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Florida – Critical Care Medicine – Intensivist Unavailable To Assess Patient With Metabolic Acidosis, Abdominal Pain, And Vomiting
On 10/19/2011 at 5:23 p.m., a 35-year-old male presented to the emergency department at a hospital with a chief complaint of abdominal pain and vomiting, which started approximately five hours before he presented to the hospital.
The patient was admitted to the hospital under the service of an intensivist and was notified of his arrival and condition at 5:35 p.m.
Between the hours of 5:50 p.m. and 7:22 p.m. the intensivist gave verbal orders of Dilaudid and ketorolac to the patient’s nurse.
At 9:20 p.m., the intensivist gave telephonic orders to the patient’s nurse, to place him on his home BIPAP mask.
On 10/20/2011, at 3:15 a.m. a rapid response was called due to an acute change in the patient’s respiratory status.
During the rapid response, an arterial blood gas (“ABG”) was drawn that revealed critical metabolic acidosis.
The intensivist never presented to the emergency room to assess the patient when he demonstrated medically dangerous/life-threatening signs at 3:15 a.m. or any time thereafter.
The intensivist never attended to the patient when his clinical situation was from an unknown cause and when a clear treatment plan had not been determined.
From 3:43 a.m. to 4:15 a.m., the critical care practitioner was contacted approximately five times with information on the patient’s medically unstable and deteriorating condition.
At 3:45 a.m., the patient became short of breath, restless, diaphoretic, and seizure episodes followed. He was then transported to an intensive care unit.
At 5:25 a.m., a second rapid response was called due to a further decline in the patient’s health. The rapid response turned into a code blue.
The patient underwent a cardiopulmonary arrest, and the code team was unable to resuscitate him.
On 10/20/2011, the patient expired at 6:25 am.
The autopsy results were consistent with acute hemorrhagic pancreatitis with diffuse pancreatic necrosis.
The Medical Board of Florida judged the intensivist’s conduct to be below the minimal standard of competence given that he failed to presented to the emergency room to assess the patient when the patient demonstrated medically dangerous/life-threatening signs on 10/20/2011 at 3:15 a.m.
The Medical Board of Florida issued a letter of concern against the critical care practitioner’s license. The Medical Board of Florida ordered that he pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $4,503.10 and not to exceed $6,503.10. The Medical Board of Florida ordered that the critical care practitioner complete ten hours of continuing medical education in the area of critical care medicine and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: December 2017
Specialty: Critical Care Medicine, Emergency Medicine, Pulmonology
Symptom: Abdominal Pain, Nausea Or Vomiting
Diagnosis: Gastrointestinal Disease
Medical Error: Failure to properly monitor patient
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
Florida – Gynecology – Bilateral Tubal Ligation Error Results In Complications Of Tachycardia, Hypotension, Respiratory Failure, And Hypotension
On 4/21/2014, a gynecologist performed a Cesarean section and bilateral tubal ligation on a 29-year-old female at 36 weeks gestation.
The patient suffered from gestational hypertension associated with right upper quadrant abdominal pain and elevated liver function tests consistent with HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelet Count) Syndrome.
At 5:00 p.m. on 4/21/2014, the patient became hypotensive and tachycardic and was pale and lethargic.
Between 5:00 p.m. and 6:30 p.m. on 4/21/2014, a critical care consultant diagnosed the patient with acute hemorrhagic shock, possibly due to an intraabdominal bleed, transferred the patient to the ICU, ordered a transfusion of 4 L of blood, and called the gynecologist for a possible exploratory laparotomy to control the bleeding.
At 7:11 p.m., the patient was intubated and placed on ventilation due to respiratory failure.
At 9:10 p.m., an ultrasound examination was performed on the patient’s abdomen and pelvis that revealed moderate fluid in the right and left upper quadrants of the patient’s abdomen.
Immediately following the ultrasound examination, the gynecologist diagnosed the patient with a liver rupture. The patient’s lab testing results did not support or corroborate the gynecologist’s diagnosed.
The gynecologist called the on-call general surgeon and discussed the patient’s case. After the conversation, at 9:23 p.m., the gynecologist initiated the transfer of the patient to a medical center.
At 1:45 a.m. on 4/22/2014, the patient was transferred to the medical center with a tachycardic heart rate of 140 beats per minute and a hypotensive blood pressure of 89/44. The gynecologist and a surgeon performed an exploratory laparotomy on the patient, which revealed that the patient had an arterial bleed from the tubal ligation procedure.
