OB-GYN Fails to Recognize Symptoms of Infection

This case takes place in Rhode Island and involves a 41-year-old female who had been scheduled for an appendectomy and a hysterectomy / bilateral salpingo-oophorectomy. The surgery was uneventful and the patient was scheduled for discharge from the hospital on the next day.  After the surgery, and before discharge, the patient experienced an elevated white blood cell count of 24 on the day after surgery and 20 on the following day.  The patient also experienced difficulty breathing after surgery. A chest x-ray taken two days after surgery revealed infiltrates in the right lower lobe of her lung. The patient had contracted a serious blood infection referred to as an anaerobic septicemia. She was nevertheless discharged home with a prescription for Zithromax, and set for an office visit in 2 weeks.

In the days after her discharge she began experiencing an altered mental status. Four days after the surgery she was brought back to the hospital by her family and was admitted, at which point she came under the care of her family doctor. She was given medications to calm and sedate her, and a stronger antibiotic, Levaquin. No tests were done to determine the cause of the respiratory problem, and her blood oxygenation and related vital signs were not watched adequately. Two days after she was admitted she began experiencing severe respiratory distress, but repeated complaints by the patient and her family were ignored by the nursing staff, until the patient began to turn blue. Later that day she was ordered to be transferred to the ICU. By the time adequate treatment had begun, the patient’s blood oxygen saturation had fallen to 42, and her brain had been deprived of oxygenation for an extended period. As a result, she suffered permanent brain damage.

Question(s) For Expert Witness

Expert Witness Response E-007825

I do believe that the treating physician should have recognized the patient’s symptoms as suspicious for infection. Further investigations were warranted prior to discharge. Based on the case summary it seems that there was potential negligence on the part of the defendant. This is a very bad outcome and falls below the standard of care.

At first brush, without seeing the medical records, the event timeline based on the brief summary of the case suggests the need for a more vigorous work-up and aggressive treatment for this patient, prior to her initial release and even after her second admission. The differential of post-op shortness of breath and mental status changes would have included pulmonary embolus as well as infectious or medication-induced; a chest x-ray suggesting pneumonia and a significantly elevated white count would have certainly made infection a more likely diagnosis. Her altered mental status at readmission should have prompted an aggressive evaluation as well, particularly in light of her recent diagnosis of septicemia. Clearly, a delay in recognizing the gravity of the problem contributed to her permanent encephalopathy.

This apparent issue comes down to physician judgment regarding the timing of the discharge and follow-up (one to two days vs. two weeks). Judgment is also in question with re-admission with progressive symptoms that were not apparently evaluated and were attributed to psychiatric causes versus medical.

The respiratory and infectious issues and possible causes of the altered mental status clearly needed to be addressed first and thoroughly before considering psychiatric issues as the cause of the altered mental status.

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