Monica Malone

Article Specialty: Orthopedic Surgeon and Hospitalist

The Incident

The Patient

A 44-year-old male who had been a two-pack per day smoker with a history of a blood clotting disorder and deep vein thrombosis (DVT). He also had back pain, for which he took 30 mg of OxyContin four times daily and Lortab 10/500 five times daily.

The Procedure

Our insured, an orthopedic provider, performed an anterior lumbar interbody fusion at L4-5 and L5-S1. A week before the procedure, our insured orthopedist saw the patient at his office, where it was noted, “…patient will stop Coumadin seven days prior. Has stopped many times without problems.”

Post-Procedure

The patient underwent the procedure and tolerated it well. Our insured hospitalist ordered Heparin 5000 units subcutaneously every eight hours, a sequential compression device, and TED hose stockings. The physician assistant (PA) to our insured hospitalist was consulted on hospital care for the patient. The PA noted the patient’s history of DVTs and that he was on chronic Coumadin therapy at home. She also noted that his home Coumadin regimen would resume as soon as it was authorized by the orthopedic and that mechanical thromboprophylaxis with TED hose would be continued.

The day after surgery, the patient was seen by our insured hospitalist, who again noted Coumadin would resume when okayed by an orthopedic. This was noted again the next day.

Two days following the surgery, an orthopedic resident saw the patient and noted he might be discharged home if it was okayed with medicine and pain management. The resident told the patient he was to follow up with our insured orthopedic provider in 10 days. Neither our insured hospitalist nor his PA saw the patient before his dismissal, and there was no notation in the chart that they’d been contacted regarding his dismissal.

The discharge summary, signed by our insured orthopedic provider, did not instruct the patient to resume anticoagulation therapy. It only mentioned that the chart indicated he had been given his prescriptions. The Discharge Medication Reconciliation Report, signed by the orthopedic resident, listed Coumadin as a “home medication,” but it was not marked as a medication the patient was to continue or resume after he was discharged from the hospital.

The patient received one dose of the ordered Heparin before his discharge, and the patient contended a nurse told him to restart his Coumadin upon discharge.

Post-Discharge Complications & Recovery

Four days post-discharge, the patient developed a rectus sheath hematoma and pulmonary embolism. He was taken to the hospital via EMS. Upon his arrival, his INR was 3.9 as he had resumed his Coumadin at home. The patient received a vena cava Greenfield filter and was discharged from the hospital six days later.

The patient was seen by our insured orthopedic provider three days after discharge for follow-up. He was doing well as far as his back pain was concerned but still had some shortness of breath. That same day, the patient was seen by his PCP, at which point his INR was 2.8, and his 02 sats were normal.

The patient progressed well with physical therapy, was able to wean himself off some of his pain medications, and did well on his Coumadin therapy.

Four months later, the patient began complaining of shortness of breath to his PCP. He was seen at the Mayo Clinic for these complaints, where it was noted there was no evidence of residual pulmonary embolism nor any evidence of pulmonary hypertension at rest or with exercise. Extensive exercise testing suggested his reduced exercise capacity was due to excess weight and deconditioning.

The Patient’s Complaint

The patient alleged:

• The defendants failed to communicate as a team to restart his Coumadin before he was discharged from the hospital.
• The defendants failed to inform him of the risk of not restarting Coumadin and to obtain his consent not to receive Coumadin.
• The defendant resident specifically failed to communicate with the orthopedic provider that the hospitalist provider was waiting for the surgery team to give the order to restart the Coumadin.
• The hospitalist provider failed to communicate with the orthopedic provider about restarting the Coumadin after becoming aware that his progress notes for a treatment plan were not being followed.

Trial Resolution Summary

Result: There were three defendants at trial. The resident defendant was dismissed during the trial. The jury felt the patient and his wife weren’t credible witnesses, and they unanimously found in favor of the remaining two defendants.

Damages Claimed:  $1,135,735.76

Length of Trial:  7 days

Length of Jury Deliberation:  1 hour and 15 minutes

Cost of Defense:  $350,942.20 (2 defendants). This does not include what the Health Care Stabilization Fund incurred defending the resident.

Length of time from filing of the lawsuit until start of the trial:  1 year, 10 months, and 24 days

Risk Management Tips

Document any discussions between providers regarding patient medications and when to restart them after they’ve been stopped. Discuss any medication instructions with the patient prior to their discharge, and note in the record the details of that discussion.