It has been more than a year since I sat in the Buncombe County courthouse, Asheville, NC, with my career hanging in the balance. At the time, the unfairness of it all was overwhelming. Looking back now, I see it as a cautionary tale for other trauma surgeons.
The case
A 76-year-old female was a passenger involved in a motor vehicle crash. Her husband of more than 50 years died in the collision. She remained awake and alert at the scene and was brought to my hospital, Mission Hospital, Asheville, a trauma center, by rapid transport helicopter. While en route, the patient’s blood pressure dropped briefly.
In the emergency department (ED), an emergency room (ER) physician gathered a quick history and performed a physical exam. In spite of the patient’s age, she was healthy. Her only medical issues included hypertension and an allergy to intravenous (IV) contrast. By this time, my partner, a board-certified trauma surgeon, was at the patient’s bedside. He ordered multiple computed tomography (CT) scans as well as blood tests and X rays. The patient was given a dose of steroids and antihistamines to blunt her allergic response to IV contrast.
In the CT scanner, the patient had an episode of nausea and vomiting. She was given zofran and the scans were completed. A little later, the patient was given phenergan. The patient’s blood pressure dropped, so my partner gave her a bolus of fluid. Scans determined that the patient had a forearm fracture, various rib fractures, and a large degloving injury of her hand. My partner admitted the patient to the intensive care unit (ICU) and consulted orthopaedics. The patient’s blood pressure dropped a second time, and my partner administered another bolus of fluid.
Both an orthopaedic surgeon and an anesthesiologist evaluated the patient. Approximately three hours after her arrival in the ER, the patient was taken to the operating room to have her wounds addressed and her forearm fracture fixed. The patient’s blood pressure dropped again after the induction of anesthesia. This reaction is not uncommon. After she was given neosynephrine, the rest of the operation continued without event. In the recovery room, the patient’s systolic blood pressure was in the 80s. She was awake and alert. For the first time, she had an odd-looking arrhythmia, which showed up on her cardiac monitor. The anesthesiologist was called, and he ordered another bolus of fluid. After about 45 minutes, the patient was transferred to the ICU.
In the ICU, the patient’s systolic blood pressure remained in the 80s. Awake and alert, she spoke with her family, who were at the bedside. As the trauma surgeon on call, I received a call around midnight concerning this patient’s stability. Again, her blood pressure had dropped. Having already been brought up to speed about the patient when my partner and I signed out for the night, I ordered another fluid bolus. Approximately an hour later, the computer showed that her blood pressure hadn’t really changed. I called and asked the nurse to set up for a central line. I also requested that the nurse start administering dopamine.
After 20 minutes, as I drove to the hospital, the nurse called to say that the patient’s blood pressure was very low. The nurse thought that the patient was about to code. I ordered emergency labs and asked the nurse to increase the dopamine. Ten minutes later, I was at the patient’s bedside as the nurses started doing chest compressions. The patient did not respond to cardiopulmonary resuscitation or to cardiac drugs and was declared dead.
What happened?
For the next 20 minutes, I focused on writing and dictating the mandatory death note. At the same time, I reviewed the possibilities, the would-haves and could-haves, trying to think of anything I could have done to prevent the patient’s death. With the paperwork complete, I spoke with the family and explained that the patient had died.
In our monthly trauma morbidity and mortality conference, my colleagues and I discussed the patient and reviewed the case. Perhaps this patient died of myocardial infarction. Perhaps she had a massive pulmonary embolism. Would she have benefitted from a preoperative electrocardiogram (EKG) in the ED? Perhaps; however, recommendations from the American Heart Association and American College of Cardiology stipulate that a 70-year-old female with hypertension as her only preoperative history does not need an EKG before emergency surgery.1
About 12 months later, I received a notice that I was being sued, along with my employer, the hospital, for being inept, according to my interpretation of the document. In the official legal complaint, it stated that I failed to use my “best judgment” and “reasonable care and diligence.” As we lined up our experts, a theory began to come together. This patient died of a myocardial contusion. Most patients who have this rare injury in the ED show multiple irregular heartbeats. Some patients can have frank heart failure, which is an overloading of the cardiac system where the heart is unable to pump out all of the blood that returns to the heart, leading to shortness of breath and swelling of the feet and legs.2 Most patients with a cardiac contusion, however, survive and regain normal heart function. Although this was our theory, I remained hesitant to accept it.
The trial
Months later, sitting in the courtroom, I was more convinced than ever that I did everything that I could have done. I was extremely nervous and unsure of my ability to persuade 12 jurors that I am an excellent physician who had done his best to care for this patient.
