Sample Case Evaluation Reports - Nursing Expert Witness

Please click on the titles below to go to the corresponding sample Case Evaluation Reports.


Elderly Nursing Home Patient Develops Urine Infection, Severe Dehydration Untreated and Dies.

At age 83 this patient was in the Nursing Home for rehabilitation from fractured ribs and for “generalized deconditioning.” She was receiving breathing therapy and bronchial dilator drug therapy. On 1/1 she began to cough, and had some wheezing. This progressed and on 1/6 she had a chest x-ray which showed no acute (pneumonia) changes.

On 1/8 she developed watery diarrhea and Dr. S prescribed Kaopectate. This was good care. The nurse noted: “No signs of dehydration.” Persistent diarrhea with low fluid intake can cause severe dehydration, and elderly patients are at higher risk. She also was receiving the very potent diuretic (“water pill”) Lasix at 20 This was never stopped. That would dehydrate her more, and more quickly.

The diarrhea improved from 1/9 – 1/14. Her appetite decreased dramatically from 1/8 until 1/18 where she only consumed 25% of her meal, and from 1/18 – 1/19 she refused all food and liquids. The nursing sheet section “Health Conditions: Indicators of fluid status” is totally blank. The Physician never ordered any fluid “Intake and Output” to be recorded, and the Nurses never initiated that basic evaluation, even after they documented a six pound weight loss from 1/8 until 1/17 and advised Dr. S of that significant fact on 1/17.

She had been receiving the potent broad spectrum antibiotic Ceftin for approximately 10 days, from 1/6 – 1/16. This antibiotic, like many others can cause a severe form of diarrhea caused by the overgrowth of the bacterial germ Clostridia difficile in the large intestine. This was never considered, tested for, or specifically treated.

On 1/17 Dr. S saw the patient and noted that: “She had decreased approximately 10 pounds from previous weights.” He noted good skin turgor (evidence against severe, but not mild, dehydration). Her abdomen was soft and not distended. Evidence against a perforated appendix or gangrenous intestine. He wrote: “observe her closely for any other problems.” But that same day he wrote an order: “Do Not Resuscitate” that allegedly her son was aware of. Why was that done?

From 1/12 until 12:30 p.m. on 1/19 no nurse ever checked her pulse, respiratory rate, blood pressure, or temperature (vital signs). That is negligent care by the Doctor and nursing home, as well as its employees. This is especially flagrant because of her six or ten pound weight loss, severe lack of appetite, catheterized urine specimen showing “dark cloudy amber urine with sediment” on 1/17 at 2 p.m., consistent with serious dehydration and infection (confirmed by laboratory testing: nitrite positive and 30 white blood [pus] cells seen per microscopic high power field). Dehydration promotes urinary tract infection by decrease washing out the germs. The blood white blood count was slightly elevated to 14,500, but there were 13% Band forms, seen with serious infections. And on 1/17 blood kidney creatinine test was normal at 1.7 (consistent with no serious chronic kidney disease or kidney failure), but the BUN (Blood Urea Nitrogen) kidney blood test was significantly elevated to 42 (normal is 5-22), diagnostic of significant and serious dehydration.

All those tests Dr. S ordered were faxed to him that day, and he negligently did nothing. He did NOT write an order to “force oral fluids,” start an intravenous, monitor “Intake and Output,” nor to check her vital signs, not tested for five days, as noted above. This is not “close observation”. This is gross neglect.

On 4/18 the Nurse noted: “Patient remains in bed, still not feeling well, patient has red raw butt from diarrhea, will fax note to M.D..” Her appetite remained poor, and the diarrhea continued to dehydrate her.

On 4/19 the Nurse noted: “Not feeling well, state lower abdomen has pain today, patient has UTI (urinary tract infection), Dr. S has not ordered antibiotic for UTI yet. Referred labs to M.D. today.”

By 12:30 her respiratory rate increased to 40 which is two to three times normal. And “Patient voiding only small amount urine. Continues to have loose BM (bowel movement)….patients condition has really deteriorated.”

AT 2:15 p.m. she had a respiratory rte of 50 and “stated she couldn’t breathe.” Nasal oxygen was started. Still no I.V. (intravenous) was begun. No one was directly encouraging her to drink liquids.

Elderly patients lose the sense of thirst, especially when ill. With infections, they often do not respond to temperature rises (although no one took her temperature for one week).

