Timing is everything

Story

Mrs. S.L. was a 58-year-old woman with a past medical history of stable chronic obstructive pulmonary disease and remote breast cancer, who presented to the hospital with a 2-3 day history of a swollen right leg. She was quickly diagnosed with a right femoral deep vein thrombosis, and she was admitted to Dr. Hospitalist for anticoagulation. Mrs. S.L. denied any chest symptoms on admission, and other than discomfort in her leg, she said she felt like her "usual self." Dr. Hospitalist ordered a heparin bolus and infusion along with monitoring of her activated partial thromboplastin time (aPTT). Mrs. S.L. had difficulty achieving therapeutic anticoagulation and, during the first night in the hospital, she received two additional heparin boluses per a heparin weight-based nomogram.

The following morning, Mrs. S.L. complained of a headache. Dr. Hospitalist was contacted and gave a verbal order for acetaminophen. A few hours later, Dr. Hospitalist visited Mrs. S.L. and noted her to be very sleepy. Dr. Hospitalist ordered a CT of the head without contrast. Several times that afternoon, the nurses documented that the patient was "sleeping" or "resting comfortably" in bed.

At 5 p.m., patient transport arrived to take Mrs. S.L. to radiology. She was unarousable and cyanotic but had a weak pulse. A Code Blue was called, and Mrs. S.L. was intubated and transferred to the ICU under the care of a critical care physician. Subsequent head imaging confirmed a large intracranial hemorrhage. Mrs. S.L. survived another 2 months in ICU, but she never regained consciousness. After discussions with the family regarding her poor prognosis, care was ultimately withdrawn.

© iChip/iStockphoto

Complaint

Following the initial Code Blue, Dr. Hospitalist called the husband and left a message that Mrs. S.L. had been transferred to the ICU. However, despite several subsequent attempts by the family to reach Dr. Hospitalist, he never actually spoke with the husband or the family about what had happened.

According to the family, they were informed that since Dr. Hospitalist was no longer involved in caring for Mrs. S.L., all information would need to come from her current care team. The family was convinced that a mistake had somehow occurred, and they contacted an attorney.

The complaint alleged that Dr. Hospitalist failed to evaluate Mrs. S.L. at the time of her headache, failed to stop her anticoagulation when she developed mental status changes, failed to ensure timely head imaging, and subsequently failed to reverse anticoagulation and/or obtain appropriate consultation to address her intracranial bleed. Had Dr. Hospitalist met the standard of care, Mrs. S.L. would be alive with minimal neurologic sequelae.

Scientific principles

Intracranial hemorrhage, primarily intracerebral hemorrhage, is the most serious and lethal complication of heparin therapy. Hemorrhagic complications are more closely related to underlying clinical risk factors than an aPTT elevation above the therapeutic range.

Patients at particular risk are those who have had recent surgery or trauma, or who have other clinical factors that predispose to bleeding, such as peptic ulcer, occult malignancy, liver disease, hemostatic defects, aged greater than 65 years, female gender, and a reduced admission hemoglobin concentration. The management of bleeding in a patient receiving heparin depends upon the location and severity of bleeding. Full neutralization of heparin effect is achieved with a dose of 1 mg protamine/100 U heparin.

Complaint rebuttal and discussion

The defense argued that the headache was a nonspecific finding and that Dr. Hospitalist was actively rounding at the time of the verbal acetaminophen order. The defense further asserted that as soon as Dr. Hospitalist was aware of the mental status change, he ordered STAT CT scan of the head to assess for a bleed and that he had a right to rely on hospital personnel to do their jobs.

Dr. Hospitalist testified that it was his expectation that he would be contacted if the study were delayed, or the results abnormal. In contrast, depositions of the primary nurse and the unit secretary revealed that the CT order was initially placed as routine, not STAT. The physician order sheet in the paper chart showed a signed CT order without a priority designation, but immediately underneath the order, the word "STAT" was written. No part of the order was dated or timed.

Dr. Hospitalist testified that the word "STAT" was his and that he wrote it contemporaneously with his order. The unit secretary testified that the word "STAT" must have been added after she took the order off, or the order would have been placed STAT. The plaintiff’s attorney hired a handwriting expert who concluded that the word "STAT" was written with a different pen than the original order, making it unlikely to have been written contemporaneously.

