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    Was it an infection? A jury decides

     

     

     

    Andrew I Kaplan, Esq, is a partner at Aaronson, Rappaport, Feinstein & Deutsch, LLP in New York City, specializing in medical malpractice defense and health care litigation. 

    Facts

    On May 14, 2010, a 41-year-old woman was admitted to a hospital's ambulatory care center by a private attending gynecologist for a D&C, saline hysteroscopy, and resection of a submucosal myoma. The patient had a history of 2 prior cesarean deliveries, a right ovarian cystectomy, and ventral hernia repair. The gynecologist was assisted by an ob/gyn chief resident who had discovered the patient’s 1.4-cm endometrial lesion during a recent evaluation for menometrorrhagia.

    The patient was taken to the operating room and placed under general anesthesia via LMA. Mannitol solution was infused to dilate the uterus for evaluation. After the hysteroscope was inserted, a probable fundal submucosal myoma was visualized. The patient was dilated to allow for insertion of the resectoscope into the uterine cavity. A myoma measuring 1.5 x 1 cm was resected in 2 parts and retrieved for pathology. A mannitol deficiency of 950 ccs was noted and the suspicion was potential uterine perforation as the cause. Upon reinserting the resectoscope, a small 1- to 2-mm fundal perforation was identified. There was no active bleeding from the site. All instrumentation was removed and the codefendant ob/gyn observed the patient intraoperatively for approximately 10 minutes to make sure there was no excess vaginal bleeding. The procedure was then terminated. The defendant ob/gyn decided to admit the patient for observation overnight rather than repair the uterine perforation intraoperatively or obtain surgical consultation.

    In his dictated operative note, the codefendant ob/gyn wrote: “…patient was being admitted for observation with Foley catheter that was inserted. Strict I’s and O’s, CBC and electrolytes to be monitored closely throughout the night and decision about further procedures will be determined based on clinical findings. Because of the patient’s previous surgical history, laparotomy as opposed to laparoscopy will be required if clinically necessary.” A mannitol deficiency of 950 ccs was noted. Intravenous (IV) Kefzol was infused intraoperatively. Pathology confirmed a submucosal leiomyoma with underlying muscle.


     

    At 8 PM on the day of surgery, a nursing note documented guarding and pain on movement, which was consistent with local peritonitis. The patient’s white blood cell (WBC) count spiked to 16.90 (nl: 4.0–10.6) in the 8 PM labs. The plaintiff was receiving IV fluids at a rate of 150 ccs per hour and her urinary output was decreasing. At 12:30 AM on May 15, the patient reported pain of 10 out of 10 and repeat complete blood counts (CBCs) were done at 12:09 AM, 3:08 AM, and 6:42 AM; the WBC counts were 5.69, 3.01, and 3.54 respectively. In the early morning hours the plaintiff was described as tachypneic and her urine output was still decreasing. Her abdomen was described as “hard.” She was prescribed toradol for abdominal pain and given fluid boluses. By 6 AM the patient was suffering tachycardia and hypotension. Notes reflected that the codefendant ob/gyn was made aware of all findings overnight and directed continued observation.

     

    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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