Her heartbeat was very irregular, “Patient did c/o of SOB (shortness of breath) and this is very unusual for this patient.”

At 3:15 p.m. Dr. S finally ordered her to be sent to the Emergency Room where she arrived at 3:40 p.m. There the blood showed that the creatinine had risen to 3.0 (from severe dehydration and infection) and the BUN was 81 for the same reasons. Her arterial blood, oxygen level was normal, but the carbon dioxide level was decreased to 28 (normal is 32-48) from hyperventilation to try to eliminate the acid build-up from her severe urinary tract (kidney and bladder) infection. The white blood count was now 33,300 (normal is 5,000-10,000) and the “bands” were grossly elevated to 31%: overwhelming infection.

At 5:30 p.m. the Emergency Room Doctor ordered intravenous fluids at 125cc (4 ounces) per hour. That is grossly inadequate for such a severely dehydrated patient. This order was written two hours after she arrived so ill. Why was it delayed? The intravenous Cipro was ordered at that delayed time. But it appears that the Nurse was not able to start the I.V. at 6:05 p.m. (1805), she began to vomit at 6:10 p.m., became very short of breath turned blue around her mouth at 6:15 p.m., they verified the “DNR” status and they let her die. Dr. Z pronounced her dead at 6:10 p.m.

After three hours in the Emergency Room she died. Was an autopsy done?

In my opinion her death was preventable and was caused by the negligence of Dr. S and the nursing home for all the reasons stated above. She was allowed to become severely dehydrated over one week, and the last two days she was obviously very sick from dehydration and her UTI and it was not treated despite all the obvious signs, tests, and they still failed to do all the “observation” the standards of care would require.

Prior to this illness she was awake, alert, ambulatory and otherwise stable, and would not have died at this time.

The Emergency Room Physician, corporation and employees were negligent for their delays which, in my opinion, would have had some chance for success if aggressive intravenous fluids and antibiotics would have been immediately started upon arrival, since they knew she was coming and presumably Dr. S would have called ahead and in fact, the note says “Discussed with Dr. S.” Who discussed what with whom, when and when did the “DNR” issue arise for the E.R. and why? The E.R. records notes that the E.R. Physicians were: Dr. T and Dr. M. Who did what and when?

I would suggest trying to supply the answers to my questions, and then authorize us to have these records reviewed by Experts in Infectious Disease, Geriatric Medical experience, and Emergency Medicine, as well as a Nurse with Elder Care Experience.

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Post–Operative Narcotic Drug Overdoses Causing Respiratory Arrest, Brain Death and Death.

According to the records, the patient was described as morbidly obese. She was 4 feet 11 inches in height and weighed 152 pounds. Much of this was fat, and her muscle mass and organ size, which would be responsible for the metabolic destruction and elimination of medications, including the narcotic medication, morphine, was certainly that of a small, elderly woman at age 72. Elderly patients are much more sensitive to the effects of narcotic medication, including the well-known respiratory depression effects of that type of drug. 

The patient had known lung disease. She was a heavy smoker, smoking five packs a day for many years, and then cut back to a half a pack a day. They believe, and I agree, that the heavy cigarette smoking was a substantial proximate causation of her kidney cancer. 

Her lungs were not normal. Prior to surgery on room air, she had a measurement of her oxygen capacity and pO2, the partial pressure of oxygen within the blood, that was only 65. Although the oxygen saturation was 96%, the hemoglobin will suck up and hold on to oxygen quite readily. But when the pO2 is at 65%, only a small drop of another 10 pressure points will totally drop the saturation curve down dramatically and put a patient in grave danger. 

Furthermore, the anemia that the patient had decreased postoperatively down to a hemoglobin of 8.2 (with a normal range of 12.4-15.2) and a hematocrit (the packed red blood cell volume) of 25.8 (with the normal range of 36.7-45.1). This meant that postoperatively the ability of her blood to carry oxygen throughout her body was at approximately only two-thirds of normal. Thus, there was a lowering of the oxygen content within the blood, and with the anemia level showing that her blood could not carry a normal amount of oxygen into her body, these would both contribute to a potential fatal outcome. 

The patient developed painless, bloody urine and her physician correctly obtained a intravenous polygram (kidney x-ray dye study) which showed a probable cancer of the kidney. This was confirmed by the CAT scan and then by the cystoscopy examination and evaluation. Thus, the radical operation that was scheduled and performed on this patient by Dr. #1 on January 2 the radical left nephroureterectomy (removal of the kidney and the adjacent flesh, including the adrenal gland and the ureter) was clearly indicated. 

