Medical Malpractice and Post-op Medical Care

TASA ID: 3656

Optimal medical care after a patient has abdominal surgery should involve general surgery.  As an Internal Medicine expert, I was recently asked to review a case involving a bad outcome caused by poor post-operative care after urologic surgery, where care was rendered only by the urology team and medical hospitalist.

This patient was a 60-year-old woman who’s only prior medical condition was recurrent kidney stones.  Her urologist had performed several outpatient procedures to remove kidney stones from her ureter that required placement and removal of stents.  Due to scarring in her ureter, he then opted to do Robotic ureteral re-implant surgery, which involved removing a piece of her scarred ureter and reconnecting her remaining ureter back into her bladder.

During the robotic procedure, he noticed excessive scar tissue in her abdominal cavity (a condition associated with prior abdominal surgery; in this case, she remotely had her appendix and uterus removed). He elected to convert to an open surgery and proceeded to cut her scar tissue, a procedure known as ‘lysis of adhesions’.  During this surgery, he accidentally nicked an area of her small intestine and subsequently sewed up the nick that he caused.

This urologist never rounded post-op and instead, his residents assumed that duty.  For assistance, they requested an Internal Medicine hospitalist consult. During the next several days, she did not do well due to abdominal distention, mild pain, and tachycardia or a fast heart rate, which were attributed to ileus, a benign delayed return of peristalsis after surgery. Her internist increased IV fluids, thinking her tachycardia was due to dehydration, but this had no effect and was not further addressed.

On the third day, she collapsed walking to the bathroom and was found to be non-verbal and confused.  Although she was examined for this, it was only concluded that she did not have a stroke, yet no explanation was provided for this mental status change.  

General surgery was later consulted to place a central line for better IV support and during their consult, they noticed that her abdomen was ‘rock hard’, distended, and that the surgical drain was showing brown stool coming out of the abdomen. Her blood pressure around this time was also dropping to shock levels and she was taken immediately to surgery, where a bowel leak was discovered.  However, given her advanced stage of septic shock, she arrested during surgery and later in the recovery room, where she died.

From my expertise, the internist missed early signs of sepsis, including persistent tachycardia and later by altered mental status. Timely recognition of this would have prompted immediate antibiotics and a timelier surgical consult, given that abdominal sepsis should have been high on the list.  Yet, I was also impressed by the fact, that internists are not accustomed to post-operative complications and needed better guidance, which they were obviously not getting from the urology team. The failure to recognize stool drainage by the urology team was clearly below the standard of care and something that a general surgeon would have easily recognized.

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