March 2008
By Kathy Dwyer, Tom A. Augello, William Berry, MD, MPH

Care required better resident supervision, closer follow-up on ordered test.

• William Berry, MD, MPH; CRICO/RMF; Cambridge, MA

The following case abstract is based on closed claims in the Harvard system. Some details were changed to mask identities.

A 60-year-old Russian-speaking woman was referred to a surgeon after a pap smear indicated possible cervical cancer. The biopsy report showed severe dysplasia and carcinoma in situ, and she underwent a hysterectomy and removal of both ovaries and fallopian tubes.

The surgeon found dense adhesions between the bladder and the uterus and the uterus and the rectrosigmoid colon. Blood loss was 600 cc’s, and one unit of blood was given. After surgery, the patient developed a low grade fever and pneumonia and the surgical resident started her on antibiotics. A postoperative ileus lasted several days. The surgeon did not see the patient, but received updates over the phone from the residents.

Four days post-op, at 2:45 pm, the patient complained of abdominal pain and nausea. Her temperature was 101.5, abdomen was distended, and her heart rate was 102. This hospital did not have a full-time Russian interpreter and her pain symptoms were not detailed enough to assist with discussion of her pain symptoms, but at 11:57 p.m., after she complained loudly of continued pain, the rotating surgical resident ordered an abdominal x-ray. During off-hours this hospital relied on preliminary reads until radiologists came on duty in the morning, but the resident did not know this. The next morning at 10:20 a.m., the attending surgeon was notified that the X-ray showed a marked amount of free air and antibiotics were started.

At 4:30 p.m., 26 hours after the onset of pain complaints, a CT scan confirmed a perforation of the small bowel. The patient was taken emergently to surgery where a portion of her bowel was removed. Sepsis required an extended course of IV antibiotics and admission to a rehabilitation facility for six weeks.

The patient sued the attending surgeon, the hospital, and the surgical residents, alleging negligent delay in diagnosing the perforation and resulting infection. The case was settled in the mid-range.

To discuss the risk management and patient safety implications of this case, we are joined now by Dr. William Berry. Dr. Berry is a surgical consultant for CRICO/RMF in the Harvard system.

Q.	Bill, thank you for joining us… Where do we look first when we look at this case to see how either the care could have been different with a potentially different outcome or where the legal case maybe would have been more defensible?
A.	After careful analysis of the surgery and the lead up to surgery and the preparation of the patient, it becomes pretty apparent that the standard of care, the care that was provided by the surgeon in this case up to that point really was quite good. Where things break down in this case center around the care that the patient got from fourth postoperative day onward and centered primarily on a delay in acting on a clinical change and then on a study that was ordered that delayed the patient getting proper care and then led to her getting quite sick.
Q.	Along the way part of that may have been how the communication went between the residents and the patient. There was an evaluation of the level of pain, and we often see in our malpractice cases that communication issues can make a difficult clinical scenario worse and contribute to a bad outcome. Is that a factor, do you think in this one?
A.	There is no question that it’s a factor. Where this became problematic was again on the fourth day after surgery when the patient started to get sick. There wasn’t a Russian translator available in the hospital and when the resident evaluated the patient on that afternoon, the resident was limited in kind of questions and information exchange that they could have with the patient because they didn’t speak the same language. So that asking questions to the patient in English was of little use. In evaluating a patient who gets sick, as this woman did four days after surgery, it is fairly important clinically to have an understanding of the character of the pain that the patient is experiencing, even something as simple as grading the pain on a scale from 1-10 is much more difficult when you are not a native English speaker.
Q.	Because they did go through some key steps in trying to diagnose the condition. They ordered an x-ray, but you almost get the sense that they decided that it wasn’t a serious problem. What can be built into the process postop that might prevent that kind of a problem and the delay in getting the x-ray back and read?
A.	As you say, it’s certainly possible that the resident was just covering all the bases here and didn’t think that it was urgent to get the results from that x-ray. I think that this illustrates that it is normally good practice in clinical medicine that if you think a test should be ordered urgently and an x-ray that’s done in the afternoon or in the evening is certainly not routine, that the x-ray should be interpreted. Now the resident does not appear to have been aware of the fact that this particular institution did not have 24-hour radiology coverage and if the x-ray was going to be interpreted in the night that the resident was the one that was going to need to interpret it. As the case transpired, what happened was the x-ray that was performed in the evening was not interpreted until the radiologist came in the next day and looked at the film and realized that something was amiss and called the attending surgeon directly to pass on the fact that there was quite a bit of free air, a worrisome amount of free air in the abdomen indicating that there was probably a hole in the bowel somewhere that needed to be acted upon. One of the problems that we see when we look more broadly across the cases here at CRICO is that the orientation of residents when they are rotating to facilities that they are not familiar with is often not robust. And in this case, you can see where the fact that the resident was not familiar with the way that this hospital worked in terms of the kind of radiology support that was available at what times and that probably had a negative impact on the patient’s care. The resident, because of what they brought with them from their home institution, had a different set of expectations. Those kind of things can usually be taken care of in a good orientation to the facility is something that I think is getting more attention but probably still can be done a little bit better than we are doing.
Q.	We have seen studies in recent years that really point to communication involvement postop with the attending. What was the attending’s role here in making this outcome better?
A.	Again, our experience here bring together analyses of many, many cases has pointed to a problem that we think exists with the amount of attending involvement at the bedside, particularly in patients toward the end of their hospital stays. Certainly, the care the residents are delivering could be guided by the attending, either directly at the bedside or through telephone, e-mail communication so that the residents are being supervised and that supervision just isn’t being documented in the record, but we think and in this case believe that the attending probably did not see the patient themselves on that 4th postoperative day. You wonder, and there is no way to know for certain, but you wonder if the added clinical experience that an attending brings to even something as simple as a physical examination might not have picked up subtle clues that there was more going on here than routine postoperative recovery. The patient did have a fever, and the patient was complaining of pain, again, the pain difficult to characterize because of the language barrier, but then you wonder if the physical examination done by less experienced hands also could have missed some signs, physical signs that more was going on in the abdomen even if the only result of that would have been a heightened awareness that there was an acute process perhaps going on and the x-ray needed to be checked as soon as it was taken. That in and of itself could have changed the clinical outcome here.

Thank you, Bill Berry, Surgical Consultant for CRICO RMF. For resource, I’m Tom Augello