My review of the detailed operative report shows that the patient was placed under general anesthesia, and after the correct operation to remove the kidney with the cancer and the adjacent flesh, a separate incision was made in the lower abdomen to excise that specimen along with the ureter as an intact specimen. All this meets the standard of care. 

The Pathologist confirmed that the patient had a grade I-II papillary transitional cell carcinoma, and that the cancer was confined to the kidney. This is a low-grade cancer that had not had any evidence of metastatic spread, and thus this patient had a high chance of a cure, particularly considering her age at 72. 

According to the anesthesia record, the patient had a pulse oximeter measuring her blood oxygen level, and the safeguard measurement of expired carbon dioxide confirmed that there was no dislodgment of the endotracheal tube or the connection between the ventilator and the endotracheal tube during the anesthesia. The patient was generally reasonably stable and I find no fault with the actual operation itself, or with the anesthesia performance. 

Postoperatively, the patient was admitted to the postanesthesia recovery room in basically an extremely stuporous condition, and shortly thereafter as the minutes began to pass, she began to awaken. During that time, to control pain, the patient did receive injections of the narcotic medication, morphine. 

Generally speaking, an elderly patient at age 72 who was actually a small person in a fat body, in my opinion, should not receive more than 1-2 mg of morphine every two to four hours. The morphine given to the patient must be to control pain, and only when the patient has pain. 

In the recovery room, the patient received her first dose of morphine, 1 mg intravenously, at 17:42, and through 18:20, received a total of 8 mg of morphine as well as 30 mg of the non-narcotic pain medication, Toradol. This is a lot of morphine and the patient, who was awakening initially, was noted to have very shallow respirations at 19:30, at the time she was discharged from the recovery room. This was an ominous sign. 

When she was admitted to her regular hospital floor and bed from the PACU, she was noted to be lethargic. She opened her eyes and was trying to get out of bed and thus was obviously quite confused. This confusion is not pain. I have not seen the doctor’s orders to determine who, in fact, actually ordered the PCA (Patient Controlled Analgesia), which is a button the patient pushes that allows a special calibrated pump to inject narcotic medication, in this case, morphine, into the intravenous line. The calibration adjustments are determined by the Physician’s order and set by the Nurse. Thus, when the patient has pain, the patient pushes the button and get a dose of narcotic medication. 

Usually, the Anesthesiology Department is in charge of the PCA orders and machine, but this can vary from hospital to hospital. I cannot tell who ordered the medication or which Physician was responsible for monitoring the dosage given to the patient at the Hospital #1.

According to the records, the patient had very poor eyesight. At 21:30, she opened her eyes. The respiratory rate was 16. The PCA was being used for pain control as noted in the nurse’s notes. She was receiving 3 liters of nasal oxygen, and the pulse oximeter on 3 liters of oxygen showed that her percentage of saturation of oxygen in the blood was 97%. 

After midnight on January 3rd at 00:05, the patient was noted to be very lethargic and not responding to verbal stimuli or pain. If she was not responding to verbal stimuli or pain, why was she still receiving dosages of the narcotic pain medication? Obviously, a lethargic or stuporous patient would not be pushing the button. Who was pushing the button all this time because throughout her entire stay until the respiratory arrest that caused the cardiac arrest, she was noted to be lethargic or stuporous and still was getting pain medication. 

At 01:30, she remained lethargic, only opening her eyes, but they had a glazed appearance. At 02:20, the patient said yes, but not in response to any question, and she was lethargic. At the time that the number appears to be blocked but looks like it ends in a 45, so it was either 04:45 or 05:45, it was noted that the patient had a leg in the bed rail and was repositioned. Then it says, “PCA pushed for patient,” by a Nurse or Nursing assistant who appears to be #1. In my opinion, that is a negligent act. Why would a Nurse or Nurse’s aid push a button of a patient on narcotic medication other than to basically have them more easily controlled? That is not the purpose of the PCA machine in giving the patient pain relief, and stuporous patients are not in pain. This act defies any rational basis in my mind. 

The patient remained lethargic, including at 8:40 in the morning and throughout that day. At 17:00, she was noted to be lethargic at times. She was resting. At 19:00, she was noted to be resting comfortably. This was from the Nurse’s aid. Thirty minutes later at 19:30, (7:30 p.m.), the family yelled for “help,” and that “she is not breathing.” They found the patient without respirations, cyanotic (blue from lack of oxygen) and pulseless. 