Regardless of the truth, the plaintiff argued that somebody made a mistake and it cost Mrs. S.L. her life. The defense countered with the argument that regardless of when the diagnosis was made, the outcome most likely would have been the same.

Conclusion

Mrs. S.L. suffered a known complication from anticoagulant therapy. Whether there was a delay in diagnosis and treatment that could have been averted, an adverse outcome remains unknown. However, Dr. Hospitalist did not help himself in several important respects.

First, he did not speak with the family after the unexpected transfer to the ICU. A demonstration of empathy may have gone a long way to avoiding the lawsuit altogether. As it was, the family interpreted Dr. Hospitalist’s reluctance to speak with them as an admission of guilt. The plaintiff further used this to portray Dr. Hospitalist to the jury as a callous physician.

Second, Dr. Hospitalist was in the habit of writing orders that were not dated or timed. The plaintiff held this up as an example of "sloppy work" – Dr. Hospitalist was not only callous, he was lazy as well.

In the end, Dr. Hospitalist was adamant that he had written orders for a STAT head CT immediately after his evaluation of Mrs. S.L. and that he did not alter the medical records. Nonetheless, he chose to settle with the plaintiff for an undisclosed amount before the jury had a chance to return a verdict. A post-trial jury survey confirmed that Dr. Hospitalist had little credibility with the jury and that he had made a wise decision to settle when he did.

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.

Story

Mrs. S.L. was a 58-year-old woman with a past medical history of stable chronic obstructive pulmonary disease and remote breast cancer, who presented to the hospital with a 2-3 day history of a swollen right leg. She was quickly diagnosed with a right femoral deep vein thrombosis, and she was admitted to Dr. Hospitalist for anticoagulation. Mrs. S.L. denied any chest symptoms on admission, and other than discomfort in her leg, she said she felt like her "usual self." Dr. Hospitalist ordered a heparin bolus and infusion along with monitoring of her activated partial thromboplastin time (aPTT). Mrs. S.L. had difficulty achieving therapeutic anticoagulation and, during the first night in the hospital, she received two additional heparin boluses per a heparin weight-based nomogram.

The following morning, Mrs. S.L. complained of a headache. Dr. Hospitalist was contacted and gave a verbal order for acetaminophen. A few hours later, Dr. Hospitalist visited Mrs. S.L. and noted her to be very sleepy. Dr. Hospitalist ordered a CT of the head without contrast. Several times that afternoon, the nurses documented that the patient was "sleeping" or "resting comfortably" in bed.

At 5 p.m., patient transport arrived to take Mrs. S.L. to radiology. She was unarousable and cyanotic but had a weak pulse. A Code Blue was called, and Mrs. S.L. was intubated and transferred to the ICU under the care of a critical care physician. Subsequent head imaging confirmed a large intracranial hemorrhage. Mrs. S.L. survived another 2 months in ICU, but she never regained consciousness. After discussions with the family regarding her poor prognosis, care was ultimately withdrawn.

© iChip/iStockphoto

Complaint

Following the initial Code Blue, Dr. Hospitalist called the husband and left a message that Mrs. S.L. had been transferred to the ICU. However, despite several subsequent attempts by the family to reach Dr. Hospitalist, he never actually spoke with the husband or the family about what had happened.

According to the family, they were informed that since Dr. Hospitalist was no longer involved in caring for Mrs. S.L., all information would need to come from her current care team. The family was convinced that a mistake had somehow occurred, and they contacted an attorney.

The complaint alleged that Dr. Hospitalist failed to evaluate Mrs. S.L. at the time of her headache, failed to stop her anticoagulation when she developed mental status changes, failed to ensure timely head imaging, and subsequently failed to reverse anticoagulation and/or obtain appropriate consultation to address her intracranial bleed. Had Dr. Hospitalist met the standard of care, Mrs. S.L. would be alive with minimal neurologic sequelae.

Scientific principles

Intracranial hemorrhage, primarily intracerebral hemorrhage, is the most serious and lethal complication of heparin therapy. Hemorrhagic complications are more closely related to underlying clinical risk factors than an aPTT elevation above the therapeutic range.

