by Wayne Wenske, Senior Marketing Strategist, and
Stacey Agnew, Risk Management Representative
Presentation
A 31-year-old woman came to her obstetrician-gynecologist (ob-gyn) on August 22 for a well-woman exam. The patient reported pelvic and abdominal pain for a year and leaking urine when coughing or sneezing. The patient had a history of leaking urine and kidney stones.
A pelvic ultrasound showed a left ovarian cyst suggestive of an endometrioma. The ob-gyn recommended a bilateral oophorectomy. The ob-gyn obtained informed consent from the patient, and surgery was scheduled.
Physician action
On August 18, the ob-gyn took the patient to surgery. During the procedure, the ob-gyn discovered that the patient’s descending colon was adhered to the left abdominal sidewall. The left ovary could not be identified. The procedure was changed to a multi-port robotic surgery. The adhesions were broken down by lysis and freed, and the descending colon was freed from the left abdominal wall. The pneumoperitoneum was evacuated. No complications were noted.
Post surgery, the patient reported a high level of pain. She was admitted for observation and pain management. Lab work and vital signs were normal. The nurses reported that the patient was clinically sound for discharge on August 19.
The patient came to the emergency department (ED) on August 23 with fever and lower left abdominal pain. Her vitals, lab work, and a CT scan were all normal, and she was sent home. The patient returned to the ED on August 25 with the same symptoms and was again sent home after test results and vitals were normal.
On August 28, the patient returned to the ED and was admitted to the hospital. An on-call urologist performed a cystoscopy and stent placement. During surgery, the urologist found and repaired two holes in the patient’s bladder. The urologist noted that the area was gray/white, consistent with burn injuries from the cautery used in the August 18 surgery.
A colorectal surgeon examined the patient’s abdominal cavity and found a large amount of stool, succus, and bowel content with gross food. The surgeon also found a significant perforation in the patient’s sigmoid colon in the left lower quadrant. The perforation was resected in its entirety to the proximal rectum.
The left colon was firmly adhered secondary to the inflammatory reaction and abscess in the left lower quadrant. The plaintiff’s ascending colon was mobilized and brought out as a loop colostomy. No complications were documented.
The patient remained in the hospital for approximately eight weeks. During that time, she experienced acute renal failure, sepsis, and altered mental status. She was also kept on a ventilator for part of her stay.
The patient was discharged on October 23. She requires an ostomy bag, incontinence medications, and annual cystoscopy.
Allegations
A lawsuit was filed against the ob-gyn with allegations of:
- improper performance of laparoscopic bilateral oophorectomies, causing pelvic pain and resulting in colon and bladder injury;
- failure to consult a general surgeon to assist with taking down the adhesions during the August 18 surgery; and
- failure to timely diagnose bowel perforation due to surgical injury.
Legal implications
The plaintiff’s expert stated that the ob-gyn damaged the patient’s bowel when she dissected it off the ovary. This expert criticized the use of cautery to take down adhesions, stating that the ob-gyn should have limited the use of cautery near the bladder and bowel to prevent “thermal injury and eventual breakdown.” This expert argued that sharp dissection was the preferred method.
The plaintiff’s expert further stated that the ob-gyn should have consulted with a general surgeon to assist with taking down the adhesions. The ob-gyn testified that the procedure was within her training, and she had successfully performed similar procedures without a general surgery consult.
A difficulty for the defense of this case was the length of time that elapsed between the oophorectomy and diagnosis of the bowel and bladder injuries. The patient’s continued reports of abdominal pain and repeat visits to the ED should have alerted the ob-gyn to the possibility of surgical complications.
Consultants for the defense stated that the perforation of the patient’s sigmoid colon from an electrocautery burn is a known complication of this procedure, but that it takes three-to-five days for the area to “necrose and open up.” The ob-gyn would not have known about the injury during the surgery. Further, they felt the delay in diagnosis was understandable given that the patient’s vital signs and labs were normal.
One defense consultant also noted that the ob-gyn’s preoperative documentation was substandard, with illegible handwritten notes and lack of detail.
Disposition
This case was settled on behalf of the ob-gyn.
Risk management considerations
Repeat visits to the ED should be closely watched for post-surgical patients. In this case, the patient came to the ED three times within 10 days of the initial surgery before being admitted to the hospital. It is unclear if the ob-gyn was notified of the patient’s multiple visits to the ED; however, the patient’s continued abdominal pain should have indicated a possible complication.
Accurate, legible, and complete documentation can be your best defense against a medical liability claim or a board action. Even with electronic health records, the use of handwritten notes is still sometimes seen in hospitals and physician practices. Handwritten notes that are illegible can pose problems, including a delay in care or misinterpretation by other health care professionals.
Additionally, the Texas Medical Board (TMB) has rules that outline standards for an “adequate medical record” that include legibility. (1) A medical board may discipline physicians if their medical records are incomplete or illegible.
Source
1. Texas Administrative Code. Chapter 165. Medical Records. Rule 165.1. Available at https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=165&rl=1.
Accessed August 15, 2024.
Wayne Wenske can be reached at wayne-wenske@tmlt.org.
Stacey Agnew can be reached at stacey-agnew@tmlt.org.
