Tripping Points in a Hospital Handoff: A Case of Retrospective Clarity

A news article claimed that the patient died from surgical complications, but that he would have lived if, in the words of his daughter, “the surgeon and the staff had paid more attention to him.” 

The autopsy revealed perianastomotic bowel perforation. A news article claimed that the patient died from surgical complications, but that he would have lived if, in the words of his daughter, “the surgeon and the staff had paid more attention to him.” The lawsuit alleged failure to timely diagnose and treat a bowel perforation, resulting in sepsis and death.

Was this a case of hindsight bias, too little, too late, or damned-if-you-do-damned-if-you-don’t? Dr. S would tell you it was all three. He was the surgeon who assumed care for the patient when his colleague who’d performed the surgery went off duty for the weekend. Put yourself in his shoes as you read through this case, and consider how you might have responded at each decision point.

A Complicated Surgery
The patient was a 67-year-old man with a history of COPD, asthma, diabetes, hypertension, obesity, and an abnormal EKG. Surgery to remove a pre-cancerous colon mass had been successful, although it required conversion from a laparoscopic to an open procedure, due to scarring from prior surgeries. Before transferring care the next morning to Dr. S, the surgeon rounded with the patient and confirmed normal vital signs.

When Dr. S saw the patient on his second post-operative day, he was sitting in a chair visiting with family. Along with a first-year resident, Dr. S confirmed an abdominal exam within expected parameters, with no signs of infection. 

On the morning of the third post-operative day, the patient told the resident he wasn’t feeling well. The resident didn’t find the vital signs concerning, and helped the patient with pain relief. When the resident saw Dr. S early that afternoon, he didn’t mention that the patient’s creatinine had doubled from the day before, with an increase to 3.0.  

Dr. S learned about the elevated creatinine at 3pm, when a rapid response team transferred the patient to the ICU with decreased mental status, hypotension, and decreased urine output. He was tachycardic, and a chest x-ray showed effusion and atelectasis.

Justification for Delay?
At that point, Dr. S was eager to get his patient to the OR. His assessment included sepsis, hypovolemia, abdominal compartment and renal-ureteral injury. But without a clear diagnosis, it was too risky to take this unstable patient into surgery. He needed an ultrasound to either rule out a renal-ureteral injury, or to involve a urologist in the surgery. Since Dr. S had to wait for the test result, he didn’t declare an emergency when reminded that it was Sunday, which meant only one available OR suite.

Even if he had called an emergency, it would likely have taken two hours to get a second team and prep an operating room. For that reason, he felt justified in waiting for a repeat ultrasound result when the first result lacked critical information. He accepted the next available OR time slot for 6pm.

Dr. S discussed the plan of care with the patient’s wife and daughter. During his informed consent review, he took extra time to answer their questions and brought up the possibility of major complications, including death.

Just after the second ultrasound confirmed no obvious ureteral injury, the patient went into cardiac arrest. Dr. S called a code and delivered the first set of electrical shocks.  After three hours of rescue attempts, he notified the family that their loved one had died. They expressed gratitude to Dr. S for his efforts to revive him.  Then they requested an autopsy to “see what happened.”

Only in Retrospect
In retrospect, Dr. S would have taken his patient to the OR earlier. But only in retrospect was it clear that the patient was septic. The clinical findings at the time did not show signs of sepsis. In a mock-trial focus group, 95% agreed the patient was too weak on the third day to be rushed back into a second surgery. Only 20% agreed that the patient would probably be alive today if he had been taken to surgery sooner. 

Would the patient have died from septic shock in a week or two even if he had survived the surgery? That’s what the defense attorneys argued, supporting Dr. S’s more cautious approach. They asserted that the standard of care had been met for this patient who presented with a complex medical history, after a complicated surgery.

But even the defense experts had concerns that there was sufficient reason to go ahead with surgery without waiting for the results of the second ultrasound. As for the plaintiff experts, they used hindsight to their advantage, along with additional factors that became barriers in Dr. S’s defense.

The Resident
It goes without saying that the resident should have relayed the abnormal lab results. However, both the plaintiff and defense expert testified that the resident met the standard of care. By relying on the assessment of a first-year resident, Dr. S greatly increased the risk to his patient, and compounded his own liability.

The Nurse
The ICU nurse criticized Dr. S’s care. Her deposition noted that she repeatedly voiced concerns about the patient’s low blood pressure and heart rate with Dr S.  In her opinion, not enough was being done for him, and while Dr. S didn’t recall her expressing that opinion, the patient’s family did.

The Family
The patient’s wife declared that everyone at the hospital stood by idly while her husband suffered. His daughter tearfully agreed. She also let it be known that her dad had been the sole caretaker for his mother, and that the family couldn’t afford to hire a caretaker.

The Timing
We may not know if the patient would have survived if he’d gone to surgery sooner. But unquestionably he was a patient that required close monitoring. The judge concluded that had Dr. S seen the patient earlier on Sunday morning and ordered the ultrasound of both the upper and lower abdomen simultaneously, he would have been aware hours earlier that the patient’s current problem was not with the kidneys or ureter. When sepsis is a possibility, every minute matters.

Lessons from the Rearview Mirror
Dr. S has adopted two practices because of this case that have elevated his professional and personal life:

  1. He has a more collaborative relationship with residents. Dr. S calibrates care to the experience of the resident and the patient’s condition. He takes time to ask teaching questions, to learn about the residents’ perspectives, and to share his professional experience. He organizes quarterly meet-ups to review challenging case scenarios. His clinical skills and his teaching skills have improved as a result.
  2. He maintains a closer relationship with the medical team. He recognizes that he is the champion in care and leads the care team. Dr. S plays the role of active listener, acknowledging the viewpoints of nurses, other providers, and patients/families. He uses morning rounds to identify solutions to potential risk events.  At first, he doubted the practicality of encouraging team members to express their concerns, thinking he would never round past the first patient. But Dr. S found instead that sharing concerns expedited decision-making and strengthened morale. Patients and families have expressed that they feel more informed and included in important choices. Consequently, Dr. S is more likely to make better decisions, especially when time is a critical factor.

It took some additional training for Dr. S to incorporate these relationship skills which included professional counseling. He sought out workshops on teaching and rapport-building in a medical setting, and has made a commitment for continued learning. Beyond the improved skills and professional satisfaction, he’s happier overall. He feels a greater sense of purpose, more humility for the tough decisions and the unknowns—and more acceptance that despite his best efforts he will sometimes get it wrong.