A woman in her 30s presented to a freestanding ED at 10am with severe right side abdominal pain.
Pelvic ultrasound demonstrated a right ovarian torsion and 8 cm ovarian cyst.
She had a history of left-side ovarian torsion 10 years previously and had an oophorectomy in Jordan prior to immigrating to the US.
The ED physician called the on-call OBGYN (Dr. S) at a nearby medical center, and the patient was accepted for transfer to their ED.
The patient arrived at 11:15am.
The ED physician at the receiving hospital paged Dr. S to let him know the patient was there.
Dr. S called back at 12:02pm and said his resident would be down to evaluate the patient.
At 2:05pm an OBGYN resident was noted to be at the bedside, and the plan was to take her to the OR.
The patient would later claim that she requested no residents participate in her surgery, and that it be done as an open procedure, not laparoscopic.
She had a good experience with minimal scarring from the previous (open) oophorectomy.
At 3:06pm the ED doctor spoke with the OB again to advise that her pain was worsening and to “potentially get her to surgery sooner”.
A laparoscopic salpingo-oopherectomy was begun at 4:19pm by Dr. S and Dr. A (OBGYN resident).
The patient later claimed that Dr. S said he would likely be able to salvage the ovary, but during the procedure it was noted to be necrotic and was removed.
Unfortunately, extensive bleeding occurred.
The case was converted to an open procedure, and another OBGYN came to assist.
A left iliac artery laceration was noted, felt to be from the trocar.
Vascular surgery was consulted and stented the artery.
She was given 3u of whole blood and 1u plasma during the surgery.
Become a better doctor by reviewing malpractice cases.
Paying subscribers get a new case every week.
The following day, she was noted to have a cool and painful left foot.
A different OBGYN resident (Dr. L) saw the patient and called vascular surgery.
Extensive arterial thrombus was noted in the left leg, requiring intra-arterial thrombolysis.
She now suffers chronic left leg pain and disability.
A lawsuit was filed against the OBGYN attending (Dr. S), resident (Dr. A), and the hospital.
During her deposition, the patient and her husband (Mr. P) made various allegations that sensitive exams were done without consent and in a manner that felt inappropriate.
The defense filed a motion to prevent mention of this at trial.
Learn from bad outcomes to help avoid them yourself.
CME subscriptions available.
The patient was upset by the perceived inappropriate exams, delays in getting to surgery, and vascular complications.
She attempted to contact the doctor in Jordan who had done the initial oophorectomy 10 years prior, hoping that he could somehow help the situation.
The patient and her husband reported that a hospital case manager made racist remarks about their attempts to communicate with the doctor in Jordan.
The patient had undergone a previous elective abortion.
Her attorney was worried that the defense would use this to diminish her claim of lost fertility.
He filed a motion to prevent mention of her previous abortion in front of the jury.
A confidential settlement was reached and the lawsuit was withdrawn prior to trial.
MedMalReviewer Analysis:
It’s pretty hard to defend a >4 hour delay to surgery, especially during daytime hours. Getting OR time seems to be a constant source of bickering among surgeons and causes a lot of stress in many hospitals. It’s not clear if Dr. S was trying to get her to the OR as fast as possible but was blocked by factors outside of his control, or if he was flippant and didn’t proceed with the urgency he should have. The fact that it took 2 hours for anyone from OBGYN to even seen the patient, in addition to the fact that the defense never offered any explanation for this delay, seems to imply that there was no justification for the delays. The fact that the patient only had one ovary should have increased the degree of urgency beyond a standard torsion case. For a specialty that is accustomed to emergency surgeries and is responsible for preserving fertility in cases like this, it’s hard to explain the lethargic response.
It seems that the patient’s poor experience was influenced by cultural and religious concerns. The court documents note that her Muslim faith was important to her. It’s hard to know if her complaints about sensitive exams were communicated in real time or if her poor outcome tainted her memory of these issues in hindsight. Regardless, this case is an important reminder to be sensitive about these issues, explain their importance to patients, and to use chaperones.
When I first read that the patient claimed she refused a laparoscopic procedure, I found it hard to believe. I’ve never heard of a patient asking for an open procedure, especially a young woman who wants an optimal cosmetic outcome. However, learning that she had an open oophorectomy in Jordan and was happy with the outcome makes this request slightly more plausible. Despite our medical understanding of why a laparoscopic procedure would be preferable, she may have simply been scared about trying something different when she was satisfied with the previous approach. Alternatively, this claim may have been a post hoc fabrication in order to argue that she never would have had a trocar injury to the left iliac if the OBGYN had honored her request. Simply reviewing the signed informed consent could clarify this, but the case settled before the topic was fully argued and the court records are silent about this issue.
The resident was dropped from the lawsuit when the hospital settled. Residents should not be named in lawsuits outside of extremely unusual circumstances. Holding trainees responsible for the actions of their attendings is morally wrong, and I would like to see legislation passed to protect learners by default.
The delay in operative care stands out significantly here, especially in a woman with only one ovary. I have to say that I am pleasantly surprised that the receiving hospital ED physician wasn't roped into this. I wonder if that one-liner about them re-contacting OB "to get them to surgery sooner" they threw in the chart was enough to get them off the hook. One common thread I see in many of these cases is the plaintiff accusation of "failure to reassess/re-examine" The new "ED Course" area in Epic makes little tidbits like this easy to drop in without fully opening the chart. I use this liberally, as a result. Brief statements that show you're constantly thinking about the pt and involved in their care. Seems to have saved the ED doc here.
Also another reminder of the importance of chaperones for any sensitive exam.
The whole bit about wanting to have her records sent to her outside OB in Jordan is really strange. I can imagine the exact case manager stereotype that seemed bewildered by this odd request, and how the racial undertones would have permeated that conversation.
One of the themes that stands out to me is the patient’s discomfort with residents. Often surgical services at academic hospitals (including OB/GYN) are not staffed to function without residents. (It’s impossible to do our surgeries without a trained assist... let alone for an emergency case...)
I tend to be sympathetic about multiple pelvic exams. But I thought the way the patient described her postop exams was surprising. Typically I won’t do anything more than visualize the abdominal incisions and a basic abdominal exam after this kind of surgery. It just made me wonder whether there were multiple residents performing medically unnecessary and violating vaginal exams postop… or if the fact that multiple people came into her room each day in a teaching hospital itself was upsetting...