There is nothing swift about justice or our judicial system. Picking a jury took nearly three days. Finally, the trial started, and each lawyer had his say. Over the course of seven days, I spent more than five hours on the witness stand. I took my time in answering questions. I directed all of my answers to the jury, asking the prosecuting attorney to repeat convoluted questions.
We were in the second week of the trial when we got a message from the prosecuting attorney indicating that he wanted to settle. The plaintiff’s offer was $250,000. During arbitration, we never offered anywhere close to six figures. It was our combined opinion that the trial was clearly going in our direction. To think that we would give them two or three times what we had offered only two months ago was either bold or an act of desperation. We rejected the offer and made no counteroffer.
Two days later, the lawyers made their closing arguments. The prosecuting attorney gave a long, point-by-point summation, which took more than three hours. He ended his argument by stating that a judgment of $3 million would be just. My attorney spoke for about 30 minutes. He pointed out that several physicians had seen this patient, and they could have called me had they believed the patient was in danger, but they did not. He pointed out that we covered the standard of care and that my partners and I had, in fact, exceeded the standard in every way. Unfortunately, we don’t know why this patient died. This outcome was a tragedy, but it was not malpractice.
The jury got their instructions the following morning before they went to deliberate. I later learned that the jury went over the highlights of the case and then voted. The first vote was 10–2 in my favor. Another vote minutes later was 11−1. One juror believed that I should have been in the hospital the whole time. They asked for expert testimony to be read. This testimony clearly stated that there is no requirement at a Level II trauma center for the trauma surgeon to stay in the hospital 24 hours a day. Instead, the trauma surgeon needs to get to the hospital within 15 minutes.3 This point was explained in detail by several of our experts, as well as having been recounted by me while on the witness stand. After about five hours, they came back with a decision. I was not guilty of malpractice, and my hospital was not negligent in hiring me. I felt a huge weight begin to lift from my shoulders.
Lessons learned
Midway through the trial, I figured out why I was sued.4 It was my fault. I had only one interaction with the family. I walked into the small family room and told them their mother was dead, and I thought she had suffered a massive heart attack. I had very little in the way of answers for the family. I felt totally unprepared. Having reviewed the chart, nothing obvious was jumping off the page. I had nothing. I made this interaction about me instead of about them. Yes, it is true that I really had nothing to say, but this death was about their mother. She was the one who had died. I needed to be less doctoral and more human. I needed to engage the family. If they were angry, I needed to embrace their anger. If they were frustrated, I needed to embrace their frustration.
One question remains: Why did this patient die? One could argue that this patient died of a myocardial infarction, although I think this is a little far-fetched. Fewer than two years earlier, the patient’s family physician worked her up for cardiac disease and found none.
More likely, this patient died as a result of an anaphylactic reaction to the IV contrast. The patient’s trouble began upon administration of the IV contrast in the CT scanner. She developed nausea and vomiting in spite of receiving steroids and antihistamines prior to her IV contrast.5 As the steroids and medication began to wear off, the patient’s blood pressure dropped. The patient’s arrhythmia in the recovery room was likely secondary to her beginning to have a full-blown anaphylactic response to the IV contrast. It has been well documented that patients can have all kinds of arrhythmias secondary to an anaphylactic reaction.6
I have fretted over this patient’s chart for many hours; I have read and re-read the details, trying to come up with a reason for this patient’s death. I think that an anaphylactic reaction is the correct diagnosis. I feel such regret that I did not make the correct diagnosis while the patient was still alive.
References
- Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (writing committee to revise the 2002 guidelines on perioperative cardiovascular evaluation for noncardiac surgery). Anesthesia & Analgesia. 2008;106(3):685-712.
- Lindstaedt M, Germing A, Lawo T, von Dryander S, Jaeger D, Muhr G, Barmeyer J. Acute and long-term clinical significance of myocardial contusion following blunt thoracic trauma: Results of a prospective study. J Trauma. 2002;52(3):479-485.
- Committee on Trauma American College of Surgeons. Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons; 2006.
- Shapiro RS, Simpson DE, Lawrence SL, Talsky AM, Sobocinski KA, Schiedermayer DL. A survey of sued and nonsued physicians and suing patients. Arch Intern Med. 1989;149(10):2190-2196.
- Cochran ST, Bomyea K, and Sayre JW. Trends in adverse events after IV administration of contrast media. AJR Am J Roentgenol. 2001;176(6):1385-1388.
- Booth BH and Patterson R. Electrocardiographic changes during human anaphylaxis. JAMA. 1970;211(4):627-631.
