included a routine hospitalist consultation for “medical management,” along with orders for daily low-molecular weight heparin for deep vein thrombosis (DVT) prophylaxis. CR arrived to the orthopedic floor later that afternoon. He did well overnight, and the next morning, he began working with physical therapy. After doing some exercises in the bed, CR had his oxygen removed so that he could ambulate. While up with the physical therapist, CR reported feeling “dizzy.” A chair was brought up behind him so that he could sit down. His oxygen saturation was 88%. CR was placed back on 2L of oxygen, but as he transferred from the chair to the bed his oxygen saturation fell further to 81%. CR had his oxygen increased to 3L and over the next half-hour, his oxygen saturation came up and stayed above 92%.
Dr. Hospitalist met CR about an hour after he worked with physical therapy. CR was without complaints at the time of the evaluation and had good oxygen saturations on 3L of oxygen. Dr. Hospitalist documented that CR denied chest pain, cough, or sputum production. On auscultation, CR had a scattered wheeze. Dr. Hospitalist dictated that his differential diagnosis included pulmonary embolism (PE). He ordered bronchodilator aerosols, a chest radiograph, a troponin and a brain natriuretic peptide (BNP) level. The chest radiograph was performed that afternoon and interpreted as “no acute process,” with no evidence for atelectasis.
Overnight, CR remained on oxygen via nasal cannula. The following morning his nurse noted that CR had bilateral edema in his legs. The labs ordered by Dr. Hospitalist the previous day were now in the chart – the troponin was 0.07 ng/mL (normal < 0.04 ng/ml) and the BNP was 205 pg/mL.
At 11 a.m., CR was again seen by physical therapy. While ambulating in his room, CR began to feel “dizzy” despite the use of oxygen, and he passed out falling to his knees. The therapist and several nurses got him back to a chair and increased his oxygen. He spontaneously regained consciousness, but within a few minutes CR passed out a second time and lost his pulse. Dr. Hospitalist and the surgeon responded to the code. He was unable to be resuscitated and was pronounced dead. An autopsy was performed and determined the cause of death to be massive saddle pulmonary embolism (PE).
Complaint:
A complaint was filed against the hospital, the surgeon, and Dr. Hospitalist for failure to prevent DVT, failure to diagnose PE, and failure to treat PE. The complaint alleged that had the standard of care been followed, CR would not have died postoperatively and would otherwise have had a normal life expectancy.
Scientific principles:
Orthopedic surgery patients are known to be at high risk for venous thromboembolism. In the absence of prophylaxis, postoperative PE is common and often a fatal disease. Nonetheless, even without prophylaxis, mortality from PE can be reduced by prompt diagnosis and therapy. Unfortunately, the clinical presentation of PE is variable and nonspecific; thus, diagnostic testing is necessary before confirming or excluding the diagnosis of PE. The diagnostic approach includes algorithms designed to efficiently diagnose PE while simultaneously avoiding unnecessary testing and minimizing the risk of missing clinically important cases. While there is consensus regarding the need for algorithms, there is no agreed-upon best approach.
Complaint rebuttal and discussion:
The defense responded that the first item in the complaint was baseless as the surgeon ordered both mechanical and low-molecular weight heparin prophylaxis for DVT. The plaintiff experts agreed and the surgeon was dismissed from the case prior to trial. The focus of the case was now on Dr. Hospitalist and his failure to diagnose and treat PE.
Dr. Hospitalist defended himself by arguing that CR suffered a sudden fatal PE on the day of his death despite appropriate prophylaxis and that the “dizziness” the prior day was unrelated. The defense explained that the day prior to his death, CR was simply orthostatic from his postanesthesia state, combined with opiate analgesics, and any hypoxia was from CR’s preexisting COPD.
Plaintiff experts replied that CR had virtually no symptoms for a COPD exacerbation (i.e., no cough, no sputum production), and there was no explanation for the elevated troponin other than PE. Plaintiff experts further alleged that Dr. Hospitalist failed to incorporate an algorithm, such as the modified Wells’ Criteria, into his diagnostic approach for PE. Had he done so, Dr. Hospitalist would have recognized that CR had a high enough clinical probability for PE to warrant empiric treatment and confirmatory testing. The defense responded that the use of the modified Wells’ Criteria was nothing but an arcane “academic” exercise that did not match real clinical practice.
Conclusion:
Acute pulmonary embolism is a well-known postoperative pulmonary complication. The diagnosis must be considered in any surgical patient that has postoperative shortness of breath or unexplained hypoxia. The importance of using an algorithm to determine the need for testing and treatment cannot be understated. In this case, the PE diagnosis was considered but no algorithm was used. The jury in this case deliberated for more than a day, but ultimately returned a full defense verdict.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read past columns at eHospitalist news.com/Lessons.
Medicolegal review has the opportunity to become the morbidity and mortality conference of the modern era. The more we share in our collective failures, the less likely we are to repeat those same mistakes.
CR was a 69-year-old man who presented to the hospital for an elective total knee revision. He had a past medical history of obesity, hypertension, and chronic obstructive pulmonary disease (COPD).
