This obviously is a very sad case, and I doubt that you can have a 15 min cardiac arrest without at least some permanent consequences. However, I don't think the surgeon did anything wrong. I'm an ER doc, I see heart failure all the time, and I would not think of CHF as in my differential for RUQ pain. I guess going forward if I see pleural effusion and or body wall edema reported on a young patient I wouldn't expect to have those findings, I'll add on a proBNP and a trop. But I don't blame the general surgeon at all, although I guess cases like this are probably part of the reason that the majority of surgeons at my hospital never want to admit their own patients.
It's extra difficult as only the outside CT commented on body wall edema and pleural infusion, no one had access to this CT. The in house CT didn't mention it and body wall edema is not something that most people are going to recognize.
No mention of the patient's BMI or comorbidities but severe dilated cardiomyopathy with an essentially normal EKG and mild cardiomegaly on CT is such a zebra. I mean would we be doing a preop echo on every fat 30 year old. No way.
Also the plaintiff's general surgeon suggesting they should have converted to open is ridiculous. This is essentially an elective procedure and the patient is not tolerating insufflation with anesthesia. At that point I would cancel the case and get a preoperative workup for next time.
It just goes to show how critical EMR interoperability is, too. If that external CT had been more accessible or even available within the chart to the physician, and that was a regular standard that physicians could depend on having, it would be a whole different ball game. The constant pressure between running too many tests on patients who don't need them to potentially higher costs versus missing a diagnosis; it's an impossible position.
It seems like there's been some small progress with EMR interoperability, but they do so in the most malicious way possible. I can find some data from outside hospitals but its presented in such an incredibly jumbled and confusing format, with extremely poor user interface, that its basically unusable.
Yeah, converting to open would’ve only made things worse. The general surgeon did the right thing by stopping the case. I’m guessing the surgeon settled since the patient was so young that might have made the jury very sympathetic to her.
The only clue the surgeon had was a pleural effusion on the biliary US. It seems fairly minor, but I can't think of a benign reason someone in their 30s would have a pleural effusion. Extreme obesity shouldn't cause a pleural effusion. If the surgeon had the triad of cardiomegaly, body wall edema, pleural effusion, I would have higher expectations for him to realize something else was up. But he didn't, so I don't think he was negligent.
I will never forget the middle aged black male who presented to our VA Hospital w/ intractable N/V several hours after eating some raw oysters that he said he knew were tainted, but ate them anyway. I could never get him settled down and admitted him for further stabilization. He arrested in radiology getting a chest xray. Cause of death: acute inferior MI. He never had anything to suggest pre-existing or acute CV illness, other than the N/V. I've beat myself up over this for 45 yr. Went into GI and never had another similar experience.
I didn’t see lft’s mentioned. Also was she tender in ruq? There was no evidence for acute cholecystitis that required urgent surgery. Unfortunately, saying you were not aware of previous CT’s is not a good excuse.
LFTs unfortunately weren't mentioned in the legal documents anywhere. I'm sure the experts and attorneys had access to them, but they just didnt make it into the public documents. There was mention of RUQ pain at various points, but she also had pain in other areas including the lower abdomen at times so it doesn't seem like the exam was classic.
“otherwise healthy, albeit morbidly obese" - seems like an oxymoron - class III obesity is extremely unhealthy, including ongoing deficits of cardiac reserve, and is certainly risky in terms of anesthesia and surgery
This was a softly indicated procedure, and they persisted after not just one episode of hypotension and desaturation, but after multiple episodes....
that is absolutely not true, as evidenced by bariatric surgery having one of the lowest complication/morbidity profiles of any modern GI surgical procedure.
I think thats a reasonable guess but no one knows for sure, which is one of the frustrating things about writing up these cases. Every now and then an attorney accidentally includes the amount in a public document but its pretty rare.