How mush delay was there? What occurred before she stopped breathing? How shallow was her breathing? Cardiopulmonary resuscitation was immediately started and I have no concerns with regard to the adequacy of that process. However, the patient was without oxygen for such a long period of time that she ended up with severe brain damage (hypoxic encephalopathy). A number of EEG studies (brain wave studies) performed after the event and over the ensuing months were all consistent with that finding. In addition, the patient had a CAT scan on January 5 that showed no evidence of any hemorrhage or other abnormalities. An MRI was performed on January 9th. Again, there was no evidence of any mass, mass effect or hemorrhage. There were no other mechanical problems in the brain. Another CAT scan on January 23rd showed that the brain was within normal limits. That is, there was no evidence of any hemorrhage or abnormality within the brain to cause the patient’s brain to be damaged. 

All of the above is consistent with a gross overdose of narcotic medication (morphine) given repetitively to a stuporous and lethargic patient by negligent orders by the physicians not terminating the PCA machine and by the nurses actually pushing the button at least one time. The doctors in their progress notes questioned who was pushing the button. The family denied pushing the button giving the stuporous patient more pain medication. 

In any event, the order should have been changed to stop the PCA machine, or at least to drop it back to 1 mg of morphine, not every hour, but every two or three hours as needed, or to stop the PCA machine and give the patient injections of pain medication as had been done for many years upon demand when, in fact, the patient needed pain medication and was not in a stuporous state. 

The Hospital Patient Controlled Analgesic (PCA) flow sheet is most informative. She was receiving morphine sulfate (MSO4) initially at 2 mg per dose, and then sometime on January 3rd, with the time not stated, was decreased to 1 mg with 10 minutes of lock out. This would allow the patient to receive 6 mg of morphine on an hourly basis. This is a gross overdose for a 72-year-old woman who is of very small muscular and skeletal stature. 

I want to point out that I was shocked to note that on this sheet, as of 6:30 in the morning on January 3rd, she had received 11 mg of morphine and until 19:00, which is 7 p.m., she received 25 mg. Thus, in the twelve and one-half hours between 6:30 in the morning and 7 p.m., she received 1.12 mg of morphine per hour. This, in my opinion, is a significant overdose for such a small patient of age 72. But more importantly, she did not need this pain medication. The patient was narcotized; that is, she was receiving a continuous gross overdosage of narcotic medication when she was continually stuporous. The first thing to consider in a patient who is postanesthesia who is still not waking up to the extent that one would want is to stop the pain medications. 

I also wanted to point out that by 15:20, she had received 23 mg of morphine through the PCA machine. But, from 15:20 until 19:00, she received another 2 mg. Why was she receiving all this narcotic medication when the record shows the patient was not in any pain? She was resting very quietly, but that quiet resting was actually substantial oversedation from the narcotic medications. All of this is negligent care. 
The patient was also receiving an antipsychotic medication which, to some degree, can also cause some sedation, but, in my opinion, the clear negligence is in giving a stuporous patient, a patient who is not in pain, narcotic pain medication. She could not push the button. Who was pushing the button? How did she get all these high dosages throughout the night? Was there someone sitting by her bedside pushing the button throughout the night, and why do the Nurses’ notes show that, in fact, a Nurse or Nurse’s aid actually pushed the button for the patient when the patient was stuporous or lethargic. This is not a patient who needed pain medication. 

This was a patient who needed a doctor to stop the pain medication to allow the metabolic effect, that is, the stuporous effect of the narcotic and the excessive sedation of this patient, to terminate for many reasons. Patients who are so stuporous cannot effectively cough and clear their airways. They can choke on food and on liquid. Such patients will be breathing shallowly. There are times she had shallow respirations. Such a patient will eventually end up with an accumulation of the narcotic within her body and the effect of respiratory depression to such an extent, and particularly as her anemic state progressed and became worse, in a patient who had chronic lung disease to start with wherein it would all combine to basically kill the patient. To kill patient by stopping her breathing.

