Episode 059: A Recipe for Disaster

Speaker 1: You are listening to Your Practice Made Perfect: Support Protection And Advice For Practicing Medical Professionals, brought to you by SVMIC.

J. Baugh: Hello everyone and welcome to this week's episode of Your Practice Made Perfect. My name is J. Baugh and I'll be your host for this episode. Today, we're going to look at another one of our closed claim files. We can always learn something when we look at these files, maybe things that were done well, and maybe some things that could have been done a little differently. And so once again today, we have Katy Smith back with us. Katy, welcome.

Katy: Hey, J. Thanks so much.

J. Baugh: It's good to have you here. Katy and I are both senior claims attorneys here at SVMIC. Katy's been here for 13 years and I've been here for 18 years, so we've seen a lot of cases in the time that we've been here, and we're going to talk about another one of these closed claims that should provide us with some information that will help all of us.

Today's case looks at what happens when a doctor provides the same style of treatment for all their patients instead of looking at the unique needs of each individual patient. And Katy, a phrase that I hear doctors use sometimes is the phrase cookbook medicine.

Katy: Yes, cookbook medicine.

J. Baugh: Yeah. They get really upset when they feel like there are guidelines and other rules maybe in place that require them to practice cookbook medicine, because they always tell us that every patient is unique, and they don't need a cookbook to guide them as to how to treat the patient. But unfortunately, it seems like in this case that's exactly what happened. It was cookbook medicine.

Katy: Unfortunately, I do think that that is what happens. Our case starts out with what's probably a familiar presentation to a lot of our listeners. We have an older middle-aged female patient with multiple comorbidities, and morbid obesity is at the center of them. She was overweight most of her adult life, which caused her to develop chronic back problems, also sleep apnea, a list of heart problems, as well as fibromyalgia and additional other health problems.

J. Baugh: Wow. Sounds like she had some pretty big odds that were already stacked up against her.

Katy: That's right, J., I think she did. And it sounds like she continued to just live her life with them as best she could. But ultimately, her back pain became so unbearable that there were days where she was unable to walk without using a cane. So once it developed to that point, the patient presents to our defendant doctor in this case, the local neurological surgeon, who had been practicing in this town for more than 20 years. And during this time, the physician had treated thousands of patients with diagnoses and complaints very similar to our patient. Chronic back pain, other health issues, with the common denominator being morbid obesity. The surgeon had performed many surgeries involving spinal columns without any major issues.

J. Baugh: So the neurological surgeon diagnosed his patient with herniation of the lower lumbar region and canal stenosis. These afflictions contributed to the pain radiating throughout her lower body and was the primary cause of her inability without assistance on a frequent basis. The surgeon had tried attempts at conservative treatment, but ultimately the patient expressed her desire for surgical intervention, and so the surgeon decided to perform a lumbar decompression and microdiscectomy.

Katy: Now, or surgeon did warn the patient that due primarily to her poor physical condition and her overall health, she was at risk for complications that may arise during the surgery, including, but not limited to, death. And this is an important thing to point out. The patient is informed. The surgeon obtains her informed consent to the risks, and the patient still elects to proceed with the surgery in light of knowledge of the risk. Our surgeon is very diligent here. She sends the patient to her cardiologist for cardiac clearance evaluation-

J. Baugh: Yeah, and that's a good step to take. Unfortunately, we sometimes see cases where that isn't done, and it's alleged later that it should have been.

Katy: ... should have been done. It's-

J. Baugh: So that's good that in this case the surgeon did think to get a cardiac clearance.

Katy: She did. And apparently they did get clearance for the surgery. But the cardiologist also indicated that the patient was at a moderate risk for a cardiovascular event during and subsequent to the procedure. So again, significant risks that this patient is facing.

J. Baugh: That's right.

Katy: The hospital also performed a sleep apnea assessment preoperatively, probably in conjunction with her anesthesia assessment, and that assessment placed the patient in a high risk category consistent with the history of sleep apnea.

