Legally Speaking: Who was to blame for this perirectal abscess?

THE FACTS

This was the first pregnancy for the patient, who was 24-years-old when she received prenatal care at the offices of the defendant obstetrician. Her prenatal course was routine and her last visit took place on June 19. At approximately 4:30 AM on June 20, the patient's membranes ruptured and she contacted the physician's answering service, at which point she was told to go to the affiliated Hospital Center. The woman was admitted at 6:40 AM to Labor and Delivery, 2-cm dilated, the fetus in the vertex position, and clear fluid reported upon rupture of the fetal membranes.

She was placed on a monitor and the fetal heart rate was described as reactive. The labor itself was uneventful as well. The patient was started on oxytocin at about 8:45 AM and received an epidural at 11:15 AM. By 12:30 PM she was 4-cm dilated according to a vaginal examination documented by the attending ob; by 1:45 PM she was 5 cm, and at 2:45 PM. she was fully dilated. The labor itself was uneventful. The records indicate that she was pushing from 2:45 PM until 3:35 PM and the infant was delivered vaginally at 3:46 PM.

The patient first returned to the defendant on June 26th, with an unrelated complaint of numbness of the tongue. A full physical examination was documented and the episiotomy site was examined and noted to be healing well. There were no signs of infection or post-delivery hemorrhoids, and the patient did not return until July 19, at which point she was complaining of rectal pain. The ob/gyn diagnosed rectal hemorrhoids, which were not near the episiotomy repair site, and recommended suppositories and acetaminophen with codeine. There was no evidence of abscess.

On July 31, the patient returned with continued complaints of rectal pain and the defendant saw what appeared to be an abscess upon physical examination. She got the impression that it was a perirectal abscess and because it appeared to be larger than 1 cm and the patient was complaining of significant pain upon gentle palpation of the mass, the physician referred the woman to the emergency department (ED) rather than attempt drainage herself.

The referral, which was written on the doctor's prescription pad, requested a surgical evaluation for perirectal abscess. The patient was evaluated by a physician assistant and an emergency department attending, who documented induration in the perineal area, extending to the perianal area with pus draining on the right side of the anus. Once again, the impression was perirectal abscess and a surgical consult was requested. The surgical resident incised and drained the area under local anesthesia in the ED, and after the incision was made, he used a gloved finger to break the pus pockets within the abscess to ensure full drainage. Approximately 10 mL of pus were drained.

The patient followed up in the surgical clinic with the surgical resident the following day. He found that she was healing well, the size of the induration had decreased, and there was no further discharge from the abscess. He maintained her on antibiotics and recommended she return to the clinic the following week, and at regular intervals thereafter until the abscess and infection were completely healed. Unfortunately, the patient never returned.

Over the next 6 months, she saw a new ob/gyn, who documented continued complaints of intermittent bilateral perirectal pain, purulent perianal discharge, painful defecation, and dyspareunia, to the extent that she was unable to have intercourse. Despite these complaints, the patient was not referred to a colorectal surgeon, and one office note by this second physician indicates the patient refused to see a surgeon on recommendation. The patient's perianal lesion was treated conservatively with antibiotics and instructions on vulvar hygiene, and this subsequent physician's differential diagnosis included a sinus tract fistula and stitch allergy.