I cannot tell from these records whether or not the oxygen, that is the supplemental nasal oxygen of 3 liters per minute, was on in a continual, ongoing basis. This will have to be clarified through discovery. However, giving a patient nasal oxygen where they are so overdosed with a narcotic that the respiratory center is so depressed will not keep them alive. You cannot give enough nasal oxygen to a patient. They need to be placed on a positive ventilator to actually force air and oxygen into their lung, but in this case it would have been so simple to just stop the narcotic for a period of time and give the patient an adequate dosage to relieve the pain, but not to overly sedate her and not to place her into the great zone of danger through which all of the negligence of the Nurses and of the Physicians combined to cause her to have a respiratory arrest that stopped oxygen through her entire body and caused her heart to temporarily stop. They were able to restart the heart, but the brain is much more sensitive to oxygen deprivation, and after three to five minutes of lack of oxygen, one would have a patient who, in this case, had severe and irreversible hypoxic encephalopathy; that is, brain damage from lack of oxygen. The subsequent CAT scans and MRI studies, as well as the EEG studies, were all consistent with this finding. There is no other cause of this condition. 

In addition, the patient did not sustain a pulmonary embolism. As for the traveling blood clot from the leg or pelvic veins to the heart-lung circuit as a cause, the findings here are not consistent with that, and in fact, she had a lung scan study a number of weeks later that showed no evidence of any pulmonary embolism. Pulmonary embolism in an acute postoperative period would be quite unusual in any event. All of the above, in my opinion, was related to the negligence of a gross overdosage on an ongoing basis in this patient to the point where it overwhelmed her, stopped her breathing and caused her to have irreversible brain damage, which was the proximate cause of her eventual death. 

I would suggest that you authorize us to have Experts review these records, who would be Experts in the field of Nursing and in Anesthesiology. You also need to determine who, in fact, was responsible for the PCA narcotic orders, and because the patient was also treated by a Urologist, a Urologist as a Surgeon would be responsible also for seeing the patient and determining what would be necessary to benefit the patient, which, in this case, would be to read the medical orders and stop the narcotic pain medication until she awakened, and call any consultations as necessary. 

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Intra-venous site developing thrombophlebitis, and it causing Reflex Sympathetic Dystrophy (R.S.D.)

This patient had a long history of recurrent diverticulitis (infection of weak out-pouchings of the large intestine), that previously was correctly treated with antibiotics. But on 8/27 his pain was much worse and he was properly hospitalized, fed only by intra-venous fluids and after CT Scan confirmation of significant pathology that did not resolve with antibiotic therapy, surgery was indicated.

His sigmoid colon (23 centimeters: 10 inches of the left side of the large intestine) was grossly diseased (as confirmed by the Pathologist in his report) and was surgically removed (resected) by Dr. #1 on 9/1. The surgery went well and that part of his care was acceptable. The operative site healed and on 9/8 he went home.

His post-operative surgical office care also was acceptable. On 10/15 he was referred back to his family doctor concerning the problem with his left hand. The Surgeon met the standard of care (but see below).

Now, I will focus on the intra-venous (I.V.) problem in the hospital. It is generally accepted that an intra-venous needle or catheter should be removed and a new one inserted by 48 hours and definitely by 72 hours. The longer it remains in place, the greater there is a risk of serious infection (sepsis:germs spreading from that site throughout the body with a high mortality rate). If there is any problem with an I.V. site (leaking, redness and red streaks: consistent with vein infection, thrombophlebitis and lumps or "cords" in the vein: clotted blood), it should be immediately removed.

Furthermore, this patient had a football injury as a child and had his spleen removed. That increased his risk of infection, and would require even more diligence concerning I.V. site problems.

The first mention in the nurses notes of an I.V. is on 8/27 at 0325 (3:25 a.m.) and it was in his left forearm. At 1545 it was running (infusing) without difficulty. At 2340 there was no abnormality.

On 8/30 at 2400 that I.V. was discontinued (I.V. D/c'd) and a new one place in his right hand. This left forearm I.V. was in place for almost three days. Warm compresses were applied to the old site for 1/2 hour and a heating (K) pad was ordered.

The patient's daughter claimed that "shortly after his surgery, I noticed that his left arm was very edematous (swollen) and I asked a Nurse to change his I.V. Many hours later a third shift nurse did change the I.V." This is not consistent with the medical records.

On 8/30 at 0500 the nursing record says: "K pad (heating pad) to (L) arm applied to site of old infiltrate." Intra-venous needles and catheters (tubes) do frequently puncture the wall of the vein with the intra-venous fluid leaking into the flesh. The use of a heating pad is the standard of care. The changing of the I.V. location and use of the "K pad to old I.V. site" is also noted on the "Medical Treatments /Nursing Interventions" record signed by Nurse #1. At 1600 (4 p.m.) the new I.V. was "infusing without difficulty."