Patients at particular risk are those who have had recent surgery or trauma, or who have other clinical factors that predispose to bleeding, such as peptic ulcer, occult malignancy, liver disease, hemostatic defects, aged greater than 65 years, female gender, and a reduced admission hemoglobin concentration. The management of bleeding in a patient receiving heparin depends upon the location and severity of bleeding. Full neutralization of heparin effect is achieved with a dose of 1 mg protamine/100 U heparin.

Complaint rebuttal and discussion

The defense argued that the headache was a nonspecific finding and that Dr. Hospitalist was actively rounding at the time of the verbal acetaminophen order. The defense further asserted that as soon as Dr. Hospitalist was aware of the mental status change, he ordered STAT CT scan of the head to assess for a bleed and that he had a right to rely on hospital personnel to do their jobs.

Dr. Hospitalist testified that it was his expectation that he would be contacted if the study were delayed, or the results abnormal. In contrast, depositions of the primary nurse and the unit secretary revealed that the CT order was initially placed as routine, not STAT. The physician order sheet in the paper chart showed a signed CT order without a priority designation, but immediately underneath the order, the word "STAT" was written. No part of the order was dated or timed.

Dr. Hospitalist testified that the word "STAT" was his and that he wrote it contemporaneously with his order. The unit secretary testified that the word "STAT" must have been added after she took the order off, or the order would have been placed STAT. The plaintiff’s attorney hired a handwriting expert who concluded that the word "STAT" was written with a different pen than the original order, making it unlikely to have been written contemporaneously.

Regardless of the truth, the plaintiff argued that somebody made a mistake and it cost Mrs. S.L. her life. The defense countered with the argument that regardless of when the diagnosis was made, the outcome most likely would have been the same.

Conclusion

Mrs. S.L. suffered a known complication from anticoagulant therapy. Whether there was a delay in diagnosis and treatment that could have been averted, an adverse outcome remains unknown. However, Dr. Hospitalist did not help himself in several important respects.

First, he did not speak with the family after the unexpected transfer to the ICU. A demonstration of empathy may have gone a long way to avoiding the lawsuit altogether. As it was, the family interpreted Dr. Hospitalist’s reluctance to speak with them as an admission of guilt. The plaintiff further used this to portray Dr. Hospitalist to the jury as a callous physician.

Second, Dr. Hospitalist was in the habit of writing orders that were not dated or timed. The plaintiff held this up as an example of "sloppy work" – Dr. Hospitalist was not only callous, he was lazy as well.

In the end, Dr. Hospitalist was adamant that he had written orders for a STAT head CT immediately after his evaluation of Mrs. S.L. and that he did not alter the medical records. Nonetheless, he chose to settle with the plaintiff for an undisclosed amount before the jury had a chance to return a verdict. A post-trial jury survey confirmed that Dr. Hospitalist had little credibility with the jury and that he had made a wise decision to settle when he did.

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.

Story

Mrs. S.L. was a 58-year-old woman with a past medical history of stable chronic obstructive pulmonary disease and remote breast cancer, who presented to the hospital with a 2-3 day history of a swollen right leg. She was quickly diagnosed with a right femoral deep vein thrombosis, and she was admitted to Dr. Hospitalist for anticoagulation. Mrs. S.L. denied any chest symptoms on admission, and other than discomfort in her leg, she said she felt like her "usual self." Dr. Hospitalist ordered a heparin bolus and infusion along with monitoring of her activated partial thromboplastin time (aPTT). Mrs. S.L. had difficulty achieving therapeutic anticoagulation and, during the first night in the hospital, she received two additional heparin boluses per a heparin weight-based nomogram.

The following morning, Mrs. S.L. complained of a headache. Dr. Hospitalist was contacted and gave a verbal order for acetaminophen. A few hours later, Dr. Hospitalist visited Mrs. S.L. and noted her to be very sleepy. Dr. Hospitalist ordered a CT of the head without contrast. Several times that afternoon, the nurses documented that the patient was "sleeping" or "resting comfortably" in bed.

At 5 p.m., patient transport arrived to take Mrs. S.L. to radiology. She was unarousable and cyanotic but had a weak pulse. A Code Blue was called, and Mrs. S.L. was intubated and transferred to the ICU under the care of a critical care physician. Subsequent head imaging confirmed a large intracranial hemorrhage. Mrs. S.L. survived another 2 months in ICU, but she never regained consciousness. After discussions with the family regarding her poor prognosis, care was ultimately withdrawn.

© iChip/iStockphoto

Complaint

Following the initial Code Blue, Dr. Hospitalist called the husband and left a message that Mrs. S.L. had been transferred to the ICU. However, despite several subsequent attempts by the family to reach Dr. Hospitalist, he never actually spoke with the husband or the family about what had happened.

According to the family, they were informed that since Dr. Hospitalist was no longer involved in caring for Mrs. S.L., all information would need to come from her current care team. The family was convinced that a mistake had somehow occurred, and they contacted an attorney.

The complaint alleged that Dr. Hospitalist failed to evaluate Mrs. S.L. at the time of her headache, failed to stop her anticoagulation when she developed mental status changes, failed to ensure timely head imaging, and subsequently failed to reverse anticoagulation and/or obtain appropriate consultation to address her intracranial bleed. Had Dr. Hospitalist met the standard of care, Mrs. S.L. would be alive with minimal neurologic sequelae.

Scientific principles

Intracranial hemorrhage, primarily intracerebral hemorrhage, is the most serious and lethal complication of heparin therapy. Hemorrhagic complications are more closely related to underlying clinical risk factors than an aPTT elevation above the therapeutic range.

Patients at particular risk are those who have had recent surgery or trauma, or who have other clinical factors that predispose to bleeding, such as peptic ulcer, occult malignancy, liver disease, hemostatic defects, aged greater than 65 years, female gender, and a reduced admission hemoglobin concentration. The management of bleeding in a patient receiving heparin depends upon the location and severity of bleeding. Full neutralization of heparin effect is achieved with a dose of 1 mg protamine/100 U heparin.

Complaint rebuttal and discussion

The defense argued that the headache was a nonspecific finding and that Dr. Hospitalist was actively rounding at the time of the verbal acetaminophen order. The defense further asserted that as soon as Dr. Hospitalist was aware of the mental status change, he ordered STAT CT scan of the head to assess for a bleed and that he had a right to rely on hospital personnel to do their jobs.

Dr. Hospitalist testified that it was his expectation that he would be contacted if the study were delayed, or the results abnormal. In contrast, depositions of the primary nurse and the unit secretary revealed that the CT order was initially placed as routine, not STAT. The physician order sheet in the paper chart showed a signed CT order without a priority designation, but immediately underneath the order, the word "STAT" was written. No part of the order was dated or timed.

Dr. Hospitalist testified that the word "STAT" was his and that he wrote it contemporaneously with his order. The unit secretary testified that the word "STAT" must have been added after she took the order off, or the order would have been placed STAT. The plaintiff’s attorney hired a handwriting expert who concluded that the word "STAT" was written with a different pen than the original order, making it unlikely to have been written contemporaneously.

Regardless of the truth, the plaintiff argued that somebody made a mistake and it cost Mrs. S.L. her life. The defense countered with the argument that regardless of when the diagnosis was made, the outcome most likely would have been the same.

Conclusion

Mrs. S.L. suffered a known complication from anticoagulant therapy. Whether there was a delay in diagnosis and treatment that could have been averted, an adverse outcome remains unknown. However, Dr. Hospitalist did not help himself in several important respects.

First, he did not speak with the family after the unexpected transfer to the ICU. A demonstration of empathy may have gone a long way to avoiding the lawsuit altogether. As it was, the family interpreted Dr. Hospitalist’s reluctance to speak with them as an admission of guilt. The plaintiff further used this to portray Dr. Hospitalist to the jury as a callous physician.

Second, Dr. Hospitalist was in the habit of writing orders that were not dated or timed. The plaintiff held this up as an example of "sloppy work" – Dr. Hospitalist was not only callous, he was lazy as well.

In the end, Dr. Hospitalist was adamant that he had written orders for a STAT head CT immediately after his evaluation of Mrs. S.L. and that he did not alter the medical records. Nonetheless, he chose to settle with the plaintiff for an undisclosed amount before the jury had a chance to return a verdict. A post-trial jury survey confirmed that Dr. Hospitalist had little credibility with the jury and that he had made a wise decision to settle when he did.

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.