Failure to timely treat obstructed/ruptured bowel

The case below involved the doctor’s failure to timely treat obstructed/ruptured bowel.  It was tragic and resulted in the patient’s death.  We represented his family in a wrongful death and survival action.

SUMMARY OF ARGUMENT

On or about August 18, 2005 Mr. R was seen at the Cenla Family Clinic for complaints of abdominal pain, constipation and no bowel movement for several days.  The doctor there, noting that Mr. R’s abdomen was distended and tender to exam, suspected obstruction and made arrangements to rush Mr. R to the Christus St. Frances Cabrini Hospital via ambulance.

After arriving at Cabrini and noting the aforementioned symptoms, a CT scan of Mr. R’s abdomen and pelvis revealed a diffuse intestinal ileus complicated by fecal impaction, a massively distended bladder, with a dilated bladder extending out to the pelvis and lying within the right lower quadrant of the abdomen; small volume of free fluid layering anterior to the liver and within the right subhepatic space; minimal pericolonic inflammatory stranding within the left pericolotic gutter; and numerous linear radiopacities within the dilated small and large bowel loops, suggesting recently ingested material of an uncertain etiology.  Blood work for Mr. R revealed leukocytosis in the range of 20,000.

Despite these emergent triggers, Mr. R was admitted by Dr. Mai to the care of Dr. Liu for observation and minor palliative measures.  No consultation or further workup was ordered.[1]  Mr. R was left to languish without the necessary and required emergent care for approximately sixteen (16) hours until he suffered cardiac arrest caused by septic shock secondary to a necrotic bowel.

Despite the heroic efforts of Dr. Wayne Honeycutt and Dr. James Parish, Mr. R passed away thirty-three (33) hours after presentation to the emergency room on August 19, 2005.

The cause of death according to Dr. Honeycutt was septic shock, ARDS, and refractory hypoxemia.

The bottom line:  Drs. Mai and Liu and the staff of Cabrini Hospital failed to render appropriate care to Ivry R in the sixteen hours between his initial admit to the emergency room and his first cardiac event.

ISSUES PRESENTED TO THIS PANEL

1. Should Drs. Mai and Liu have ordered an expert consultation?

2. Should Drs. Mai and Liu have ordered further testing and treatment? and

3. Did the defendants’ substandard care cause Mr. R’s death, or in the alternative, did the substandard care cause the loss of a chance of survival?

RELEVANT HISTORY AND EVENTS

Prior to August 18, 2005 the deceased was a 47-year-old male living at the Westside Habilitation Center in Cheneyville, Louisiana.  He had lived there since 1984.  Plaintiffs have attached as Exhibit “1” a copy of Westside’s Social Service Termination Summary for Mr. R which will give this panel sufficient background information.

On the morning of August 16, 2005, Mr. R was taken by Westside employees to the Cenla Family Medical Center with complaints of constipation and abdominal pain.  A copy of the Cenla Family Medical Center records are attached herewith as Exhibit “2”.  He saw Dr. Slaughter who noted that Mr. R reported he had not had a bowel movement for several days.  His abdomen was distended and tender.  The doctor, fearing obstruction, and recognizing the emergent situation, had Mr. R transported via ambulance to the Christus St. Frances Cabrini Hospital.

Upon presentation to the Cabrini emergency room, Mr. R was seen by Dr. Stuart Yoas.  A copy of an excerpt from the emergency room record with Dr. Yoas’s findings is attached herewith as Exhibit “3”.  Significant findings as charted by Dr. Yoas were that Mr. R’s abdomen was tender and that there were no bowel sounds.  His differential diagnosis included pancreatitis, appendicitis, PUD, bowel obstruction, diverticulitis and abdominal pain – etiology unknown.  He ordered a CBC, chemistries and a liver profile as well as abdominal x-rays and a CT.  The record reveals that Dr. Yoas saw Mr. R at 1330 hrs., August 18, 2005.