On 8/31 at 2400 - 0100 the nursing notes state: "Patient keeps K pad on abdomen instead of Left Forearm (LFA) old I.V. site - old infiltrated area is very hard and warm - c/o soreness and streaking up forearm noted. Warm moist compress applied to arm for 10 minutes while patient watching TV Patient verbalizes plan for O.R. (operating room) Wednesday."

At 0800 the nurse noted: "Old I.V. site to LFA remains red in color with edema (swelling) and small bump noted to old insertion site."

All this time, from 8/27 through 8/31, he was receiving potent intravenous antibiotics Flagyl (metronidazole) 500 mg. every 6 hours, and Mefoxin 2 grams every 6 hours, both by I.V. That would also be effective treatment for any infection in his arm.

On 9/1 at 0920 he went to the operating room. The Anesthesia record says that an I.V. was present on the "left" and a Right I.V. was also started. The recovery room nurse's record at 1215 notes: "I.V. going into Right hand and right inner forearm without redness or swelling."

Obviously, the Anesthesia record is in error when it said left instead of right, since that is where the nurses before surgery had noted it was located a few times. At 1220 the right hand I.V. was "HL" which is Heparin (anti-coagulant) solution "lock" to keep it from clotting when not in use.

On 9/3 at 0410 "I.V. site right wrist leaking around insertion site. I.V. dc'd "and a new one was started in his "left hand without difficulty."

On 9/3 at 2110 "I.V. site red." The left hand I.V. was discontinued and a new I.V. was started in his right hand.

On 9/5 "I.V. site right under forearm without abnormality, at 2400 and at 1600 that I.V. in his right forearm "site without redness/edema."

The I.V.'s were maintained until his discharge date on 9/8 and at 1740 that I.V. was discontinued and "site without redness/edema. Dressing applied.

According to the nurses notes, the I.V. that caused the problem was inserted on 8/27 at 0325 and when there was a problem it was removed on 8/30 at 2400 and warm compresses and a heating pad used thereafter (except the patient put it on his abdomen). After a few days, there were no complaints and no mention of any problem persisting involving his left forearm.

The Surgeon did not have to address that problem since the nurses were doing the correct care, and he was already receiving two intra-venous antibiotics (for his diverticulitis) that would treat this problem with his arm.

Reflex Sympathetic Dystrophy (RSD) is a bizarre and very uncommon reaction of the sympathetic nervous system to any injury that can cause uncontrollable pain and disability.

On 9/24 he told the Surgeon "still has tingling sensation." The statement of facts notes that the patient said to the Surgeon he could not go to work because he could not move four fingers or can not stand anyone to touch his left arm or hand. He could not even hold a cup and certainly not a large window in his job installing them. Based on the facts in that note by the family, the surgeon should have referred the patient, without any delay to a Neurologist, or a M.D. specializing in Physical Medicine and Rehabilitation. That symptom complex, coming three weeks after the I.V. problem is consistent with early R.S.D., and the earlier aggressive therapy is begun, the better the chance for cure.

On 10/8 the Surgeon noted "continues to have tingling left fifth finger." The Surgeon did nothing but the family said he saw his own doctor (#2) on 10/5. On 10/15 the Surgeon noted that the patient was to call that same private doctor. Therefore, this is a 2-week delay, by the Surgeon because the patient already saw his own doctor for that problem. And on 10/19 the Surgeon noted that the patient was contacted about getting an appointment with his own doctor. If he saw that doctor on 10/5, why was he referred to him by the Surgeon on 10/15 and on 10/19?

The HMO was negligent for denying and canceling the visits to the Neurologist.

On 10/21 he saw his private doctor (#2) who noted the patient "reports he is weak in the left 4th and 5th fingers." He also had some paresthesias (tingling). His physical examination noted: "left hand with no clear evidence of inflammation or swelling. Slight weakness on grip strength testing." He concluded: "Presumed peripheral nerve injury left arm." There was no finding of severe pain or pain to touch as noted in the "statement of facts." He ordered tests.

The EMG (electro-myogram) and NCV (nerve conduction velocity) studies were done on 10/27, and there were abnormalities involving the median and ulnar nerves.

The HMO should not have negligently cancelled his appointments with Dr. #3, a Neurosurgeon on 11/15 and with Dr. #4, a second Neurosurgeon on 11/16.

