Episode 042: The Case of Late Expectations

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 welcome to this episode of our podcast. My name is Brian Fortenberry, and today we are going to be looking at a closed claim case here, that's got some interesting information that I think will be of benefit to our physicians, and those that listen to this. To help us with our discussion is attorney Alisa Wamble. Alisa, thanks for being here.

Alisa: Thank you for having me.

Brian: So, before we get even into the case itself, or any discussion at all, why don't you take a minute and tell our listeners a little bit about yourself, about your time here at SVMIC, and your experience?

Alisa: Sure. I've been with State Volunteer for exactly 20 years now. I went to law school at the University of Memphis, had a couple of years doing other things, and then came to State Volunteer  in claims. Started as a claims attorney, worked up to senior claims attorney, and now I'm an Assistant Vice President of Claims, so I've been doing this a long time, and enjoy it very much.

Brian: Well, we certainly appreciate you taking time out of your busy schedule to be with us to review this today. Alisa, before we even get into a discussion, I think it's only fair for our listeners that we give them a little bit of a background on what we're going to be talking about today.

Occasionally, the sound of hoofbeats should lead a medical provider to consider a zebra instead of a horse, when evaluating a complex medical presentation. This obstetrical case involved a 24-year-old female who was pregnant with her first child. Meghan had no previous medical problems, and had normal blood pressure, normal weight, and she did not smoke. She had an unremarkable pregnancy until she was hospitalized at 32 weeks and three days due to severe epigastric pain, nausea, and vomiting. On admission, the patient had no fever, no contractions, no headache, and fetal movement was positive with some uterine irritability.

The plan was to observe Meghan, and work her up for possible preeclampsia with an atypical presentation. She was given a steroid injection, Demerol, and Phenergan. Her lab results indicated a slight decrease in her platelets, and elevated liver enzymes. Meghan later reported, "Stabbing pain," in her epigastric region, and she was given a second dose of Phenergan and Demerol. The next morning, she reported that the pain was still present but better, and she was starting to feel contractions. Demerol and Phenergan were repeated twice that day. Approximately 48 hours after her symptoms first began, Meghan reported so much pain that she was unable to lie down, and electronic fetal monitoring could not be continued. Her blood pressure was 170 over 101 and 172 over 91. Her oxygen saturation levels varied from 83 to 96. She described the pain as constant, with no relief from Demerol. Meghan's obstetrician, Dr. Hall, was paged at 1:52 AM. He ordered lab work, and was at her bedside at 3:30 AM. At 4:00 AM, an EKG was performed, which was normal, and Meghan received 10 milligrams of Valium intravenously. After consulting with a maternal fetal medicine specialist over the phone, Dr. Hall made plans for a VQ scan to be performed in a nearby facility to rule out Pulmonary Embolism. Meghan still had elevated blood pressure, constant pain, and a headache. At 5:30 AM, she was given 100 milligrams of Demerol, and was finally able to lie down for an ultrasound. At 6:08 AM, fetal monitoring was resumed, which showed no variability, decelerations, or probable late decelerations. Dr. Hall was notified of the fetal heart tracing at 6:25 AM, and reviewed the strip several times, but he elected to proceed with the VQ scan, which, by the way did not show a PE.

Meghan returned to the hospital, and Dr. Hall assessed her at 9:45 AM. At 10:30 AM, Dr. Hall noted minimal variability, no accelerations, and late decelerations on the strip. At 11:48 AM, he discussed the need for a C-section, but it was not performed until 2:31 PM. At delivery, the four pound male infant was limp and pale, with Apgars of zero, one, and two. Meghan developed Disseminated intravascular coagulation at the time of surgery. Her diagnosis was HELLP Syndrome, and atypical presentation of severe preeclampsia. She received transfusions and recovered. The baby, however, suffered permanent and severe neurologic damage. A lawsuit was filed against Dr. Hall and the hospital, which alleged multiple breaches of the standard of care. So Alisa, this is obviously a very sad case, and a traumatic case that we're dealing with. How did the breach of the standard of care occur in this situation, in this case?

Alisa: When the plaintiff filed the lawsuit, there are multiple allegations, which is pretty typical.

Brian: Okay.

Alisa: They allege that both the hospital nurses and Dr. Hall failed to recognize fetal distress, failed to recognize and treat the symptoms of preeclampsia and HELLP Syndrome. Failed to refer Meghan to a high risk specialist, and they allowed her to labor much too long. Of course, when the lawsuit is filed, you have the benefit of knowing the outcome, and they alleged everything that went wrong.

