Episode 038: Doing It Right and Getting It Wrong

Speaker 1: You are listening to Your Practice Made Perfect, support, protection, and advice for practicing medical professionals, brought to you by SVMIC.

Brian: Hello, and thanks for joining us for today's podcast. I'm Brian Fortenberry, and on today's episode, we're going to be looking at a closed claim review. Prior to getting to the review section, let's go through the story and setup the review that we will be talking about today.

It was a warm day on a long July 4th holiday weekend when 39-year-old William, his wife Carrie, and their two sons decided to go hiking on the family's property where they intended to build a new home. The site was undeveloped and mostly flat except for a steep ravine on the rear side of the parcel. They began to walk the property around noon. As they gazed down into the ravine, William and one of his boys decided they would like to hike to the bottom and then back up.

William, at 260 pounds, was technically obese, but he felt that he could make the trek up and down the ravine. Carrie decided to wait at the top. At approximately 2:00 p.m., as he was climbing back up the hill, William developed numbness and tingling in his legs and had pain in his back. Carrie and one of her sons ran to a neighbor's house to get help. The neighbor helped Carrie get William into the truck and Carrie rushed him to the hospital.

An emergency department nurse examined William at approximately 4:01 p.m. William reported to the nurse that prior to arriving at the hospital, the feeling had come back in his legs and the tingling had gone away. He described that there had been bilateral pain in his hips, but this had resolved by the time he had reached the ED. He stated he experienced no nausea or vomiting. Although not entirely clear from the hospital chart, he may have had some abdominal discomfort at the time he developed the other symptoms.

William also reported to one of the ED nurses that he had a "weird feeling in the center of his back after the tingling resolved.” It was unclear whether the complaint of abdominal pain had resolved itself before or after arrival at the ED. However, a nurse's note at 4:01 p.m., stated that William was alert and oriented and denied any pain.

Dr. Kindly came in to examine William at 4:15 p.m., approximately one hour after his arrival at the ED. William told Dr. Kindly about having pain in his lower back at the midline of the lumbar area, although it is not entirely clear whether that complaint had already resolved itself by the time she saw him. Dr. Kindly does not believe she was told about the "weird feeling in his back" by the nurse and does not believe she saw the nurse's note.

Dr. Kindly noted that there was no significant past medical history other than a hernia repair. She checked William's general constitution, respiratory, cardiovascular, and gastrointestinal systems and performed a bilateral straight leg raising test because of the complaint of bilateral hip pain and low back pain. The straight leg raising test was negative bilaterally even though he had complained of some midline lumbar tenderness.

Dr. Kindly ordered a lumbosacral X-ray, which she read personally. The X-ray revealed no fractures or descriptive lesions. However, a first-degree spondylolisthesis of L5 and S1 with bilateral spondylotic defects at L5 was detected and verified by a radiologist the next day.

William was discharged that evening with instructions to take a muscle relaxant three times a day and an over-the-counter anti-inflammatory medicine three times a day as needed. He was instructed to follow up with his regular physician if his symptoms persisted or return to the ED if the symptoms worsen.

After arriving home, William ate supper and went to bed early. Carrie went to work the next day, and when she returned home, she said he appeared sleepy. William took a short walk out into the yard, but came back in complaining his legs were becoming numb and tingly again. She had him sit until the symptoms cleared. Later, they went to bed. Carrie woke up at 3:00 a.m. and found William asleep on the couch. She woke up and urged him to come back to bed. He said he did not feel well and would sleep on their son's bed.

She left for work at 6:15 a.m. and observed him sleeping on her son's bed. She spoke to her son around 1:30 p.m. and asked how is dad was doing. The son reported that his dad had been sleeping all day. She asked her son to check on him, and he reported that his dad looked blue and was not breathing. She instructed her son to call 911.

Carrie also called 911, and then immediately drove home. When she arrived home, the emergency team told her "he's gone, and there's nothing we can do.” Carrie, who is a registered nurse, requested an autopsy several weeks after her husband's death. The autopsy report stated that the cause of death was aortic dissection. Carrie filed suit against Dr. Kindly and the hospital.

With us today to discuss this case is Miss Judy Reneau. Welcome, Judy.

Judy: Hello, Brian.

Brian: Before we really even get into all the complexities of this case, first, tell our listeners a little bit about yourself.

