Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
In October 2007, a 72-year-old Pennsylvania woman underwent an elective cardiac catheterization in the right femoral artery at the recommendation of Dr. K. Shortly after the procedure, the patient had abdominal pain and back pain, with apparent bleeding in the abdominal cavity. She was kept at the hospital.
Almost two days later, the woman had persistent abdominal pain, a heart rate greater than 120 beats/min, and abdominal tenderness on palpation. Dr. L. was informed of this but did not examine the decedent; instead, he ordered abdominal x-rays, lab work, and administration of morphine.
Four hours later, the woman was found unresponsive. She had experienced cardiac arrest and was placed on a ventilator. In late November, she was transferred to another hospital, where she died about five weeks later. Her death was attributed to multiple organ failure and decreased intestinal blood flow.
The plaintiffs alleged negligence on the part of several defendants, including Dr. K., Dr. L., and the hospital. Dr. L. did not contest causal negligence but argued that other defendants were also at fault.
Outcome
According to a published account, a jury returned a $5.16 million verdict, including $4.13 million in wrongful death damages and $1.03 million in survival damages. The jury found Dr. L. 95% liable and Dr. K. 5% liable. Defense verdicts were entered for the other defendants.
Under the terms of an agreement into which the plaintiffs had previously entered with the defendants’ insurer, the plaintiffs recovered in the amount of $1.75 million.
Comment
This patient was hemodynamically unstable, with a pulse of 120, abdominal pain and tenderness, and an established intra-abdominal bleed. The standard of care required an effort to intervene immediately and stabilize her. Clearly, this did not occur.
Missed bleeding is hard to defend in court. Jurors understand bleeding and expect it to be identified, stopped, and remedied. As clinicians, we know that hemorrhage can be subtle, occult, and difficult to manage. In malpractice cases involving missed hemorrhage, however, plaintiff’s counsel will frequently argue that the clinician exhibited a brazen lack of concern for the patient and will seek a punitive component to damages. Allowing a patient to exsanguinate will inflame a jury, resulting in a heavy damage award—similar to the verdict returned in this case.
Undetected acute bleeding often stems from a misplaced reliance on hemoglobin and hematocrit (H&H) values. In short, H&H values cannot effectively detect acute hemorrhage. As an index of concentration, H&H values will decrease only after time or volume replacement. A skilled plaintiff’s lawyer can vividly demonstrate the fallibility of H&H to detect acute bleeding by emptying half the volume of a pitcher of red liquid in front of the defendant (and the jury) and asking if the concentration changes. As in an exsanguinated decedent’s H&H values in a malpractice case, it will not.
While the facts of this case are silent regarding the patient’s H&H values, it is of paramount importance to understand that the briskly bleeding patient will have a normal or near-normal H&H. During deposition in malpractice case after malpractice case, clinicians are pinned down as having failingly relied on a relatively normal H&H in the setting of rapid hemorrhage.
Hemorrhage must be considered in any patient with hemodynamically unstable vital signs in the setting of trauma, surgery, or coagulopathy—or in any patient with obvious volume loss or apparent unexplained internal fluid accumulation. —DML