Presentation
A 74-year-old woman visited Cardiologist A with symptoms of congestive heart failure. She had a history of dilated cardiomyopathy, mitral valve regurgitation, and significant pulmonary hypertension. An electrocardiogram (EKG) revealed significant left ventricular dysfunction with moderate mitral valve regurgitation, and an apical thrombus in the left ventricle.
Physician action
After his evaluation, Cardiologist A recommended right and left heart revascularization with possible defibrillator placement, and warfarin therapy. Two days later, the patient was taken to surgery.
While performing the surgery, Cardiologist A was assisted by Cardiologist B who was part of a university fellowship program. Cardiologist A’s staff privileges included training and supervising Cardiologist B.
Upon performing the left heart catheterization, Cardiologist A found that the left internal mammary artery and left anterior descending artery were unobstructed. He proceeded with a percutaneous transluminal coronary angioplasty. These actions were not noted in the operative report or medical record.
Cardiologist A placed the stent in the first diagonal artery. While preparing the stent for the main artery, Cardiologist A noticed a slight spasm. He instructed Cardiologist B to give nitroglycerin to relax the heart muscles. Cardiologist B administered the nitroglycerin through a catheter with a saline flush. Seconds later, Cardiologist A noticed the QRS complex of the EKG began to widen and the patient went into ventricular fibrillation and then cardiac arrest. The catheter was pulled, and Cardiologist A noticed the saline flush coming out of it. He realized that Cardiologist B had not closed the saline flush valve after giving the nitroglycerin.
CPR was administered for approximately 30 minutes. Once the patient stabilized, Cardiologist A checked the diagonal artery for patency and found no evidence of stent thrombosis. He spoke with the family about continuing the procedure, although they deny the discussion took place. He then proceeded with a left main stent followed by intra-aortic balloon pump. The patient’s hemodynamic condition improved and a temporary pacemaker was placed.
The patient was transferred to the Critical Care Unit, but became unresponsive once she arrived. She was placed on mechanical ventilation and was hypoxic for approximately 30 minutes with saturations of 88% down to 84%. There was no gag reflex and she was not considered a candidate for hypothermic protocol secondary to prolonged hypoxemia.
The patient never regained consciousness nor had any improvement in neurological function. She died less than a year later.
Allegations
The family filed a lawsuit against Cardiologist A alleging:
- failure to treat the patient conservatively before attempting a high risk, invasive procedure;
- failure to supervise Cardiologist B;
- failure to disclose Cardiologist B’s actions to them; and
- failure to properly document his actions in the medical record.
Legal implications
Consultants for the plaintiff did not agree with Cardiologist A’s decision to proceed with an invasive procedure that was not medically necessary. Defense consultants expressed similar concerns. Cardiologist A’s lack of documentation in the medical chart also affected his credibility. In addition, the family testified they were not informed of Cardiologist B’s involvement until after they filed suit.
Cardiologist A admitted in deposition that he had control over all of Cardiologist B’s actions due to his responsibilities in supervising and training cardiac fellows in the university fellowship program. This included telling the cardiac fellow to shut the valve after administering the nitroglycerin during the catheterization procedure.
Disposition
Given the multiple defense challenges, this case was settled on behalf of Cardiologist A.
Risk management considerations
When Cardiologist A accepted the responsibility of supervising and training cardiologists in the fellowship program, he assumed vicarious liability for these cardiologists. Vicarious liability extends liability beyond the original defendant to a person or entity responsible for the defendant’s actions. In this case, Cardiologist A was vicariously liable for the actions of Cardiologist B.
Procedure notes should accurately reflect the details of the procedure, including any complications. Effort should be made to avoid a documentation approach that, apart from the date, makes each procedure read the same. Templates can be used; however, prepopulating the script can make the notes appear as if the physician was hurried and did not take time to accurately document what happened during a procedure. A thoroughly documented procedure note provides a good reference should the physician need to recall details of his course of actions and may also be valuable to subsequent treating physicians.
Fully documenting discussions with patients and family members is also important in the event of a bad outcome. In the record, include who was present, what matters were discussed, decisions made, and outstanding matters, along with the date, location, and time. Guidance on how to best document patient and family discussions and decisions in the patient’s records may be attained from a qualified attorney. Hospitals and other large providers usually employ legal counsel to provide such guidance.
