Episode 083: Crucial Communication

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, because I feel like we can always learn something when we look at one of these closed claims. We have back with us, Katy Smith. Katy, welcome.

Katy: Thanks J. Glad to be here.

J. Baugh: It's good to have you. Katy and I are both senior claims attorneys here at SVMIC. Katy has been here for 13 years, I've been here for 18, and so we've seen a lot of cases during our time here at SVMIC. Today we're going to examine a case where non-communication was the plaintiff's overriding theme, and Katy, it seems like we talk a lot about communication when we talk about these closed claim cases, don't we?

Katy: Yes, that is an issue that continues to surface. It's very important.

J. Baugh: It's one of those issues that we see recurring in these cases, and so we really need to talk about how communication can be very important when it comes to these types of cases.

Katy: And this particular close claim demonstrates how crucial communication is between providers, patients, we are one complete unit. So providers have to have a full clinical picture of what is going on with the patient to appropriately treat them, you know, not just the symptoms of one component of perhaps the multiple issues that are ongoing.

J. Baugh: So this case involves a 26-year-old female that presented to her local emergency department over the weekend, with a chief complaint of left abdomen and lower quadrant pain. No cardiac, respiratory, or acute stress was noted. The patient had a pain level of nine out of 10. The blood pressure was 141 over 67, her heart rate was 89, and her O2 saturation was 97%. The ED physician did a workup, ordered an abdominal and pelvic CT with contrast and an ultrasound. The CT returned an impression of an 11 centimeter, left-sided pelvic mass arising from the patient's left ovary, and the ultrasound findings were consistent with a large ovarian cystic lesion.

Katy: So after the workup had been completed, the ED physician contacted the on-call OBGYN, and our ER physician would later testify in her deposition that during this phone call with the OB, the ER physician detailed the patient's symptoms and the findings, including her stable condition. The test results were reported to the OB, and both of the physicians agreed upon a plan for the ER physician to admit the patient for pain management. The ER physician wrote the admitting orders and admitted the patient under the OBGYN's care. According to both providers, it was the OB's intention to have the patient admitted to the floor overnight, and he would evaluate her in the morning, and likely perform surgery unless there was a contrary indication. Unfortunately for everyone involved, the patient never reported to any of the providers in the ER setting that she had a history of severe sleep apnea for which she used a CPAP device.

J. Baugh: So the ED physician testified that she mentioned in her phone conversation with the on-call OBGYN that she had given an eight-milligram dose of morphine to the patient, but she wasn't sure when it was given. While the patient was still in the ED, she continued having complaints of pain. So, the ED physician ordered a second dose of morphine, this time it was five milligrams after the patient was admitted to the floor around 1:20 AM. At this point, the patient was assessed by one of the floor nurses. The floor nurse obtained the patient's medical history and noted the patient was obese, suffered from severe sleep apnea, and was noncompliant with her use of a CPAP device. This is the first time that the patient told any of the providers that she had severe sleep apnea. During the assessment, the patient's oxygen saturation level was charted at 98%.

Katy: However, when the patient's vitals were checked later at 3:25 AM, her oxygen saturation level had dropped to 90%. This was never communicated to anyone by the floor nurses. During this check, the patient continued to complain of pain. So the floor nurse called the OBGYN, requesting stronger pain medicine. The OBGYN testified in his deposition that he knew the patient had received a dose of morphine previously, and as J reported, she had received two doses of morphine but didn't receive any information on the dosage, or the timing perhaps. And during the call with the floor nurse, the OB, regardless, he ordered one milligram of Dilaudid, stronger than the morphine she'd previously received. 

The nurse was deposed and testified during the case, and she explained that she did not tell the OBGYN the pain score level or any other information, such as the sleep apnea report or the decrease in oxygen saturation. She simply explained the situation, telling the OB that the morphine wasn't working. The nurse had no recollection of any other information besides that, and it can happen to any provider. Really compartmentalizes the care, at this point. She's calling about an issue that the patient is experiencing her ongoing pain, but all she addresses is just that one issue when she has the opportunity to discuss all of the issues that are presenting to this OBGYN.