J. Baugh: Yeah. That's right. And by all standards, the surgery itself was routine, completed without any issues. And so the patient was transferred to postoperative care, given high dose IV narcotics in the immediate postoperative period. Upon admission to the floor, her vital signs were stable, and after a few hours the patient asked a nurse to remove the pulse oximeter, which the nurse did, because in the nurse's opinion, the patient had worn the pulse oximeter long enough to meet the hospital's postoperative protocol. Unfortunately, the next day the patient was found unresponsive in her hospital bed, and shortly thereafter she passed away. The cause of death was most likely severe anoxic brain injury as a result of respiratory arrest.

Katy: Perhaps not unexpectedly, a wrongful death lawsuit was ultimately filed against the surgeon, as well as the hospital and addition hospital providers. The main allegation against the surgeon was that she deviated from the standard of care by failing to order telemetry monitoring in the postoperative period. The allegations against the hospital were focused on the nursing staff's failure to appropriately administer and monitor the pulse oximeter that was placed on the patient while in recovery.

J. Baugh: And so as this case develop, there were indicators that the patient should have been placed in the cardiac telemetry unit immediately after the surgery, because the patient had pre-existing heart problems. But the surgeon had performed procedures like this for years on patients who were similar to this patient and had not had a catastrophic outcome with those patients, so he treated this patient in the same way. And that goes back to what we talked about at the beginning of the podcast regarding treating the unique needs of patients, looking at them individually and, again, not practicing cookbook medicine.

Katy: I think that is definitely the main point of this case that we're talking about here. And ultimately, in this case, because of this cookbook medicine allegation and theory that the plaintiff was able to develop throughout the case, the case ultimately had to be settled.

J. Baugh: So Katy, what are some of the points that we can take away from studying this closed claim?

Katy: Well, I think this case gives us some good clinical takeaways. First of all is carefully review all of your evaluations, that you get your sleep apnea evaluations here, you have the cardiac clearance evaluation that was received. Review them and plug them into your treatment plan for this patient. A second takeaway point is if you're writing postoperative pain orders, consider whether they need to be tapered. Appropriate medicine for mild complaints of pain, or moderate or severe. And again, that goes back to our cookbook kind of recipe issue, think about what this specific patient may need, and not just writing one global treatment for the patient.

J. Baugh: Yeah, that's a good point I have seen in cases in which a physician would chart something in the patient's medical record that was too generic. Something like, "Pain."

Katy: Right.

J. Baugh: And it wouldn't say, "Mild" or "Moderate" or "Severe", and so a subsequent treating physician sees that note and doesn't really know what to make of it. And so maybe the patient stays on the pain medication too long. Maybe the original physician thought it would be titrated down and it wasn't. And so you need to be pretty specific when it comes to making those types of entries into the chart, because it's not only there to remind you of what you saw, but it is also there to help subsequent treating physicians.

Katy: That's right. And J., overall, I think, as we've discussed, the point here is patient outcomes in the past, the prior cookbook, your prior recipes, may not be accurate predictors for this patient's situation. So assess the patient individually. Use your prior experiences for references, but not as a template, not as a recipe.

J. Baugh: That's something that's pretty basic when it comes to the study of science, that just because something has worked X number of times in the past does not necessarily mean it's going to work that way in the future, because you have so many different factors that go into how science evolves over time, especially when you're talking about patients. I mean, there's so many different factors that go into a particular patient that you really need to think about what are the individual unique circumstances with this patient and use guidelines in general, but then you have to get really specific with each patient.

Katy: Yes, especially with all the wrinkles, with all the comorbidities that, unfortunately, our patient presented with here.

J. Baugh: Well, Katy, thank you for spending some time today talking about this case. I think we've learned a lot and we've taken a few points home that maybe will be able to help healthcare providers in the future provide better care to their patients.

Katy: I've enjoyed it, J. Thanks so much.

J. Baugh: Thank you.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host J. Baugh. 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, as specific legal requirements may vary from state to state and change over time.