Brian: So hindsight, it is easier probably to line up those allegations. It does sound like, in what we were reading, like Dr. Hall, he reviewed the fetal monitoring strips several times it said, and things seemed okay, so where did he go wrong on this?

Alisa: It's not your typical neurologically-impaired infant case where the doctor is not available, or not aware, or not paying attention. Dr. Hall was paying attention, but unfortunately Meghan's presentation was unusual, and he was so focused on her epigastric pain, and ruling out a cardiac issue, or a blood clot in her lung, that he developed tunnel vision on that issue, and really stopped focusing on what was going on with the baby.

Brian: So often, in these type of cases, then it's the physician that's not present, not there, never saw the strip, or whatnot. So, that certainly isn't the case here. That tunnel vision can obviously be pretty dangerous then, correct?

Alisa: It can, and it was even worsened by the fact that all of the tests that he was ordering came back negative. When he got the negative VQ scan, he had false security that everything was going to be okay, and that the baby needed to obviously not be delivered at 32 weeks.

Brian: Sure.

Alisa: You don't want a baby that premature, but if he had focused more on the baby, and delivered the baby sooner, it's almost certain that the baby's outcome would have been better.

Brian: And that's the hard part to hear in this, and there seemed to have been some discussion about a C-section. As I recall, it was like 11:48 in the morning, but the actual procedure did not happen. It wasn't performed until like 2:31 in the afternoon. If there was less of a delay in that time between this discussion that he had and the actual C-section itself, do you think that this case would have been defended differently? Do you think there would have been possibly a different outcome, or is that inconsequential?

Alisa: No, that three hour delay was what drove the lawsuit, I think. We had experts who could support Dr. Hall's ordering of the VQ scan to rule out the PE. That was an issue of medical judgment that they thought was appropriate. However, once he got that result back, waiting for three hours after discussing as C-section just became extremely hard to defend, both for Dr. Hall and for the nurses, because when one of the labor and delivery nurses testified, she said that she realized there were problems on the strip with the monitoring, but she didn't say anything, and so the fact that these providers weren't communicating just added another very difficult layer to the case.

Brian: And once you have that delay like that, it becomes easier at that point for people to second guess and question what was going on. So, you said there was a nurse, a labor and delivery nurse, that testified in her deposition that she thought that the fetal monitor strip had problems. She was concerned over it, apparently over a period of hours that she had concerns about this, but she didn't share the thoughts with anybody. She didn't contact Dr. Hall. She didn't talk to anybody about this. What could be said of this? I mean, this seems like it could have really changed the outcome of this case.

Alisa: It could have, honestly, and that's what made it so hard to defend. You know, she could have talked to Dr. Hall. She could have gone up the chain of command within the hospital system, if she didn't think Dr. Hall would respond to her. He was very responsive. He was attentive to the patient, but because they weren't communicating, and then the nurse admitted that in her deposition, the hospital was obviously willing to help us settle the case. So, they contributed along with State Volunteer on behalf of Dr. Hall, and we were able to resolve it, but it took years.

Brian: So ultimately, this case was settled, but it wasn't just on behalf of Dr. Hall, it sounds like, correct?

Alisa: That's right.

Brian: As we get ready to wrap up, what is some key points that you think we could take out of this tragic situation that might help other physicians? Some key points that we could say, "This could help you avoid a situation like this, and litigation in the future?"

Alisa: In this case, I think it goes back to the way you began the description on the facts, with the complex presentation, and the medical provider so focused on expecting one thing, and then when that was ruled out, not examining what else could be going on with the patient. When you have a case, any kind of case, where you have hard evidence of what was going on at the time, such as a fetal monitor strip, or mammogram films, or an EKG, and you can see exactly what was going on at a moment in time, and then you have the result, it can be very hard to defend.

Brian: It makes sense to me, being a non-legal person, that it gets more difficult when you don't look at the whole scope of it, and you get kind of tunnel vision, and it's easy to come in with maybe even preconceived notions of where you think it's going to go, but the minute that you start letting that take over the situation, I can see exactly what you're saying. That it could get difficult to defend. Alisa, I really appreciate you taking the time to be here today, and to discuss this for us, and so we can gain some information.

Alisa: 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. Policyholders are urged to consult with their personal attorney for legal advice. That specific legal requirements may vary from state to state, and change over time.