J. Baugh: So far as we've gotten through the facts of this case, we've already seen a couple of communication problems. As you mentioned earlier, Katy, you not only have communication issues between patient and physician, or healthcare provider, but you also have communication issues between the various providers of healthcare.

Katy: Yes.

J. Baugh: Especially in a hospital setting. So we're already seeing, as we're going through the facts of this case, both types of communication issues. So the nurse administered the medicine and woke the patient 30 minutes later to obtain the pain score. She checked on the patient again at 5:20, saw she was okay, and then did a safety check at 7:10. Unfortunately, at that point, the nurse found the patient unresponsive and called a code. When the OBGYN arrived at 7:30, he learned the code had been called and that the patient's respiratory suppression was likely caused by the opiates in the context of her sleep apnea condition.

Katy: So not surprisingly, the patient's estate filed a lawsuit against the hospital, the emergency room physician, and the OBGYN, alleging that the patient died from hypoxia and cardiopulmonary arrest caused by respiratory depression, which was exacerbated by sleep apnea and the administration of morphine and Dilaudid in the six hours prior to the code. The plaintiff alleged that the provider's prescribed narcotics that were too strong, and then failed to take appropriate measures to monitor the patient after administering these medicines to an opiate naive patient who has sleep apnea.

J. Baugh: So the OBGYN would later comment in his deposition, "It would have been nice to have known that the patient had severe sleep apnea." And I think that makes the defense of this case difficult. So although he testified that he would've ordered the same analgesic, he did say that he may have ordered monitoring for the patient. And it's not difficult for a jury to assume that if he had just asked the floor nurse, he would have known, and this could have made all of the difference in this case. If he had just asked and gotten the information that he needed, then the outcome might've been much different. The hospital and the ER physicians settled the case prior to trial, and the OBGYN went to trial with expert support. And we see that sometimes in cases when you have multiple defendants, when you have multiple healthcare providers, maybe a hospital's involved, maybe a nursing home's involved, you have multiple defendants, sometimes you have cases in which certain parties will settle.

Katy: Right.

J. Baugh: And other parties will decide to go to trial, either because they want to, or maybe they try to settle and can't reach an amount that's agreeable to everyone. So we do see that from time to time, where certain defendants will settle out of the case and other defendants will go to trial. That's what happened here. The OBGYN went to trial, had expert support, but the jury found him to be liable for a small percentage of a six figure verdict.

Katy: So they are a couple of key takeaways from this case. First is the need to ask questions. Providers need to solicit information from all of the people who are involved in treating the patient. What are the medications that have been given? When? What are the doses? What are the vital signs? Are there any changes in the patient? And in this case, most significantly, what is the patient's medical history? Another key takeaway is to know a patient's condition before prescribing medications. A third is, don't rely on others to give you the information that you personally need to treat the patient. If necessary, go to the hospital. And certainly in situations where you're continuing to get calls about a patient, as in this case, she continues to struggle with pain, something else is going on or could be going on. So maybe the best option for you at this point, to provide your best care, is to go to the hospital and eyeball her. Look through the chart. A final takeaway is this idea that you may be judged on what you should have known rather than on what you actually knew at the time. So go ahead and be proactive. Dig into information for your patient, wherever you can find that.

J. Baugh: Yeah, I think sometimes with these cases, when we're talking about communication and how important that is, there are at times a resistance, it seems, to ask for the information that you need.

Katy: Right.

J. Baugh: And I can understand why that might happen. You might be very busy, it could be that there are personality differences between the parties who are trying to exchange information. There could be several different reasons why there might be a resistance and asking for the information, but it's really important to do that. You can't just simply rely on what you're told, especially if what you're told should lead you to ask some other questions. And so, you need to go ahead and ask those questions and try to get all the information you can, and remember that what you're doing is trying to treat the patient.

Katy: Exactly.

J. Baugh: And sometimes you have to work through those difficulties in order to get all the information that you need to treat the patient properly.

Katy: J, I think you said it really well. I think the key is not compartmentalizing what you're dealing with with the patient, but treat the whole patient.

J. Baugh: Yeah, that's right. Communication really is the key when it comes to treating patients. Katy, thank you for being here today and talking with us about this closed claim. I really appreciate your being here.

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

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. All names in the case have been changed to protect privacy.