This obviously is a very sad case, and I doubt that you can have a 15 min cardiac arrest without at least some permanent consequences. However, I don't think the surgeon did anything wrong. I'm an ER doc, I see heart failure all the time, and I would not think of CHF as in my differential for RUQ pain. I guess going forward if I see pleural effusion and or body wall edema reported on a young patient I wouldn't expect to have those findings, I'll add on a proBNP and a trop. But I don't blame the general surgeon at all, although I guess cases like this are probably part of the reason that the majority of surgeons at my hospital never want to admit their own patients.
It's extra difficult as only the outside CT commented on body wall edema and pleural infusion, no one had access to this CT. The in house CT didn't mention it and body wall edema is not something that most people are going to recognize.
No mention of the patient's BMI or comorbidities but severe dilated cardiomyopathy with an essentially normal EKG and mild cardiomegaly on CT is such a zebra. I mean would we be doing a preop echo on every fat 30 year old. No way.
Also the plaintiff's general surgeon suggesting they should have converted to open is ridiculous. This is essentially an elective procedure and the patient is not tolerating insufflation with anesthesia. At that point I would cancel the case and get a preoperative workup for next time.
It just goes to show how critical EMR interoperability is, too. If that external CT had been more accessible or even available within the chart to the physician, and that was a regular standard that physicians could depend on having, it would be a whole different ball game. The constant pressure between running too many tests on patients who don't need them to potentially higher costs versus missing a diagnosis; it's an impossible position.
It seems like there's been some small progress with EMR interoperability, but they do so in the most malicious way possible. I can find some data from outside hospitals but its presented in such an incredibly jumbled and confusing format, with extremely poor user interface, that its basically unusable.
Yeah, converting to open would’ve only made things worse. The general surgeon did the right thing by stopping the case. I’m guessing the surgeon settled since the patient was so young that might have made the jury very sympathetic to her.
The only clue the surgeon had was a pleural effusion on the biliary US. It seems fairly minor, but I can't think of a benign reason someone in their 30s would have a pleural effusion. Extreme obesity shouldn't cause a pleural effusion. If the surgeon had the triad of cardiomegaly, body wall edema, pleural effusion, I would have higher expectations for him to realize something else was up. But he didn't, so I don't think he was negligent.
I will never forget the middle aged black male who presented to our VA Hospital w/ intractable N/V several hours after eating some raw oysters that he said he knew were tainted, but ate them anyway. I could never get him settled down and admitted him for further stabilization. He arrested in radiology getting a chest xray. Cause of death: acute inferior MI. He never had anything to suggest pre-existing or acute CV illness, other than the N/V. I've beat myself up over this for 45 yr. Went into GI and never had another similar experience.
Sad case, sometimes its nearly impossible to catch an MI with such atypical symptoms.
I didn’t see lft’s mentioned. Also was she tender in ruq? There was no evidence for acute cholecystitis that required urgent surgery. Unfortunately, saying you were not aware of previous CT’s is not a good excuse.
LFTs unfortunately weren't mentioned in the legal documents anywhere. I'm sure the experts and attorneys had access to them, but they just didnt make it into the public documents. There was mention of RUQ pain at various points, but she also had pain in other areas including the lower abdomen at times so it doesn't seem like the exam was classic.
white blood cell count on July 6' was 17,000 and her amylase, lipase, LFT's were all
normal.
Ah yes, you are correct. I had forgotten about that. Thanks!
“otherwise healthy, albeit morbidly obese" - seems like an oxymoron - class III obesity is extremely unhealthy, including ongoing deficits of cardiac reserve, and is certainly risky in terms of anesthesia and surgery
This was a softly indicated procedure, and they persisted after not just one episode of hypotension and desaturation, but after multiple episodes....
that is absolutely not true, as evidenced by bariatric surgery having one of the lowest complication/morbidity profiles of any modern GI surgical procedure.
Wonder how much the settlement was, I suspect it may have been on the lower end by comparison to some of the other cases on here.
I think thats a reasonable guess but no one knows for sure, which is one of the frustrating things about writing up these cases. Every now and then an attorney accidentally includes the amount in a public document but its pretty rare.