Does the fact that dural puncture occurred indicate a deviation from the standard of care?

MEDQUEST EXPERT RESPONSES

Dural punctures are frequent in performing an epidural. It is a routine consequence of needle placement and usually does not result in side effects …however, there might be a post dural puncture headache, especially in pregnant women. The other aspects of this namely seizures, and brain swelling are not expected consequences and suggest that something else is going on. What, how and why this happened obviously is conjecture and I would need to see her complete chart to get an educated sense as to what transpired. Dr. M.D. – Anesthesiologist

A dural puncture is NOT a deviation from the standard of care. It is a well-recognized complication of epidural anesthesia/analgesia. The fact that the plaintiff had brain swelling and suffers from seizures needs to be explored further. Dr R.B. – Anesthesiologist

Dural puncture during the performance of an epidural does not constitute any deviation from the standard of care – it is a known complication of the procedure.

Dr A.W. – Anesthesiologist

Is this an injury which usually does not happen absent a departure from accepted standards of care?

MEDQUEST EXPERT RESPONSES

Most definitely malpractice – totally avoidable. Dr. ML – General Surgeon

Care was not take to place the retractor in a position that avoided the lumbar roots. Dr. JF – General Surgeon

Creation of the injury is a deviation from the standard of care. Dr. DD – General Surgeon

Patient was only advised he was going to have a one level laminectomy and fusion L5-S1, but MD instead performed a two level laminectomy and fusion. The consent form did not contain any warnings about a bowel injury and the bowel is nowhere near where he was operating. Patient experienced a number of medical problems (bladder spasms, severe abdominal pain, anemia, pleuritic chest pain and atelectasis) in the post laparotomy period and was re-admitted on several occasions for post-operative wound infection fevers and anemia.

Is bowel perforation a known complication of spinal surgery and is there an informed consent issue?

MEDQUEST EXPERT RESPONSES

Vascular and intestinal injuries after lumbar surgeries are fairly well described. In general, they are defensible. The patients usually do quite well after the belly surgery with a complete recovery. There may well be an informed consent issue but likely limited damages. Dr. SS – Neurosurgeon

It is uncommon, but intestinal perforation does occur from spine surgery. It is probably not as rare as the literature indicates, as most cases do not make it into the literature. Most surgeons would not mention it in a discussion of surgical risks because of its great infrequency. Dr. JH – Neurosurgeon

I agree that there is concern if the operation was performed differently than the consent form process prepared the patient and if the complication was not discussed as a possibility in the consent form process. However, bowel injuries are well known complications of spinal surgery with interbody fusions and instrumentation with pedicle screws. Therefore, the case appears to revolve around consent. They could claim that intraoperative findings led to the extra-level being performed and that the complication is not due to poor technique since it has been described by very good centers in the literature. Dr. SB – Neurosurgeon

MEDQUEST EXPERT RESPONSES

Perforating the bowel during the procedure was below the standard of care if there was no distortion of the anatomy or extensive adhesions. Since it was recognized during the surgery, there was no significant delay in the diagnosis and treatment. Dr. DP – OBGYN

Perforating the bowel during a tubal ligation is not malpractice and was timely diagnosed. Dr. VB – OBGYN

Bowel injury is a known complication and this repair was done in a timely fashion. It was recognized during the case and repaired- that is the standard. Dr. JH – OBGYN

Laser surgery was not a viable option because patients condition was too advanced.

Issue: Did the optometrist fail to timely diagnose the glaucoma thereby impacting the outcome?

MEDQUEST EXPERT RESPONSES

Sounds like clear negligence care by the optometrist. Dr. S.H. – Optometrist

There is differing opinions as to what constitutes “advanced” glaucoma. There could also a bit of “gotcha” medicine going on with the glaucoma specialist. The phrase “without immediate treatment you will go blind” is frequently used as a scare tactic. Its difficult to acertain the severity and speed at which glaucoma is advancing without proper testing over a very long period of time. You dont have to dilate the pupil to get a good look at the optic nerve in all cases. It is standard of care to dilate if there is possible pathology present. Dr. B.L. – Optometrist

What is in question here is failure to properly diagnose and initiate treatment in a timely manner. Everything there after is up for discussion. If there were no IOP measurements taken, no visual fields done, no nerve fiber layer assessments done, than it looks likely that the optometrist in question may have a problem on his hands. This does appear to be a deviation both for lack of dilation and visual fields being performed over the years Dr. B.S. – Opthamologist

MEDQUEST EXPERT RESPONSES:

Yes this is probably a positioning injury the mechanics of which need to be detailed by reviewing all the pertinent notes in the OR record. The surgeon, anesthesiologist and nurses share responsibility for correctly placing the patient in a safe position. That being said, each team generally looks after different body parts and it is customary for the surgeon to position the legs although I have no direct evidence for what happened here. It could also potentially be from a misapplied leg restraint strap. Dr MD – Anesthesia

Positioning is a joint respomsibility of the surgical, nursing, and anesthesia care teams. If there was no pre-exisitng conditions that might pre-dispose this patient to develop nerve problems post- op there might be a case here. Dr AW – Anesthesia

Issue:

