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Discontinuous care in the post-operative environment

Discontinuous care is the leading cause of medical malpractice insurance cases

By Barry Bialek, MD – Senior CoverMD Contributing Editor

Summary

In this article, Dr. Bialek examines discontinuous care in the post-operative environment. Discontinuous care is the leading cause of medical malpractice cases. This article reviews a case where a lack of post-op continuity of care led to devastating consequences for a 12 year old girl.

Twelve-year-old Tiffany walked with her mom into the suburban surgi-center, a satellite out-patient facility, which was part of a much larger and well-known university hospital system. Tiffany was having a routine T&A (tonsils and adenoids) that day. She was nervous about the surgery but excited about the unlimited ice cream that had been promised while she healed.

Tiffany’s surgeon, Dr. E, had suggested she perform the T&A at the surgi-center, rather than the hospital, since this was a routine procedure and Tiffany was scheduled to go home later that same day.

Everything unfolded as planned. Tiffany and her mom went straight from the admitting desk to the pre-op area, where Tiffany changed into her patient gown. There, a pleasant nurse asked a few questions, determined that Tiffany was the right patient, and started an IV. Dr. E arrived, spoke briefly with Tiffany and her mom, and left to scrub for the surgery.

Forty-five minutes later, Tiffany was wheeled out to the post-anesthesia care unit (PACU), minus her tonsils and adenoids. Since she was beginning to regain consciousness and moaning, the anesthesiologist, Dr. A, gave Tiffany a 50 microgram dose of Fentanyl, through her IV line. Tiffany’s breathing quickly settled into a snore.

Dr. E walked into the waiting room and assured Tiffany’s mom that everything had gone smoothly. She said that they would keep her for a couple of hours in the PACU and then send her home.

Alice was a traveling nurse; she worked in different hospitals and different departments, filling gaps in the schedule. Every few weeks she worked a shift in this surgi-center. When Alice received her patient in the PACU, Tiffany was still snoring.

Alice read the orders on the chart. They included:
Fentanyl 50 – 100 micrograms IV every 3 – 4 hours or Demerol 25 – 50 mg IV, every 3 – 4 hours, as needed.

Alice didn't pay attention to the time of the last Fentanyl dose, nor to the "as needed." She administered Fentanyl 50 micrograms through Tiffany’s IV.

Within three minutes, Tiffany stopped breathing. Alice didn’t notice because she was busy adjusting the cardiac monitor. Two more minutes passed before Alice realized something was wrong, and then another minute before she recognized that Tiffany had stopped breathing. Alice screamed for a code and two other nurses rushed in. One ran to get the surgi-center’s crash cart while the other tried to piece the story together.

Dr. A arrived and assessed the situation quickly – opiate overdose. Dr. A knew Tiffany needed two things: oxygen to feed her brain and Narcan to reverse the Fentanyl. One of the nurses arrived with the crash cart and, in less than 90 seconds, Dr. A intubated Tiffany and administered Narcan.

If only Alice hadn’t given the second dose of Fentanyl; the one that stopped Tiffany’s breathing. Or, if only she had acted faster after Tiffany stopped breathing, she wouldn’t have suffered severe brain injury; she would still be the bright pre-teenager she was before the surgery.

Instead, Tiffany lives the life of a vegetable, with highly paid caretakers around the clock. The jury awarded her family $12 million. Tiffany’s family settled – in a high-low agreement – for $7.5 million.


Analysis

Alice, the PACU nurse, and, by extension, the hospital were found liable. Since Alice was acting as an agent of the hospital, the hospital was liable, too. The physicians were found not liable.

Alice’s first act of malpractice was administering Fentanyl to Tiffany, when she did not need it. Her second was failing to appropriately (i.e. continuously) monitor a patient after administration of an IV narcotic.

A high-low agreement is an agreement reached between attorneys for the plaintiff and the defense, before the verdict is reached. The two sides agree on two numbers: a high and a low.

If the verdict falls within these two numbers, the defense pays the exact verdict. If the verdict is greater, the defense pays only the high number. If the verdict is less – even if the jury says no – the defense pays the low number. Defense lawyers use this to minimize potentially huge losses. Plaintiff lawyers use this to guarantee quick payment.

In Tiffany's case, the high-low was $7.5 million and $1 million. This meant the plaintiff settled for $4.5 million less than the $12 million verdict. This also meant the check would be in the mail in less than a month. This is attractive to the plaintiff not only for the money, but also as an end to the legal process – a very painful re-opening of old wounds.


Current Narcan recommendations to reverse opiate poisoning may be found at www.medscape.com/viewarticle/441915_4 (login required)

An interesting historical note, as found in Stedman's Shorter Medical Dictionary (1942)
Treatment for acute opiate poisoning: "Emetics ... repeated every 15 minutes; keep patient awake by walking, electricity, flagellation, or cold douches; heat to surface of body; strong hot coffee, strychnine, amyl nitrite inhalation, artificial respiration."



About the Author

Barry Bialek M.D. - CoverMD.com Senior Contributing Editor
Barry Bialek, MD

Barry Bialek, MD is a board-certified family physician living in Boulder, Colorado. His practice includes both family medicine and emergency medicine. For the past 10 years, Dr. Bialek has served as the in-house medical consultant to one of the most successful plaintiff's personal injury law firms in the US. His job was to advise on every medical step of every medical malpractice case. This gives Dr. Bialek a unique perspective on medical malpractice and how best to avoid it.

Dr. Bialek has held clinical faculty positions with the departments of family medicine at both the University of Toronto (Canada) and the University of Arizona. Dr. Bialek is currently a member of the faculty of the University of Colorado, College of Engineering, where he teaches his other passion: sustainable community development in Nepal.



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