Attached herewith as Exhibit “4” are the PA and lateral chest x-ray as well as the abdominal x-ray initially ordered by Dr. Yoas.  These were performed August 18, 2005 at 1325 hrs.  The PA and lateral examination of the chest demonstrated no radiograph evidence of cardiopulmonary disease.  The lung volumes were low, the heart was in normal limits for its size.  The radiologist’s impression for this study was a negative hypoinflated PA and lateral chest x-ray.  He did, however, note “distended bowel loops within the upper abdomen warrant dedicated imaging with abdominal plain films.”

The abdominal plain film series demonstrated a “copious volume of stool throughout the colon” and that the “length of the large bowel was dilated, with large bowel loops measuring up to 8 centimeter in maximum width.”  It further noted “stool is present within the colon from the cecum through the rectum” and that “gas is present within small bowel loops” with  “no free air is identified.”  The radiologist’s impression was that of “Large volume of stool throughout the entirety of the colon, with a radiographic appearance suggesting fecal impaction.  Large bowel loops are moderately dilated, measuring up to 8 centimeter in width.”

The abdominal and pelvis CT ordered by Dr. Yoas was performed at 1545 hrs. 8/18/05.  A copy of that study is attached herewith as Exhibit “5”.  This is a key piece of evidence this panel should take the time to study personally.  The radiologist’s findings were many.  His impression included,

“1. Copious stool throughout the right, transverse, and left colon, with marked dilatation of large bowel loops and moderately dilated, fluid filled small bowel loops.  Radiographic findings are most consistent with a diffuse intestinal ileus, complicated by fecal impaction.

2. Massively distended bladder, with the dilated bladder extending out to the pelvis and lying within the right lower quadrant of the abdomen.

3. Small volume of free fluid layering anterior to the liver and within the right subhepatic space.

4. Minimal pericolonic inflammatory stranding within the left pericolic gutter.

5. Numerous linear radiopacities within the dilated small and large bowel loops, suggesting recently ingested material of an uncertain etiology.”

The CT report (Ex. “5”), indicates that the results were typed at 1820 hrs. 8/18/05.  Cabrini’s medical records indicate that Dr. Mai admitted Mr. R at 1855 hrs. to Dr. Liu as attending.  Dr. Mai’s History & Physical is attached herewith as Exhibit “6”.  This report was apparently not dictated until September 27, 2005, five weeks after Mr. R’s death.  Dr. Mai notes that Mr. R was admitted to Cabrini “in observation” after his workup in the emergency room showed he had a case of fecal impaction and leukocytosis in the range of 20,000.[2]

Attached as Exhibit “7” are the emergency room nurses’ notes.  These notes span from the time of the initial assessment/triage at 1252 hrs. 8/18/05 to Mr. R’s discharge to the floor under Liu and Mai’s care at 2119 hrs. 8/18/05.  Mr. R was manually disimpacted at 1612 hrs. 8/18/05 and large hard clumps of stool were removed.

There is no mention in these notes of Mr. R being seen by either Drs. Mai or Liu during this time period.

Mr. R was not seen by any doctor between the time he was admitted to the floor (1855 hrs. 8/18/05) and the time of his first code (0452 hrs. 8/19/05), ten hours.  The code was witnessed by RN Janice Skinner.  Mr. R had no breath sounds and a heart rate of 96.  An Ambu bag was initiated.  Dr. Honeycutt was called and arrived moments later.  His Cardiac Arrest Note/Procedural Report is attached herewith as Exhibit “8”.[3]  Dr. Honeycutt’s report states that the nurses gave Mr. R an amp of bicarb after he was noted to be hypoglycemic but he also had a large volume of emesis and agonal respirations.  His pulse was 120 to 130.  Dr. Honeycutt suctioned copious amounts of gastric secretion from his posterior pharynx and intubated him.  Post intubation the patient became progressively bradycardic and developed asystole.  He was given an amp of atropine and an amp of epinephrine both by IV and endotracheal tube and returned to spontaneous circulation with a pulse rate of 150 and palpable.  He was transferred to ICU.

The Interdisciplinary Notes from ICU are attached herewith as Exhibit “9”.

Progress Notes from the Cabrini records are attached herewith as Exhibit “10”.  These do not contain any entries by either Drs. Mai or Liu.

Attached herewith as Exhibit “11” in globo are three reports from Dr. Honeycutt noting endotracheal intubation, central venous access catheter, and arterial line placement.

