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    Legally Speaking Case hinges on timing of bowel perforation

     

    Facts

    A 45-year-old woman was admitted to a hospital on March 29, 2010, with a diagnosis of myoma/menorrhagia. On April 1, 2009, and January 22, 2010, the patient had undergone transvaginal ultrasound at another hospital and at the defendant hospital, respectively. Both of those studies demonstrated multimyomatous uterus. Two exophytic fibroids (broad-based) were near the fundus of the enlarged uterus and 2 intramural fibroids were at the lower uterine segment. The defendant ob/gyn testified that injury to the small bowel was a specific risk of a myomectomy about which the plaintiff was advised prior to surgery. On March 29, 2010, the defendant ob/gyn, along with the chief resident and a PGY-2, performed an abdominal myomectomy on the woman. The operative report indicated that there were no complications during the procedure and that the abdomen was explored more than once before closure.

    The first postoperative note at 5:45 pm on March 29, indicated that the patient was afebrile, but her urinary output was only 200 mL over the past 2 hours. (The patient had a Foley catheter inserted in the operating room.) At 6:30 pm, the patient’s temperature was 101°F and the chief resident was notified. A subsequent note by the nursing staff at 9:30 or 9:50 pm notes that the patient was doing well and that her Foley was draining adequate urine. By 1:15 am on March 30, however, a nurse’s note indicates that the patient’s urinary output was only 50 ml since 11:00 pm and her temperature was 101.4°F. The chief resident was notified and indicated that he would be coming to see the patient. The nurse’s note at 2:20 am indicates the patient was reassessed and her temperature was 101.8° F. Urinary output was described as cloudy but the amount was not noted. The chief resident ordered 650 mg Tylenol and a urinalysis and culture.

    A progress note at 2 am, presumably by the chief resident, notes that the fever was possibly secondary to hormonal response status post-myomectomy. He spoke with an attending. By 5:00 am the nurses report that the patient’s urinary output was approximately 40 mL from 2 am to 5 am. The chief resident was notified and discussed this with the attending. The decision was to give the patient a bolus of fluid and to replace the Foley catheter.

    At 8:20 am the defendant ob/gyn noted that the patient’s fever was 102°F and her pulse was 108. He also found her abdomen to be distended and moderately tense with guarding and mild tenderness. Furthermore, he noted mild-moderate rebound in the upper quadrants. He noted that the patient had decreased urinary output during the night, despite 2000 mL of ringers lactate bolus and at that time, she had only about 50 mL over the last 2 hours. His assessment was “rule out intra-abdominal operative bleeding.” He ordered a stat complete blood count and volume expanders, and her status as NPO with a possible return to the operating room if continued “bleeding suspected.”

    At 9:30 am the resident noted that the hematocrit and hemoglobin was acceptable and that the patient still was mildly tachycardic, with a pulse rate of 100 and a temperature of 100.2°F. The patient was discussed with the defendant ob/gyn and the plan was to continue her NPO.

    By 11:15 am, a nurse noted that the patient had no urine output. The resident was notified and saw her at 12:15 pm, at which time her abdomen was still noted to be distended with positive rebound and guarding.

    At 1:10 pm, the patient complained of feeling bloated and short of breath. Her oxygen saturation was found to be 95% on room air and her pulse rate remained tachycardic at 102. The resident was notified and the patient was sent for a computed tomography (CT) scan of the chest and abdomen. The studies were read by defendant radiologist, who noted that there was a “mild to moderately layering pelvic hemorrhage. No evidence of active extravasation on the single phase post-contrast CT…” When th defendant ob/gyn saw the patient at 7:10 pm, he noted that her abdomen was more distended, very tense, and hard. In addition, her urinary output was still “scant.” He indicated that there was blood in the belly, secondary to postoperative bleed and that it was “unclear if bleeding has stopped.” He noted a plan to repeat the hematocrit and hemoglobin levels.

     

    Andrew I. Kaplan, Esq
    Mr. Kaplan is a partner at Aaronson, Rappaport, Feinstein & Deutsch, LLP, specializing in medical malpractice defense and healthcare ...

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