Presentation
A 31-year-old woman arrived at a rural hospital emergency department (ED) with severe nausea, vomiting, and abdominal pain that had lasted for two days.
Previously, the patient was seen by her primary care physician (PCP) and scheduled for an endoscopic retrograde cholangiopancreatography (ERCP). The PCP suspected that the patient had gallstones and pancreatitis.
In the ED, the patient’s white blood count (WBC) was significantly elevated at 26.7. Her amylase was more than 8,000 (normal range is 23 – 85 u/L) and lipase more than 69,000 (normal range is 0 – 160 u/L). She was transferred to a large, urban hospital for acute care.
Physician action
Gastroenterologist A admitted the patient. Her WBC had dropped to 17.4, but her amylase and lipase were not tested. An endoscopic ultrasound was performed, and results indicated that the patient’s gallbladder did not contain any retained stones.
A general surgeon examined the patient and recommended a laparoscopic cholecystectomy with an intraoperative cholangiogram. The surgeon took the patient to surgery and performed the procedure without complications. There were also no postoperative complications.
Early the next morning, the patient experienced an episode of tachycardia. The surgeon ordered continued IV infusion and monitoring of the patient. Later that day, the patient was discharged with approval from the surgeon and Gastroenterologist A.
The discharge summary indicated the patient was eating and drinking without significant pain, nausea, or vomiting, and that she was walking without difficulty. The patient was instructed to follow up with her PCP within two weeks and was prescribed pain medications, to be taken as needed.
Twelve days later, the patient returned to the rural hospital ED and reported an inability to urinate with bladder pressure lasting for three days. WBC was significantly elevated at 36,000. Amylase and lipase were elevated at 722 and 436, respectively. A CT showed phlegmonous pancreatitis. The patient was transferred back to the urban hospital.
The admitting hospitalist contacted Gastroenterologist B, the gastroenterologist on duty, and requested a consult. Gastroenterologist B agreed that the patient needed a surgical consult and that her condition was possibly related to the procedure performed two weeks earlier.
The patient was diagnosed with pancreatitis, pancreatic pseudocyst, superior mesenteric vein (SMV) thrombosis, and main portal vein thrombosis. She had significant occlusions caused by blood clots.
Gastroenterologist B and a hematologist saw the patient the next day. The hematologist ordered warfarin and monitoring for bleeding complications due to the pancreatic pseudocyst. He noted, “necrotizing pancreatitis” in the chart, and that after anticoagulation, the patient required a hypercoagulable work up to rule out other underlying conditions.
One week later, the on-call hospitalist discharged the patient. Documentation indicated that the patient’s warfarin level was in therapeutic range. She was given a prescription for warfarin and instructed to follow up with her PCP and “other physicians” within one week.
Two days later, the patient returned to the rural hospital ED with severe abdominal pain. When a CT scan was performed, hemorrhagic pancreatitis was discovered. She was also severely hypotensive.
The patient was transferred back to the urban hospital. She was given blood pressure support medications and her hemoglobin was 8.3 and hematocrit was 25.7. Lipase was elevated to 1829. The patient was admitted to the ICU and seen by critical care and pulmonary care specialists.
She went into acute renal failure and was seen by a nephrologist. The patient had active bleeding in two locations — the gastroduodenal artery and the jejunal branch of the superior mesenteric artery (SMA).
Due to respiratory failure, the patient was placed on a ventilator. The treating physicians were unable to maintain adequate blood pressure, and the patient developed episodes of bradycardia. Despite reversing the coagulopathy, she developed refractory hypotension and hypoglycemia. The patient had a cardiopulmonary arrest and died.
Allegations
The patient’s family filed a lawsuit against Gastroenterologist A. The allegations included failure to test the patient’s amylase and lipase levels postoperatively and discharging the patient prematurely instead of treating her for pancreatitis.
A lawsuit was also filed against the hospital’s gastroenterology group for vicarious liability.
Legal implications
It was alleged that Gastroenterologist A failed to obtain the patient’s outpatient labs at discharge during the first hospitalization. However, the defense consultants indicated it is not common practice to rely on one parameter, such as lipase, to determine if a patient can be discharged. Many patients with acute and chronic pancreatitis can be discharged with abnormal amylase or lipase, as long as the values are trending downward and the patient is clinically improving.
Defense consultants were concerned that a CT scan of the abdomen was not performed during the first hospitalization, as this may have shown that the pancreatitis was more severe than first thought. The patient did not have follow-up care arranged with her PCP, and there were no provisions for home health monitoring of her warfarin levels and severe pancreatitis.
Disposition
The lawsuit was settled on behalf of Gastroenterologist A and the group.
Risk management considerations
A defense consultant questioned the use of warfarin in this patient. He cited a study that found no evidence to support that treating acute pancreatitis with anticoagulation therapy is either beneficial or detrimental to the patient. (1) Due to the patient not securing a clear discharge plan from the hospitalist, including monitoring of warfarin levels, the consultant took exception to prescribing anticoagulants.
Although the hospitalist urged the patient to remain in the hospital for further monitoring, the patient indicated that she wanted to be discharged. Her discharge orders included follow up with her PCP and other physicians within a week. However, the patient failed to list a PCP on her admitting paperwork. No arrangements were made for home health care or any other specific follow up.
Had the discharging physician established follow-up care for the patient, including discussing the patient’s condition with her PCP, the subsequent hospitalizations may have been avoided. Taking these actions would have also prepared the patient for continued self-care. In addition, scheduling follow-up appointments assists the patient, who may be in a weakened state and unable to act alone.
Source
1. Nadkarni HS, Naina HV, Vege SS. Splanchnic vein thrombosis in acute pancreatitis: A single-center experience. Pancreas: Journal of Neuroendoccrine Tumors and Pancreatic Diseases and Sciences. Volume 42, Issue 8. Available at http://journals.lww.com/pancreasjournal/Abstract/2013/11000/Splanchnic_Vein_Thrombosis_in_Acute_Pancreatitis_.9.aspx. Accessed May 12, 2017.