Two weeks prior to the surgery, he received preoperative clearance from his primary care physician. CR had a morning surgery that went well and was without complication. He was transferred to the postanesthesia care unit in good condition with normal oxygen saturations on 2L of oxygen by nasal cannula. His postoperative orders included a routine hospitalist consultation for “medical management,” along with orders for daily low-molecular weight heparin for deep vein thrombosis (DVT) prophylaxis. CR arrived to the orthopedic floor later that afternoon. He did well overnight, and the next morning, he began working with physical therapy. After doing some exercises in the bed, CR had his oxygen removed so that he could ambulate. While up with the physical therapist, CR reported feeling “dizzy.” A chair was brought up behind him so that he could sit down. His oxygen saturation was 88%. CR was placed back on 2L of oxygen, but as he transferred from the chair to the bed his oxygen saturation fell further to 81%. CR had his oxygen increased to 3L and over the next half-hour, his oxygen saturation came up and stayed above 92%.
Dr. Hospitalist met CR about an hour after he worked with physical therapy. CR was without complaints at the time of the evaluation and had good oxygen saturations on 3L of oxygen. Dr. Hospitalist documented that CR denied chest pain, cough, or sputum production. On auscultation, CR had a scattered wheeze. Dr. Hospitalist dictated that his differential diagnosis included pulmonary embolism (PE). He ordered bronchodilator aerosols, a chest radiograph, a troponin and a brain natriuretic peptide (BNP) level. The chest radiograph was performed that afternoon and interpreted as “no acute process,” with no evidence for atelectasis.
Overnight, CR remained on oxygen via nasal cannula. The following morning his nurse noted that CR had bilateral edema in his legs. The labs ordered by Dr. Hospitalist the previous day were now in the chart – the troponin was 0.07 ng/mL (normal < 0.04 ng/ml) and the BNP was 205 pg/mL.
At 11 a.m., CR was again seen by physical therapy. While ambulating in his room, CR began to feel “dizzy” despite the use of oxygen, and he passed out falling to his knees. The therapist and several nurses got him back to a chair and increased his oxygen. He spontaneously regained consciousness, but within a few minutes CR passed out a second time and lost his pulse. Dr. Hospitalist and the surgeon responded to the code. He was unable to be resuscitated and was pronounced dead. An autopsy was performed and determined the cause of death to be massive saddle pulmonary embolism (PE).
Complaint:
A complaint was filed against the hospital, the surgeon, and Dr. Hospitalist for failure to prevent DVT, failure to diagnose PE, and failure to treat PE. The complaint alleged that had the standard of care been followed, CR would not have died postoperatively and would otherwise have had a normal life expectancy.
Scientific principles:
Orthopedic surgery patients are known to be at high risk for venous thromboembolism. In the absence of prophylaxis, postoperative PE is common and often a fatal disease. Nonetheless, even without prophylaxis, mortality from PE can be reduced by prompt diagnosis and therapy. Unfortunately, the clinical presentation of PE is variable and nonspecific; thus, diagnostic testing is necessary before confirming or excluding the diagnosis of PE. The diagnostic approach includes algorithms designed to efficiently diagnose PE while simultaneously avoiding unnecessary testing and minimizing the risk of missing clinically important cases. While there is consensus regarding the need for algorithms, there is no agreed-upon best approach.
Complaint rebuttal and discussion:
The defense responded that the first item in the complaint was baseless as the surgeon ordered both mechanical and low-molecular weight heparin prophylaxis for DVT. The plaintiff experts agreed and the surgeon was dismissed from the case prior to trial. The focus of the case was now on Dr. Hospitalist and his failure to diagnose and treat PE.
Dr. Hospitalist defended himself by arguing that CR suffered a sudden fatal PE on the day of his death despite appropriate prophylaxis and that the “dizziness” the prior day was unrelated. The defense explained that the day prior to his death, CR was simply orthostatic from his postanesthesia state, combined with opiate analgesics, and any hypoxia was from CR’s preexisting COPD.
Plaintiff experts replied that CR had virtually no symptoms for a COPD exacerbation (i.e., no cough, no sputum production), and there was no explanation for the elevated troponin other than PE. Plaintiff experts further alleged that Dr. Hospitalist failed to incorporate an algorithm, such as the modified Wells’ Criteria, into his diagnostic approach for PE. Had he done so, Dr. Hospitalist would have recognized that CR had a high enough clinical probability for PE to warrant empiric treatment and confirmatory testing. The defense responded that the use of the modified Wells’ Criteria was nothing but an arcane “academic” exercise that did not match real clinical practice.
Conclusion:
Acute pulmonary embolism is a well-known postoperative pulmonary complication. The diagnosis must be considered in any surgical patient that has postoperative shortness of breath or unexplained hypoxia. The importance of using an algorithm to determine the need for testing and treatment cannot be understated. In this case, the PE diagnosis was considered but no algorithm was used. The jury in this case deliberated for more than a day, but ultimately returned a full defense verdict.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read past columns at eHospitalist news.com/Lessons.