Judy: Well, I am an attorney. My hometown is Memphis. I graduated from law school at the University of Memphis, and I moved to Nashville more than 15 years ago for this job.

Brian: Well, fantastic. There's a lot going on obviously in this case. Let's start by looking at the fact that it seems as though Dr. Kindly and the ED nurse did everything they could when William arrived at the ED on that initial visit. Is there something that was missed or that maybe could've been done that would've changed the outcome of this case. Do you think there's something there?

Judy: I think she did a really good history on him. No family history of aortic dissection. She used a process that I think was very thorough.

Brian: There was really no problem then whenever William arrived with anything that they did in the initial evaluation. What was the outcome of this case?

Judy: It was tried to a jury and we got a defense verdict.

Brian: If it turned out favorable for Dr. Kindly, how did she show the jury that she really didn't deviate from the standard of care and perform sufficient steps for ruling out a dissecting aorta?

Judy: She showed to the jury that she went through a series of evaluations of the patient. She talked to him. She listened to his symptoms. She ordered films to be taken. She did a physical exam as well as straight leg raising, which is a test to detect certain things. She did all of those things and nothing that indicated a dissecting aorta rose to the top of her mind.

Brian: Was there anything that could have additionally been done that may have been brought up that was accused of, "Had you done this, that might have been detected."

Judy: I believe what the plaintiff tried to show in the trial was that she should have suspected a dissecting aorta, in my research, at least. I know it was brought out in the trial that one would expect to find a ripping or tearing pain in the area of the dissection. You read in the summary that the patient described, I quote, "weird feeling" in an area in his lumbar spine. This is a far cry from a description of a ripping pain or tearing pain. I suppose there are cases that are pain-free or can be less painful, but that's not what you'd expect with a dissecting aortic dissection.

Brian: It definitely sounds like it wasn't a classic presentation of a dissecting aorta. Those, I guess, can be very difficult to look and to diagnose. Do you believe that there was any kind of tunnel vision here when it came to looking at, "Okay, I hear hip pain, I hear back pain, I hear these things so they got tunnel vision." Do you think that was a problem or do you think that they did a pretty good complete job?

Judy: Well, it sounds like to me with the kinds of testing and the kinds of questions Dr. Kindly asked, I believe she was trying to gather all the information in a complete way. She discharged the patient later after getting the result of the films, and it did show some spondylolisthesis, which can be painful, and also, she listened to his history. I mean, they had been hiking up a steep...

Brian: Ravine, yeah.

Judy: ... ravine up and down. It was a hot day. I think she probably was trying to consider all of those factors in her decision to discharge the patient.

Brian: What would your advice be for a doctor that was going through a similar case as this? We've discussed that we think she handled it appropriately. What would your advice be to a physician in a scenario like this that might help them avoid some type of litigation?

Judy: I think Dr. Kindly did what doctors are trained to do, which is use her observation, her skills of evaluating a patient, listening to what he has to say about the way he felt and the way he's feeling now and just using her experience to lead her in the direction that the symptoms take her. I believe that's what this doctor did. That would be my advice to all physicians.

Brian: Given this case and how it played out and the verdict, are there any other main takeaways that might help a physician?

Judy: Usually, you don't look for a spotted elephant in the room when you don't see one, and frequently, something like this, it was a tragic ending, a sad case, and sudden. This man was young, and a young family man. There was no reason to believe that this kind of outcome would've happened after an outing like this for the family. I think that all you can do is your best, and remember, this was an acute dissecting aorta, which is something sudden, unexpected. He reported no signs of anything that led the doctor to suspect that there could be something more ominous going on.

Brian: In a case like this, it looks like the doctor did appropriate testing and probably very appropriate documentation to show her background of what she had done and was very concise in a way that that was very helpful. Would you say so?

Judy: I would say so. There was no documentation issue in this case, which frankly we find to be a problem in some cases. It's another hurdle to get over when the documentation is not complete. Fortunately, we didn't have that in this case.

Brian: Thank you for taking the time to discuss this tragic and unfortunate case but hopefully something that our listeners can learn from and help them in their daily practice. Thanks for being here.

Judy: Thank you for having me.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host Brian Fortenberry. Listen to more episodes, subscribe to the podcast, and find show notes at SVMIC.com/podcast.The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policy holders are urged to consult with their personal attorney for legal advice as specific legal requirements may vary from state to state and change over time.