Missed Complication

Description

Key Lessons

What communication improvements might prevent similaradverse outcomes?

• Generate a complete differential diagnosis; if a patient’s case takes an unexpected turn, step back and re-think the initial assumptions.
• Explore and address any cultural barriers to asking for help.
• Clarify the lines of communication and responsibility between residents and senior staff.
• Consider communication protocols around handoffs, e.g., a standardized checklist.
• Encourage staff to go up the chain of command if questions are not answered.

Clinical Sequence

A 47-year-old underwent surgical repair of his herniatedleft L4-L5 disk. The staff neurosurgeon scheduled theoperation and was on-hand during the initial positioning.The surgery was performed by the chief neurosurgicalresident who had done approximately 100 of these procedures.Near the end, the staff neurosurgeon returned toinspect the site and removed a small disk fragment.Post-operatively, the patient’s blood pressure initiallydropped to 90/30 (40 points below his pre-operativesystolic reading) and his heart rate increased. The chiefneurosurgery resident saw the patient and ordered extrafluids. The patient’s systolic pressure came up to 100;soon after, the chief neurosurgery resident went off dutyand an anesthesia resident assumed responsibility. Threetimes, nurses informed the anesthesia resident of thepatient’s persistent low blood pressure. No further diagnostictesting was performed and he was not examined. At8:30 p.m., the anesthesia resident decided to transfer thepatient to the floor. Upon arrival to the floor, the patient’sblood pressure was 86/43. At 10:00 p.m., he was givenPercocet for relief of abdominal pain. No other record ofhis vitals signs was made until 10:40 p.m.

At that time, the patient again became unresponsive whenhis systolic blood pressure dipped below 60. After the firstevent, fluids and oxygen helped, but a second event wasfollowed by progressive respiratory decline leading toapnea—at which point a code was called. At that time, hishematocrit was 14.

The patient was transferred to the medical intensive careunit. His abdomen was distended; an emergency thoracotomywas done and the aorta clamped. He was taken tothe OR for a laparotomy; a large amount of blood wasfound in the peritoneal cavity and the surgeon could seethat the left iliac vein was avulsed from the inferior venacava (apparently triggered when bone fragments adheredto it were removed). After receiving massive amounts ofblood and blood products, the patient developed acoagulopathy. With no chance for his recovery, the patient’sfamily chose to discontinue life support.

Allegation

The patient’s family sued the residents and the attending surgeon alleging negligent surgery and a delay in recognizing postoperative complications.

Disposition

The case was settled in excess of $1 million.

Discussion Points

What were this patient’s expectations?

During the consent discussion, the patient was informed that the laminectomywas a simple procedure and that he would be able to return homefrom the hospital the next day. As the staff neurosurgeon did not disclosethe extent to which the neurosurgical resident would be involved in thissurgery, the patient probably expected the attending to be fully in charge.Because no provider seemed concerned about his low blood pressure orhis complaints of abdominal discomfort (the floor nurse advised him thatthe pain was probably the result of the way he was positioned on theoperating room table, gave him pain medication, and left the room) hemay well have assumed his situation was under control.

What led to the fatal outcome in this case?

A series of small events caused the adverse outcome. The patient sufferedfrom a rare vascular injury that began when the bone fragments wereremoved (using the pituitary rongeur), weakening the wall of the iliac veinwhich later developed into active bleeding. The most critical errors wereinterpreting the blood pressure as normal and not appreciating that thepotential existed that this patient was bleeding internally. In this case, thepatient was not tachycardic. To the residents, his condition did notpresent a clear indication of bleeding. Most importantly, the residentswere not expecting that disk surgery would cause trouble in the recoveryperiod—and therefore did not recognize the significance of his bloodpressure—and the need to call for help.

Where does the criticism fall most heavily in this case?

The greatest weakness in the case was the monitoring that followed this patient in the recovery room and then to the floor. The physicians did not seriously exclude a vascular injury. Missing multiple signs of trouble with his blood pressure and the loss of critical information at the handoffs meant that the patient’s underlying problem went undetected until it was too late to intervene. The missed clues and opportunities included:

• a recognized complication of the procedure (vascular injury) is a potential cause of low blood pressure
• the patient received three liters of intravenous fluid in the recovery room and his systolic pressure, which had been in the 140s prior to surgery, never rose above 100
• no one monitored the vital signs on a frequent basis
• no one ordered a hematocrit or blood gases
• no one performed an abdominal exam following the lumbar surgery
• no one re-examined the facts following repeated episodes of unresponsiveness
• neither the neurosurgery resident, the anesthesia resident, nor the nurses called for help from senior staff.