OR WAIT null SECS
Case rests on physician’s ability to inspire confidence in choices made in the OR.
The patient was a 21-year-old single female with a presumed tubal pregnancy who presented to defendant Hospital Center on March 25, 2012 and came under the care of co-defendant-attending Dr A. A clinical history was obtained, including a last menstrual period (LMP) of February 2, 2012 and an estimated gestational age of 7 weeks 3 days. A transabdominal and transvaginal ultrasound (TVUS) revealed evidence of an ectopic pregnancy in the left adnexa of approximately 6 weeks 6 days.
The patient was taken to the operating room with a preoperative diagnosis of left ectopic pregnancy, under the auspices of Dr A along with fourth-year resident Dr B (who was not named in the case). The very brief operative report indicated that the “right tube appeared to have a corpus luteal cyst but otherwise was normal.” The left tube was identified and followed down to its fimbriated end with multiple adhesions but the ovary appeared normal. The postoperative diagnosis was right ectopic pregnancy with pelvic adhesions, and the findings were a “right fallopian tube with ectopic.” The operative report was dictated by Dr B on March 25 but signed by Dr A.
Surgical pathology was collected on the date of surgery but not received by the Pathology Department until March 26, so an ectopic was not verified prior to the patient’s discharge, which apparently occurred at 9:45 am on March 25. At that time, she was told to follow-up in the clinic in 1 week. The pathology report specifically reflected that there was “no evidence of trophoblastic tissue or chorionic villi seen.” The pathologist indicated that the case was later discussed with attending Dr C on April 2, 2012 (after the patient had returned and then left against medical advice).
The patient returned to the Hospital Center on March 30 after Dr B called her at home and told her to return to the hospital as soon as possible because of an error in the location of the ectopic pregnancy. The patient was admitted to gynecology, where she underwent a repeat transabdominal ultrasound and TVUS, which again revealed a single live ectopic pregnancy of approximately 7 weeks’ gestation in the left fallopian tube. The patient was seen by Dr D on Labor and Delivery who sent her back to the emergency department (ED) for a consultation with an ob/gyn for possible admission and repeat surgery. The electronic notes reflect, however, that the patient never returned to the ED and that a nurse called her half an hour later and found that she had left the hospital on her own accord and was at home. The patient refused admission to the Hospital Center and said that she would proceed to Hospital B. She was encouraged to take care of the ectopic pregnancy as quickly as possible to avoid rupture.
Later on March 30, the patient presented to Hospital B with a chief complaint of “lower abdominal pain, ectopic pregnancy and left fallopian tube.” She reported that surgery had been performed at the defendant Hospital Center on March 25 and that the wrong tube was removed. She was taking acetaminophen and oxycodone for her pain.
The emergency medical services (EMS) record attached to the Hospital B chart noted that the patient had been found seated and alert and oriented and had an ectopic pregnancy. She reported to have been admitted to the defendant Hospital Center from Sunday, March 25 through March 27 having been 7 weeks pregnant at the time. A sonogram had shown the fetus to be on the left side, but the doctors operated on the right side “due to error.” Today, the patient reported that she had been called by “the doctor” indicating that there had been “a mistake in procedure.” EMS noted that the patient had been in pain on and off since the procedure, and she reported bleeding vaginally, “heavy” for the first few days and currently “spotting.” She denied any other signs or symptoms. EMS reported everything else was unremarkable, including the fact that her airway was patent and her vital signs appropriate.
The patient was admitted to Hospital B on March 31. The history and physical indicated an assessment and plan regarding a 21-year old patient who was 6.1 weeks by LMP from open right salpingectomy, and a left ectopic pregnancy measuring 4.63 cm. The patient was to be admitted to gynecology for exploratory laparotomy and possible left salpingectomy. Her vital signs were normal.
A TVUS was performed that day; no prior study was available for comparison. It revealed the uterus to be of normal size with a thickened endometrium measuring up to 2.2 cm. No intrauterine gestation was identified. There were no uterine masses. There was a tubal ectopic pregnancy in the left adnexa with the fetal pole identified, with a crown-rump length of 1.3 cm compatible with gestational age of 7 weeks, 4 days. A positive fetal heart rate was present with a rate of 150 beats per minute. The left ovary was grossly unremarkable measuring 3.3 x 2.1 x 2.6 cm. The right ovary measured 3.2 x 2.4 x 2.8 cm. A corpus luteal cyst was present in the right ovary measuring up to 1.7 cm. The impression was a tubal ectopic pregnancy in the left adnexa as described with a small volume of hemorrhagic free fluid in the left adnexa.
