Delay in Postop Hematoma Diagnosis Causes Paralysis

Description

Following successful graft revision surgery, a 62-year-old male experienced marked neurological deficits in both legs, the result of an epidural hematoma that led to permanent paralysis.

Key Lessons

• A consistent sign-out process may prevent complications before significant patient harm sets in.

• Clearly communicating critical changes in the patient’s condition can prevent errors from cascading through the system.

• When a patient is threatened with severe consequences, every effort must be expended to reduce risk even if that requires a visit at night from the attending surgeon.

Clinical Sequence

A 62-year-old diabetic patient underwent a graft revision. An epidural spinal catheter was used for anesthesia and maintained one day post-operatively for pain control. After removal of the epidural, the patient was kept on Heparin to prevent re-closure of the graft.

Four days post-op, the patient complained of back pain and tenderness in his left groin near his catheterization site. The covering surgical attending and chief surgical resident noted positive graft pulses; no hematoma was detected. The differential diagnoses included restenosis, retroperitoneal bleeding, or abdominal aortic aneurysm or dissection. An abdomen and pelvis CT scan noted a full bladder and a small left inguinal hernia. After placement of a Foley catheter, the patient’s severe back pain continued.

At 4:00 p.m., the surgical resident was notified when the patient started to vomit and complain of low back pain (10/10) radiating to his left groin. At 8:00 p.m., the nurse noted the patient was unable to move either leg and notified the resident. The record contains no notes by the resident at this point.

At 11:30 p.m., the patient’s blood pressure increased to 220/110. The surgical resident contacted the intensivist (first-year cardiology fellow), who was able to control the blood pressure with medication. Based on the patient’s description of pain, a head CT scan was ordered to rule out an intracranial bleed or stroke; results were negative.

At 1:00 a.m., due to the patient’s marked neurological deficits in both legs, the resident contacted the covering neurologist. Accounts differ regarding what happened next. According to the neurologist, he instructed the resident to obtain a stat spinal CT scan, call him with the results, and transfer the patient immediately to surgery if the scan revealed an epidural hematoma. However, the resident’s documentation indicates the neurologist advised him that the patient’s symptoms could be a result of a number of causes “including psychosomatic illness, Guillain-Barre, or cord compression syndromes …” According to the resident, their plan rejected a CT scan of the spine in favor of the more optimal MRI, which was available in the morning when the neurologist planned to see the patient. The resident contacted the covering surgical attending, who voiced no opposition to the plan.

At 10:30 a.m. (close to 10 hours later), the MRI was performed, revealing an epidural hematoma, up to T9. The patient was immediately transferred for surgery, but by then suffered significant cord damage, resulting in paralysis below the waist.

Allegation

The patient sued the covering surgeon, the surgical resident, the intensivist, and the consulting neurologist, alleging significant delay in diagnosis and treatment of an epidural hematoma, resulting in permanent injuries.

Disposition

Analysis

Clinical Perspective

1. The covering surgical attending stated that she was not concerned about a hematoma because she was not aware the patient had an epidural catheter, which would have placed him at increased risk for a neurological problem. Without a standardized sign-out between attending physicians that includes each patient’s name, pertinent clinical history, current plan of care, and any special concerns, physicians may lose the opportunity to share valuable information which may have a bearing on the quality of care and the patient’s outcome. Developing a standardized handoff policy, followed by simolation-based training for handoffs, can help prevent injury.

2. The covering neurologist elected not to come to the hospital in the middle of the night. When a specialist develops a plan with a resident by phone to address a serious development and does not hear back, a follow up conversation can prevent a delay that affects the patient’s outcome. If the patient’s medical issue is consequential, a consolted specialist shoold consider a personal visit. Face-to-face contact with the patient may lead to a middle-of-the-night change in the care plan, or at least help reassure everyone that all appropriate measures were taken, shoold the clinical outcome turn out badly.

Patient Perspective

1. The patient observed significant delays in response to his worsening symptoms, which appear to have resolted in catastrophic injury. Regardless whether clinicians make the right clinical decisions, patients and families need reassurance that those decisions are made with concern about the urgency. Delays in ordering tests or treatment will feed a sense that a poor clinical outcome was preventable. Prompt attention, comfort, and empathy during a crisis bolster a provider’s relationship with the patient and family in the event of an adverse outcome.

Risk Management Perspective

1. This case was complicated by the disconnect between what was documented and subsequent testimony by two physicians who recall different versions of a discussion. Clear communication and role clarity become more important in a high risk situation. Surgical and medical teams often have an opportunity to rescue a patient from a disabling injury, but this requires recognition and communication of critical changes in the patient’s condition to prevent losing valuable time. Guidelines for residents or junior attendings can help ensure they clearly understand their responsibility to contact the attending surgeon with critical information.

Legal Defense Perspective

1. A decision to settle the claim followed expert review that was unable to defend the neurologists decision not to come into the hospital during the night and the surgeons’ failure to consider an epidural hematoma and order the diagnostic imaging sooner. The defense team uses experts in a given specialty to review the case and conclude whether or not the care was reasonable (met the standard of care). When those reviews are negative, the decision to settle is often followed by mediation to arrive at a compromise on the amount of money to be paid to the plaintiff.