Late X-ray Review Slowed Infection DX

Description

The patient’s course following her total hysterectomy was complicated by a bowel perforation, requiring a colon resection and a colostomy.

Key Lessons

Language and cultural barriers can contribute to delays in diagnosing complications.
A lack of communication in the night between residents and staff can lead to patient harm.
Appropriate communication and action on abnormal test results require robust support systems.

Clinical Sequence

A 70-year-old woman was referred to a gynecologic oncology surgeon to be evaluated for cervical cancer. The patient was not English-speaking, and the surgeon used a Ukrainian interpreter to communicate with her. The surgeon reviewed the Pap smear results, which showed a pre-cancerous lesion. The patient’s loop electrosurgical excision procedure report showed severe dysplasia and carcinoma in situ. The patient, who had expressed a fear of surgery, was encouraged to undergo a hysterectomy and bilateral salpingo-oophorectomy. She did not agree to it.

One month later, the patient returned. The surgeon, with an interpreter present, discussed and reviewed the risks of the procedure, including the risk of bowel injury. The patient signed the consent form and indicated that she wanted to discuss the surgery with her daughter.

Seven months later, the patient returned to the surgeon, discussed the risks of surgery again, and both the patient and the surgeon again signed and dated the procedure consent form, with an interpreter present.

During the operation, the surgeon found dense adhesions between the bladder and the uterus, and between the uterus and the rectrosigmoid colon. There was a 600cc blood loss and one unit of blood was given. After surgery, the patient developed a low grade fever and pneumonia, and antibiotics were started. The patient had a postoperative ileus lasting several days.

On Wednesday, five days postop (at 2:45 pm), the patient complained of severe abdominal pain and nausea. Her temperature was 101.5, her abdomen was distended, and her heart rate was 102. At 11:57 pm, the surgical resident on rotation ordered an abdominal X-ray (KUB), apparently unaware that this hospital did not have 24-hour Radiology consults. When Radiology reviewed the image Thursday morning, the X-ray showed a marked amount of free air, and the radiologist contacted the surgeon (at 10:20 a.m.) At 4:30 p.m. (16 hours after the KUB showed free air), a CT scan confirmed a large perforation of the sigmoid colon.

Emergency surgery revealed a 1.5 cm perforation in the sigmoid colon. A diverting colostomy and Hartmann’s pouch were created. Because of her bowel perforation and her history of a mechanical mitral valve replacement, the patient required an extended course of IV antibiotics and admission to a rehabilitation facility for three weeks. She had planned to have the colostomy reversed, but canceled due to fear of undergoing another surgery.

Allegation

The patient sued the hospital, attending surgeon, and two surgical residents, claiming that a bowel perforation during surgery was not recognized, resulting in infection and the need for repair with a colostomy.

Disposition

The case was resolved through binding arbitration in favor of the patient in the medium range.

Analysis

Clinical Perspective

The abnormal KUB finding was not acted upon promptly, and the surgeon was not informed for more than 10 hours.
To combat the multiple factors that can contribute to a significant delay in needed treatment, systems and protocols must anticipate breakdowns. If a need arises to order a study in the middle of the night, then the objective must be to actively seek or provide abnormal results as soon as possible. This requires protocols for communication between residents and supervisors, Radiology and ordering physicians, etc. Just covering the bases, by ordering a test when a patient complains is a risky posture without active attention to getting the results. Intervention may be needed to ensure a Radiology read on an X-ray with initial worrisome findings.
Although he kept in contact with the resident by phone, the surgeon did not see the patient for the first five days post-op.
The added clinical experience that an attending brings, even to something as simple as a physical examination, might pick up subtle clues. An examination done by less experienced hands also can miss physical signs that more is going on. Familiarity with a patient, especially with a language barrier, may help with communication issues, such as describing pain. Closer supervision of trainees in the presence of the patient may not necessarily change an action or an outcome. Still, the impact could merely be a heightened awareness of an acute process, or the fact that an X-ray needs to be checked as soon as it is taken.

Patient Perspective

As a result of the perforation and subsequent colostomy, the patient’s day-to-day life and body image were significantly altered.
Confronted with a life-altering outcome, even if it was considered during an informed consent process, patients may look for preventability. When something goes wrong postoperatively, and the surgeon doesn’t see the patient, feelings of abandonment are possible. An unfamiliar resident’s unsuccessful efforts to respond to complaints, or an X-ray left unread for many hours, impact a patient’s perception about his or her outcome.

Risk Management Perspective

Language barriers and cultural issues suggest that the patient’s postoperative pain may not have been fully recognized.
When a patient has challenges communicating with the primary caregivers, it is possible that subsequent providers will not fully understand him or her. Physicians need to be aware of possible language problems and be extremely careful to make their verbal communications understood. Using translators is key. Documentation in these situations becomes even more important.

The resident was rotating from another facility and did not know that the Radiology department would not read the X-ray until the next morning.
When residents rotate to unfamiliar facilities, the orientation should be robust. A good orientation to the facility includes processes for test result follow through. Failing to be certain that all residents are familiar with what kind of support is available, and when, is putting patient care at risk.

Legal Defense Perspective

Deciding in favor of the patient, the arbitrator determined two facts: that the perforation was a result of the procedure, and that the delay in response to symptoms and test results showing an infection was beneath the standard of care.
Two requirements for a finding against a medical malpractice defendant are that the standard of care was breached and that the breach caused the plaintiff’s harm. Binding arbitration is sometimes used when a case is very complicated or might bring an emotional response from a jury. The arbitrator—often a retired judge—hears all the evidence and renders a decision that is governed by the civil standard of negligence.