On March 31, the patient underwent an exploratory laparotomy and left salpingectomy under general anesthesia, with estimated blood loss of 30 mL. The findings included a large left-sided ectopic pregnancy with placental tissue, grossly ruptured with mild-to moderate hemoperitoneum, and grossly normal ovaries bilaterally.
Given the significant destruction of the left tube secondary to the rupture, the decision was made that the tube could not be salvaged or repaired, and the decision was made to remove the entire fallopian tube. That was done, with sparing of all ovarian tissue and achievement of excellent hemostasis. The rest of the pelvis was examined and noted to be grossly normal. The patient was noted to have tolerated the procedure well and was taken to the recovery room in stable condition. The postoperative diagnosis was consistent with preoperative diagnosis of history of a previous ectopic pregnancy with right salpingectomy for the presumed right-sided ectopic pregnancy, acute surgical abdomen, and left ectopic pregnancy of approximately 7 weeks size with probable hemoperitoneum.
Thereafter, the patient was transferred to the post-anesthesia care unit, where her stay was unremarkable. She was cleared for discharge on April 1 with no follow-up.
NEXT: What's the verdict?
The allegations were that the patient had a left ectopic pregnancy and the physicians unnecessarily removed right fallopian tube. Plaintiff alleged failure to properly treat her left ectopic pregnancy and failure to perform an exploratory laparotomy for her left ectopic pregnancy. Plaintiff also alleged the unnecessary performance of a right partial salpingectomy, more likely than not, had rendered her either infertile or at a significant disadvantage in becoming pregnant in the future.
The patient testified that after she was discharged home from the first surgery she felt pain, nausea, and weakness; was unable to eat, had difficulty walking, and was generally uncomfortable. She recalled that she received a phone call from the Hospital Center and was told that her pathology did not show any evidence of ectopic pregnancy and that she would have to return to the hospital for another sonogram and emergency surgery. However, she had lost confidence in the defendant Hospital Center and decided not to stay. When she arrived at Hospital B, ultrasound was performed and a positive pregnancy was seen in her tube. She was told that she needed emergency surgery, and the surgery was done that same evening. After the surgery, she was told that there had been severe bleeding and that her tube ruptured, and the entire tube had to be taken out. The doctors informed her that it would be difficult for her to get pregnant in the future if she did not undergo in vitro fertilization.
Dr A testified that prior to “going into the pelvic cavity,” she did not expect to see anything on the right side. She testified that she visualized both fallopian tubes from where she was standing. She testified that she palpated the left tube and did not feel a mass. She also testified that she did not see any pathology on the plaintiff’s left side. When pressed as to whether she palpated the left tube, Dr. A testified that she did not remember what she or the resident did, although she later added that the left tube “looked bigger than normal.” She added, however, that upon entry of the pelvic cavity, the right tube was enlarged and hemorrhagic, thus highly suggestive of an ectopic pregnancy. She was satisfied with the quality of sonogram prior to surgery, and she did not contact the radiology department during the procedure. She testified that she had experiences where a mass was found on a side other than displayed in the preoperative sonogram and later testified that occurs in “50 percent of cases.”
Our ob/gyn expert believed that what most likely occurred was that Dr A visualized the top of the left tube, the proximal part, and saw adhesions, so she never examined the rest of the tube in an attempt to locate the ectopic. He opined she needed to take down the adhesions in order to visualize the entirety of the left tube. If Dr A was confused intraoperatively and could not visualize the left tube completely, she also could have called in a general surgeon to take down the adhesions. Nonetheless he did not feel there was a viable defense to the failure to remove the ectopic in the correct tube, particularly after it had been confirmed on ultrasound. He did not feel the resident maintained any culpability for the attending’s iatrogenic error.
The case settled as to the codefendant Dr A before trial. We represented the Hospital Center, which was discontinued from the case prior to settlement. The decision was made by co-counsel that the case portended difficulty in defending, given the underlying facts and the sympathy likely to be afforded the patient. Dr A was not a strong witness and her testimony at deposition did nothing to strengthen her position or inspire confidence in her potential ability to convince a jury that such an error could occur in the absence of negligence.