The Medical Board of Florida judged that the gynecologist did not appropriately assess, or did not create or maintain adequate documentation of assessing, the patient’s symptoms and condition. He did not timely diagnose, or did not create or maintain adequate documentation of timely diagnosing, the patient with an intraabdominal bleed and hemorrhagic shock. The gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s deteriorating vital signs. He did not timely order an ultrasound examination of the patient’s abdomen and pelvis on the patient’s deteriorating vital signs. Also, the gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s respiratory failure. He did not recognize, or did not create or maintain adequate documentation of recognizing, that the fluid in the right and left upper quadrants of the patient’s abdomen, in conjunction with the patient’s other symptoms, indicated an intraabdominal bleed. He did not perform or order an exploratory laparotomy based on the fluid in the right and left upper quadrants of the patient’s abdomen. The gynecologist inappropriately diagnosed the patient with a liver rupture when the patient’s lab testing results did not support or corroborate the diagnosis. He also did not order, or did not create or maintain adequate documentation of ordering, a surgery consultation for a surgeon to physically examine the patient upon diagnosing the patient with liver rupture. He did not consult, or did not create or maintain adequate documentation of consulting, with one or more other OB/GYNs who might have had experience dealing with a patient with a liver rupture or a patient with similar complications and symptoms as the patient had. The gynecologist did not timely perform or order an exploratory laparotomy after diagnosing the patient with liver rupture. He also inappropriately transferred the patient to a medical center when the patient was unstable due to being tachycardic and hypotensive. The gynecologist did not create or maintain adequate documentation related to his diagnosis and treatment of the patient.
The Medical Board of Florida issued a reprimand against the gynecologist’s license. The Medical Board of Florida ordered that the gynecologist pay a fine of $22,500 against his license and pay reimbursement costs for the case at a minimum of $4,335.85 and not to exceed $6,335,85. The Medical Board of Florida also ordered that the gynecologist complete ten hours of continuing medical education in diagnosis management of complications relating to cesarean sections, complete five hours in emergency obstetric care, and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: May 2017
Specialty: Gynecology, Critical Care Medicine, General Surgery
Symptom: Abdominal Pain
Diagnosis: Post-operative/Operative Complication, Acute Abdomen, Hemorrhage
Medical Error: Diagnostic error, Delay in proper treatment, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
Wisconsin – Vascular Surgery – Perioperative Bleeding During Left Carotid Endarterectomy
On 07/10/2006, the vascular surgeon performed a left carotid endarterectomy with an AcuSeal graft on a 73-year-old woman. At the end of the surgical procedure, protamine was administered to the patient to reverse the heparin. Attempts to stop the oozing from the suture line continued for 80 minutes. No clots were observed, and three ampules of thrombin were sprayed over the suture line. Platelets were also administered, but oozing continued from the suture line. There was no arterial bleeding. The vascular surgeon made the decision to keep the patient intubated after the operation, and a critical care specialist was consulted. Following the endarterectomy, the patient was admitted to the surgical intensive care unit.
In the morning of 07/11/2006, the vascular surgeon assessed the patient, including an assessment of the neck and mouth, on two occasions. The vascular surgeon determined that in his professional opinion there was no surgical contraindication to extubate the patient. There was a dispute between the parties as to whether the vascular surgeon issued an order to extubate the patient or whether he advised the nurse that the patient could be extubated after consultation with the intensivist.
The intensive care nurse contacted the respiratory therapist who extubated the patient. The nurse noted in the chart that the vascular surgeon had given a verbal order that it was “okay to extubate the patient.” When asked to complete his charts, the vascular surgeon became aware of the nurse’s entry and after consultation with the Chief of Quality Assurance, made a correction to reflect that the order had actually been that it was “okay to extubate if okay with [vascular surgeon] et. al.” The vascular surgeon then signed both entries.
A formal complaint had been filed alleging that the vascular surgeon placed the patient at risk for harm by failing to properly evaluate the patient’s airway or to seek consultation with an intensivist prior to ordering extubation of the patient.
It is unclear from the Public Records if the patient failed extubation or if the patient developed complications from a failed extubation.
The Board understood the ongoing dispute between parties and made no determination regarding this allegation. The Order did not constitute disciplinary action against the vascular surgeon.
The Board ordered that the vascular surgeon complete The Sterling Healthcare “The Difficult Airway Course: Anesthesia;” the “Case Western Reserve: Intensive Course in Medical Record Keeping;” and the National Center of Continuing Education’s Strategies for Developing Communication Between Nurses and Physicians.”
State: Wisconsin
Date: September 2009
Specialty: Vascular Surgery, Critical Care Medicine
Symptom: Bleeding
Diagnosis: Post-operative/Operative Complication
Medical Error: Failure of communication with other providers, Procedural error
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF