Patient coverage by trusted colleagues is a necessary part of practicing medicine. But post-surgical handoffs can become a focal point if things go wrong.
A 51-year-old woman visited Dr. OBG, an obstetriciangynecologist, and told the physician that her menses had become heavier since being diagnosed with thrombocytopenia. Her surgical history included an ectopic pregnancy removal and an ovarian cystectomy. Dr. OBG’s assessment included menopausal syndrome, ovarian cyst, and peri-menopausal menorrhagia. Dr. OBG ordered additional tests, including an ultrasound that showed a large benign-appearing cyst that appeared to have grown from that shown in an ultrasound five months earlier.
When the patient’s complaints persisted over successive visits, Dr. OBG sought clearance for an exploratory laparotomy and left salpingo-oophorectomy. The woman’s PCP cleared her for surgery, as did her hematologist – so long as the patient’s platelets were above 75,000 and that she take 30 mg of prednisone daily before surgery. The patient consented to a laparoscopic procedure with possible exploratory laparotomy after acknowledging risks and alternatives.
Dr. OBG began the surgery laparoscopically with a 5mm incision, followed by placement of a 5mm trocar into the abdomen. After finding extensive adhesions, Dr. OBG changed the trocar position to the supra-umbilical area. When the adhesions persisted, Dr. OBG converted to an open procedure. Dr. OBG removed the cyst, left tube, and ovary and cauterized the bleeding areas of the uterus before closing.
The patient was seen the next day by another OBG in the medical group, who noted stable vital signs, diet tolerance, non-distended abdomen, and ability to walk about. When Dr. OBG saw the patient two days post-op, the patient reported nausea and moderate right-side gas pain. The patient’s heart rate was 120. A V/Q scan came back normal. Later that evening, the patient’s temperature reached 100.8 degrees and Dr. OBG ordered Tylenol. A stat urinalysis was negative. Dr. OBG had a nurse contact a radiology technician regarding the patient’s iodine allergy and a possible CT scan pending CBC results. The tech told the nurse preparation would take 13 hours prior to any CT scan. The next morning (post-op day three), the CBC results showed a normal WBC count of 7.9 with high bands of 54. Hemoglobin was low at 8.7 and the HCT was 25. Dr. OBG transferred the patient to telemetry with an order for two units of packed red blood cells transfused as soon as possible. When she saw the patient mid-morning, the woman complained of shortness of breath and increased “stiffness” and “tightening” of her abdomen.
Another one of Dr. OBG’s partners assumed the care of the patient later that afternoon. The record shows the patient’s iodine allergy continued to be a factor in the scheduling of a CT scan and at one point, the partner cancelled Dr. OBG’s order for a scan.
When a stat CT with contrast was performed mid-morning on post-op day four, the study showed free air and fluid, a deep pelvic abscess, and a possible developing abscess on the abdominal wall. An exploratory laparotomy a few hours later found a perforated transverse colon and infection, necrosis, and fecal contamination. After debridement and anastomosis, the patient continued to have a complicated course and died several weeks later.
A claim brought by the patient’s family was resolved informally.
Because every adverse event looks different through the proverbial “retrospectroscope,” a clear record of communications between physicians in a handoff is essential in defending the critical decisions made in a patient’s care.
Gordon Ownby is CAP’s General Counsel. Comments on Case of the Month may be directed to gownby@CAPphysicians.com.
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