1. Do women still get pregnant even after their tubes have been tied?

2. Is there necessarily malpractice if this happens?

MEDQUEST EXPERT RESPONSES

There is no procedure that is 100% effective for sterilization. However, having stated that, I need to know what kind of tubal sterilization procedure was done to her right fallopian tube and whether there was a specimen sent to the pathology department to ensure the tube was cut. During a laparotomy there should be a portion of the tube sent to Path to verify the fallopian tube was ligated. If Path report indicated portion of fallopian tube present then there was absolutely no malpractice. Dr VB- OBGYN

Tubal ligation as a failure rate of approx 1%. A failure reflects malpractice only if the ligation procedure is done improperly. DrDP – OBGYN

Women do pregnant after tubal ligation, which is called a failure. The stated failure rate is 5 per 1000 cases (every year). It is not malpractice if it happens. Dr JH – OBGYN

Indeed, this can happen 1/500 times. This is a known risk and not in and of itself, malpractice. Dr FB – OBGYN

DVT FOLLOWING ANKLE SURGERY

49 yo male suffered bilateral heel injuries in a work-related accident on 1/20. Patient is a 3 ppd smoker. Ht. 6′ Wt. 230lbs. Heel injuries were more specifically diagnosed as on the left, a fracture at the posterior facet involving the lateral one-third, some impaction in that area. “There is lateral wall blowout, the fracture line extends into the anterior calcaneal cuboid joint that is “minimally displaced.” On the right, posterior facet “more or less” intact, some fracture lines involving the tuberosity. The middle facet was a little bit impacted as well. Impression was bilateral calcaneal fractures.

Patient was completely non-weight bearing. No surgery required on the right, but surgery recommended and performed on the left on January 29. Post operatively, he was required to remain non-weight bearing. On January 27th, the patient died after suffering bilateral pulmonary emboli secondary to post traumatic blood clots.

Should patient have been prescribed prophylactic anticoagulation therapy to prevent clots, DVT and resultant PE?

MEDQUEST EXPERT RESPONSES

This is tricky. We have no guidelines to suggest DVT prophylaxis in this population, what to use, how to administer, and for how long. This is a judgment call by the physician. Given that he is a large person and in a prolonged non-weight bearing status might consider at risk for DVT. Dr RS – Orthopedist

This case will end up in a gray zone, will be hard to support one way or another. Dr JG – Orthopedist

There is no set standard for dvt prevention in surgery of the foot and ankle. Dr JH – Orthopedist

There are published criteria for the use of tPA ( American Heart Association ). tPA can be initiated within 3 hours of onset of stroke; poor documentation in the chart of time of onset makes the physician particularly vulnerable. Failure to consult family members as to time of onset can lead to mistakenly withholding tPA. It has become more common to find cases where tPA was withheld than cases where it was given inappropriately (against the AHA guidelines). The major risk factor is bleeding into the brain. As of 2009, tPA may now be used up to 4.5 hours after onset of stroke.

The efficacy of tPA as initially reported was 30-38%, thus depriving a patient the opportunity of a better outcome. A retrospective statistical review posits that the rate of improvement is actually 60%, i.e. more likely than not to have a better outcome.

The lack of administration of heparin/coumadin is more problematic. Coumadin is standard of care for cardiac sourced emboli to the brain (atrial firbrillation, ventricular aneurysm with clot). It is not currently proven to be of value for other types of stroke, TIA or stroke in evolution. However, liability may ensue from withholding coumadin (such as for dental surgery) and never re-instituting it, resulting in stroke.

TIA’s have received a great deal of attention in the most recent medical literature. TIA may be considered a medical emergency as the risk of stroke in the immediate following days is high. TIA’s are treated with aspirin, plavix or aggrenox (except cardiac sources = heparin/coumadin). Appropriate work-up may discover a severe carotid stenosis, which may be treated by surgery. Note that platelet inhibitors such as aspirin are statistically effective at about 30%, and there is little difference among them.

A relatively new issue is the risk of HIT…heparin induced thrombocytopenia. Failure to recognize this entity can result in thromboses of cerebral veins and arteries and stroke.

Although rare, PRES (posterior reversible encephalopathy syndrome) if untreated, can result in stroke. PRES is seen in pre-eclamptic/eclamptic women and requires aggressive blood pressure management. Stroke usually results in blindness due to the posterior brain location of this under recognized obstetrical problem.

Issue: Was there a deviation for the standard of care resulting in a 6 month or a 3 ½ year delay in diagnoses of colon cancer and if so the impact on the pt?

EXPERT RESPONSES

In 2005 sessile polyp needed to be removed either through the scope or by resection. Up to 30% of lesions will transform to malignancy. Three year follow up negligent also and 2008 cancer was there and they failed to completely remove recurrent lesion. Dr JF – Gastroenterologist

I think the gaps in her care were significant deviations. She should have had an operation after the 3 month follow up failed to remove all of the tumor. Dr DD – Gen Surgeon

Most likely the answer is yes, impt delay. In terms of definitive management I’d defer to a colorectal surgeon’s opinion. Dr PK – GI Oncologist.

Deviation would require a GI surgeon to opine, but likely would find merit. Causation there but a T2N1 stage IIIa has a fairly high survival rate with state of the art management, which is sounds like she got. Dr RB – Oncologist