The Critical Care Progress Note of Dr. Juan C. Soliven is attached herewith as Exhibit “12”.  It will provide this panel with a summary of Mr. R’s initial ICU treatment.  After his first cardiac event, Mr. R was stabilized and surgeon, Dr. James Parrish was consulted.  Dr. Parrish performed a left colectomy and transverse end colostomy.  His Operative Report is attached herewith as Exhibit “13”.  Dr. Parrish’s operation and findings revealed a gangrenous left colon.  The pathology report from Mr. R’s colon is attached as Exhibit “14”.  The results were, “. . . extensive mucosal necrosis and acute hemorrhage and purulent inflammation involving the full thickness of the bowel wall and adjacent pericolic fat, consistent with septicemia.”

Following the surgery by Dr. Parrish, Mr. R was transferred back to the ICU unit where his condition deteriorated.  The Critical Care Progress Note and Death Summary of Dr. Honeycutt is attached herewith as Exhibit “15”.  Dr. Honeycutt also prepared a Cardiac Arrest Note/Procedure Report which is attached herewith as Exhibit “16”.  Summarizing these two reports, Dr. Honeycutt explained that Mr. R went into septic shock secondary to necrotic bowel and further developed ARDS secondary to the septic shock.  He also suffered aspiration pneumonitis.  Dr. Honeycutt described that Mr. R had progressive hypoxemia in spite of full ventilatory support with high levels of PEEP, 100% FIO2 on pressure control ventilation with inability to adequately ventilate him as well.  At 2130 hrs. August 19, 2005, Mr. R developed progressive bradycardia leading to asystole.  He was treated with ACLS protocols and cardiopulmonary resuscitation.  He initially returned to spontaneous circulation but then suffered a second deterioration. Again, ACLS protocols were followed, but this time without success.  Dr. Honeycutt pronounced the patient and opined the cause of death as septic shock, ARDS, and refractory hypoxemia.  Attached herewith as Exhibit “17” is Mr. R’s death certificate noting the immediate cause of death as septic shock and ARDS secondary to a gangrenous colon.

Attached herewith as Exhibit “18” are the Physician’s Orders from the Cabrini medical records.  These reveal that after the initial admit at 1855 hrs. 8/18/05 by Dr. Mai there are no other orders given until Dr. Honeycutt’s involvement at 0540 hrs. 8/19/05.  A full summary of the Cabrini medical chart is attached herewith as Exhibit “19”.

SUBSTANDARD CARE

Sixteen hours.  Mr. R languished at Cabrini Hospital for sixteen hours with little or no curative care given until his first cardiac arrest at 0500 hrs. August 19, 2005.  Dr. Slaughter at the Cenla Family Medical Center recognized the emergent situation and thought it serious enough to have Mr. R rushed via ambulance to the hospital.  Mr. R arrived at the Cabrini emergency room a little after 1200 hrs. August 18, 2005.  He came under the care of the ER physician, Dr. Yoas who ordered the necessary tests and confirmed that Mr. R was very sick and in need of hospitalization.  The tests ordered included both x-rays and CT confirming fecal impaction with a massive distended bladder and large bowel loops suggesting recently ingested material of uncertain etiology.[4]  Blood work ordered by Dr. Yoas, showed leukocytosis of 20,000 plus.

Despite these significant findings, these emergent triggers, after Dr. Yoas handed Mr. R off to Drs. Mai and Liu for all practical purposes, treatment stopped.  Dr. Mai’s initial orders (phoned in) were Colace, MOM and observation.  Given the severity of Mr. R’s findings did Drs. Mai and Liu truly believe that Mr. Rebert would improve with a stool softener, an over-the-counter laxative and time?

Neither Drs. Mai nor Liu ever came to the hospital to see Mr. R in that critical time period.  They never ordered a consult.  No surgery was scheduled.  No further tests were conducted.  No medications were given save those mentioned above and Mr. R’s regular prescriptions.

