Hemorrhagic Shock from Biopsy
A woman in her 30s presented to the ED with shortness of breath and hypoxia.
She had antiphospholipid syndrome, prior DVTs and Raynaud’s disease.
Her med list included warfarin.
PE and DVT workup in the ED was negative.
She was admitted to the hospital.
In the hospital she was seen by a rheumatologist and nephrologist.
She was diagnosed with lupus nephritis, and a kidney biopsy was ordered to help differentiate between class 2 and class 3 lupus nephritis.
Due to the patient’s complicated anticoagulation situation, a hematologist was also consulted.
Her warfarin was switched to a heparin drip to help facilitate holding anticoagulation prior to the biopsy.
A CT-guided left kidney biopsy was completed by an interventional radiologist without any acute issues.
Anti-Xa levels were ordered to help monitor her complicated anticoagulation status.
The hospital did not have the capability to run anti-Xa levels, and they were sent about 10 miles away to a larger hospital.
Lovenox administration continued for several days, during which time none of the Xa levels resulted.
3 days after the biopsy, she started to have left flank pain.
She developed hypotension and tachycardia.
A CT scan was ordered, showing a subcapsular left renal hematoma.
She was taken back to IR for embolization.
Her vitals continued to worsen, and she was transferred to the ICU.
After she was in the ICU, the past 3 days of anti-Xa labs came back and were all critically elevated.
She was given blood transfusions, her anticoagulation was reversed (court documents do not state the method of reversal), and started on Levophed and Vasopressin.
She developed severe ischemia of her fingers.
Ultimately, she had amputations of all of her fingers except her right thumb.
Her left kidney also had to be removed.
Join thousands of attorneys and doctors on the email list.
Free to join, paid options available for those who want to expand their expertise.
A lawsuit was filed against numerous doctors and the hospital itself.
Expert opinions were obtained from a hospitalist, nephrologist, and a hematologist.
All of the expert witness opinions have the exact same text, word-for-word, with only minor changes to reflect the expert’s specialty.
Each of the physicians were offered $1,000,000 to settle.
The hospital’s offer is shown below:
The defense hired a hematologist:
The case is ongoing, I will update readers by email as new developments occur.
"I always enjoy reading these and find them applicable to my practice as a hospitalist."
"Thanks for all the work you do in putting these together. Always so interesting to look at cases and see how things unfold. The cases also make great teaching points for the residents on rounds."
- Dr. Emily Rushing
MedMalReviewer Analysis:
The lawyers and expert witnesses missed a big opportunity for criticism here. The treatment for hemorrhagic shock is transfusion. Vasopressors are often used in practice, but in theory have no role in the treatment of hemorrhage. They could have easily named the intensivists in this lawsuit.
What is fair compensation for losing all of your digits except a thumb? The physicians should definitely settle this case within the limits of their liability insurance. This case will be easy for the laypeople of a jury to understand and I expect them to be very sympathetic.
I think the patient will likely end up with a few million dollars, minus the 30-60% fees (plus expenses) that her attorneys will charge.
Previous Cases
Gentamicin Toxicity [Subscribers Only]
Synopsis: 18-year-old with Crohn’s disease has abscesses and a fistula. She is started on home gentamicin but a failure to monitor leads to ototoxic and nephrotoxic effects.
Synopsis: Patient seen by many clinicians including a naturopathic provider for her depression, ultimately commits suicide.
Headache and Vomiting [Subscribers Only]
Synopsis: Patient complains of headache, vomiting, bulging eyes. He is tachycardic, febrile and hypotensive at multiple points over 10 days in prison, but refused transport. He is ultimately transported to an ER where an LP is done before a head CT.
Another unbelievably sad case and in this situation how does one truly place a value on this patient's loss? Thanks again for these excellent cases.