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Malpractice Chronicle

2008;18(1):20-22
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Reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Who Was to Blame for Hyponatremia Death?
At age 63, a man visited the defendant family physician with complaints of fever and productive cough; he also needed a change in his blood pressure medication.

Chest x-ray results were negative, and the defendant prescribed an antibiotic. Six days later, the patient returned to the defendant’s office with similar but waning symptoms and new complaints consistent with anxiety and depression.

Over the following four days, the patient’s wife placed two documented calls to the defendant’s office to update him regarding the patient’s condition. The patient was subsequently taken to a hospital emergency department, where a sodium level of 101 mEq/L was detected on blood chemistry. A diagnosis of hyponatremia was made and an isotonic saline solution started.

The patient was then transferred to another hospital, where a hypertonic saline solution was ordered. Because his sodium level was replenished too quickly, the man developed central pontine myelinolysis (CPM). Three weeks later, he died of CPM-related aspiration pneumonia.

The plaintiff claimed that the defendant physician failed to diagnose hyponatremia and to give the patient proper treatment, which led to his death.

The defendant contended that there was no way to diagnose hyponatremia, based on the decedent’s signs and symptoms. The defendant also charged that death was caused by mistreatment at the hospital where the patient died.

According to a published account, a defense verdict was returned.

Pneumonia Patient Sent Home Too Soon
Complaints of upper back pain, evidently exacerbated by respiration, took a 44-year-old woman to a hospital emergency department. Tests revealed an elevated white blood cell count, but a chest x-ray was clear. A diagnosis of a pulled muscle was made; the patient was sent home with prescriptions for naproxen and hydrocodone with acetaminophen.

Four days later, the patient went to a clinic complaining of back pain. A second chest x-ray showed extensive right-sided pneumonia, for which she was hospitalized. Test results revealed that the patient was hypoxic, that her band cells were elevated to 65%, and that her white blood cell count was 5,000/mL. An additional chest x-ray was ordered, which the plaintiffs later claimed showed worsening pneumonia in the right lung.

When the patient complained of severely increased pain, her medications were discontinued and IV morphine was initiated. On day 5 of the patient’s hospital stay, her case was transferred to a different physician, and she was discharged two days later.

When the patient’s condition had not improved five days after her discharge, she placed a call to her physician, which was not returned. Very early the next morning, the woman was taken to the hospital. An hour later, she was pronounced dead as a result of cardiopulmonary arrest secondary to pneumonia.

Plaintiffs claimed that the decedent was prematurely discharged and that the defendant was negligent in failing to return her phone call. The defendant argued that the test results and x-rays that the plaintiffs claimed contraindicated discharge were not available when the decision was made to discharge the decedent. The defendant also claimed that, according to the office telephone record, the decedent had failed to convey any urgency when she called; thus, there was no negligence in failing to return the call that day. The plaintiffs maintained that the call had described the patient’s situation as urgent.

According to a published account, an $864,000 arbitration award was given.

Was Surgery for Hydrocephalus Delayed?
A 53-year-old man presented to a hospital emergency department (ED) after experiencing headaches, dizziness, nausea, vomiting, and a temperature as high as 101.9°F for several days. After the initial physical examination, nystagmus was diagnosed; meningitis was not considered. The patient was sent home with medication.

The next day, he returned to the same ED. MRI and CT of the brain revealed a 1.0-in brain tumor and hydrocephalus. The man was admitted for neurosurgical evaluation and treatment. During his examination, he was somewhat disoriented but could carry on a conversation. He was also able to stand, and his reflexes (including the pupillary reflexes) were normal. When increased hydrocephalus and intracranial pressure became evident, he was given steroids and mannitol.

The next day, the patient was lethargic, and his pupillary reflexes were slowly reactive. He responded to voice commands, but there were signs of increasing intracranial pressure.

That evening, the man ceased responding to voice commands and appeared increasingly confused. The following day, he was more lethargic. He made no spontaneous movements and no response to commands, although he did withdraw from painful stimuli. A repeat MRI showed the tumor and hydrocephalus.

Surgery was performed for removal of the tumor, which was identified as a T-cell lymphoma. The patient did not regain consciousness after the surgery. CT performed shortly thereafter showed herniation of the brain and diffuse hypoxic damage of a duration to suggest that it had occurred before the surgery.

The family refused a do-not-resuscitate (DNR) order and discontinuation of life support. For nine days after the surgery, the medical staff tried to persuade the family that the patient was dead; they then wrote a DNR order in the chart. When the family protested, doctors transferred the decedent out of the ICU and discontinued all medical support; they also clamped the ventriculostomy tube that had been placed after surgery. The decedent’s blood pressure and pulse remained normal, and his only requirements for life were IV fluids and a respirator.

After continued protest, the family was told that DNR orders are within the doctor’s decision. Consent was then sought to harvest the decedent’s organs for transplantation. Some 25 family members were present when a nurse discontinued the ventilator, and the man died.

Twenty-one family members sued for intentional infliction of emotional distress. Plaintiffs claimed that the decedent was in a coma that was caused not by the tumor but by hydrocephalus and increased intracranial pressure that accompanied the tumor. The plaintiffs claimed that a decompressing ventriculostomy would have prevented the herniation and hypoxic brain damage; this developed either before or during the surgery, which they charged was delayed. The plaintiffs also claimed that the decedent was not dead when life support was discontinued. The last electroencephalogram showed brain activity, they claimed, and the decedent’s blood pressure and pulse remained normal without any medical support. The plaintiffs also claimed that the decedent made respiratory movements for five minutes after the respirator was discontinued.

The defendants argued that the delay in performing surgery was necessary and that the decedent’s deterioration resulted from administration of sedatives to obtain a clear MRI. The defendants also claimed that the decedent was brain-dead after the surgery and that malpractice and wrongful death claims could not be applied to a person who was already dead.

According to a published report, a $425,000 settlement was reached.     

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