The progress note of Dr. Honeycutt (Ex. “10”), speaks volumes:

“8/19/05 Admitted to Dr. Liu – 47 yo Caucasian, a resident of the Westside Rehab Center – patient of Dr. Slaughter – now admitted to Cabrini in observation after w/u showed he has colon

1. Fecal impaction

2. Leukocytosis (20 K)”[5]

Obviously, Dr. Honeycutt felt strongly enough about the mismanagement of Mr. R’s case to underline and therefore emphasize “in observation”.

This panel need only ask itself:  Would you, putting yourself in the place of Drs. Mai and Liu, have acted more aggressively under the circumstances?  Would you have made a trip to the hospital, even though it was ten o’clock at night, to see the patient given these symptoms?  Would you have at least ordered an expert consultation?  Should the nursing staff, given the seriousness of the situation, done more to relay this information to Drs. Mai and Liu or to any doctor?

DAMAGES

Had proper treatment been rendered, Mr. R’s death more probably than not would have been prevented.  The defendants’ negligence was therefore the legal cause of death.

However, if this panel believes that Mr. R’s death was not preventable even with full intervention by the defendants, plaintiffs would show there are still damages suffered for the lost chance of survival.  Our law recognizes the lost chance of survival as a compensational injury in medical malpractice cases.  An example is a patient with terminal cancer.  If that patient is the victim of malpractice which further hastens death or decreases the patient’s life expectancy, our law says the patient has lost a chance of survival.  That lost chance is a damage, an injury, and it will be up to a judge or jury to place a dollar amount on that damage.

DO THE RIGHT THING

Plaintiffs have spent time and money gathering the medical records in this case, having them reviewed by a nurse consultant, and discussing the facts with a consulting expert physician.  We are confident that this is a clear case of neglect which will stand up in any court of law.

Without wishing to sound threatening or disrespectful, the truth is that many medical review panelists are too quick to dismiss a defendant doctor’s negligence.  Plaintiffs would point out that it is the job of this panel to review these facts in an unbiased manner and it is not your job to find excuses for the defendants’ substandard care.

The undersigned counsel has been involved with many, many review panels and has many friends who are physicians.  Through this experience it is clear that many panelists avoid ruling in favor of the plaintiff in the mistaken belief that this will somehow keep down their insurance premiums.  In fact, the opposite is true.  When a panel rules against a plaintiff who ultimately prevails at court, the end result is that the panel has succeeded only in driving up the costs of defense for the insurance company.  These increased costs of defense are then passed on to you, the policyholder.

If you are going to rule against the plaintiffs, then you should be prepared to testify at deposition and court as to the  basis for your opinion.  This statement is not meant as a threat and is borne out of the undersigned counsel’s frustration with several previously handled medical malpractice cases.  In two recent cases, the panel doctors in those cases ruled against the plaintiffs.  Plaintiffs proceeded with their lawsuits and took the depositions of the panel doctors.  At deposition, all the doctors, when forced to take an honest look at the facts and circumstances of the case and to do that under oath, with their own reputations on the line, changed their opinions.  They reversed themselves.  The end result, therefore, was that the insurance company and PCF settled with the plaintiffs.  Unfortunately, thousands of dollars were wasted in continuing to prosecute the case because the doctors did not do the right thing at the panel phase.  Whether they hoped they could help a friend/colleague or they just didn’t like plaintiffs and their lawyers, their refusal to render the proper decision at the panel phase cost the insurance company more money.  Again, the irony as mentioned above, is that the higher cost of defense is passed on to you, the policyholder.  What was obvious in all of those depositions was that the doctors never anticipated that they would have to go on the record and defend their opinions.

The plaintiffs are not alleging that the defendants intentionally attempted to harm Mr. R.  However, the overwhelming evidence suggests that their actions, or in this case their inaction, did cause harm.  The defendants made a mistake.  We all make them.  It does not mean the defendants are bad people, bad doctors or bad nurses.  They made a mistake which cost Mr. R his life and justice demands that they be held accountable.

RESPECTFULLY SUBMITTED,

GUILLIOT & ST. PÉ, LLC

________________________________

KENNETH D. ST. PÉ

La. Bar Roll No. 22638

428 Jefferson Street

P.O. Box 2877

Lafayette, Louisiana 70502

(337) 232-8177