On 11/16 he saw Dr. #5, an Orthopedic Surgeon, who noted "some significant paresthesias in the ulnar nerve distribution on the left hand. His ring, and especially his little finger, are very sensitive. The hypothenar eminence (little finger side of the palm) is very sensitive. Having trouble fully extending his fingers. Very tender around the elbow. Even pain going up toward the neck…" He wanted the patient to see a hand surgeon without delay.

It was obvious by 11/16 that he was developing a more severe case of RSD. Four weeks later he saw Dr. #6, a Hand Surgeon and diagnosed "acute reflex sympathetic dystrophy." The fingers were "hypersensitive" and now there also was "redness" consistent with overt R.S.D.

Since there were no trophic changes (loss of flesh) he felt that "he is still in the early phase and may do well with medication and cervical sympathetic blocks (a local anesthetic injected into the neck into the sympathetic nerve complexes)."

On 12/29 he noted the HMO approved him to see Dr. #7; a 6 week delay. There should have been no delay. He was seen on 1/3 and the patient rated his pain as "9" on a scale of 0-10. Also "he has pain, paresthesia, areas of numbness, change in temperature, swelling, and stiffness. Dysethesia is almost unbearable, to the point where no one can touch his left hand." Finger motion was limited, there was twitching (fibrillation) of his fifth finger and side of hand, and it was slightly warm to touch. He noted the earlier abnormal EMG and NCV study of 10/27. Although his official consultation note was for 1/3, it was dictated on 1/1 and typed on 1/3 and the first stellate ganglion block was on 12/30.

By 1/13 he had 30% improvement. I have no further information on his condition. He was properly prescribed medication (Amitriptyline and Neurontin) as well as a TENS (nerve stimulator) to control his pain and to try to reverse his condition, by Dr. #7. The care by Dr. #7 was good.

A MRI of his cervical spine was not pathologic for his left side.

Obviously, there are differences in the "facts" between the family and the detailed Nurses notes. If there was any problem with the I.V., it should have been removed without any delay. The longer it remains, the greater the inflammation and risk for R.S.D.

When he saw his Surgeon and private doctor, there were no overt signs of R.S.D., but since the pain persisted for weeks after surgery, he should have seen a Specialist, and the HMO was negligent in canceling those visits.

Why was there a negligent six-week delay from 11/16 until 12/30. On 11/16 it was obvious that he had developed acute changes of R.S.D. and the earlier the therapy, the better the outcome.

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The problem with the case is that R.S.D. is not always responsive to therapy. If the law in Ohio is that the negligence has to cause a 51% difference or more, it makes it harder to obtain supportive testimony.

It is necessary to clarify the issue of the I.V. problem before it was removed, and why there was a 6-week delay before Dr. #7 saw the patient.

What is his current condition?

If he is disabled or in significant pain, I would suggest that you authorize us to have these records reviewed by Experts in Neurology, Pain Control, and/or Physical Medicine and Rehabilitation, Infectious Disease, as well as Nursing, in that order.

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Intravenous in arm vein not changed for 3 days, and causes disabling thrombophlebitis (clotting and pain).

At age 46, this patient was hospitalized for diagnostic tests and therapy for chronic low back pain. In the past, she had a hysterectomy operation for endometriosis (a cause of chronic pelvic pain), and a few years before was injured in a car accident.

During her stay from 2/18 to 2/22 she was administered the narcotic morphine through an intravenous 24 gauge needle or catheter (billed as "IV set, plum pump filter") which was inserted into a vein in her left mid-forearm on 2/19 at 0050 (after midnight) and remained in place until 2/22 when she was discharged from the hospital.

They initially placed the IV in her left hand on 2/18 at 2110, but was changed to her left arm three hours later, where it remained all of 2/19, 2/20, 2/21, and part of 2/22. Although the nursing record noted no problems, it should have been changed every 24-48 hours, even without a noted complication. The longer the needle or plastic catheter is sitting there, perforated through the skin into a vein, the greater the risk there is for a blood clot in the vein, with or without an infection.

She went home on 2/22 and on 2/24 she was seen by an unknown doctor for a "swollen red arm," and was correctly started on the broad-spectrum antibiotic Keflex (unknown dose).

The problem persisted, and after obtaining an ultrasound (Doppler blood flow study) that was positive for deep venous thrombophlebitis, she was hospitalized from 3/1 to 3/8 for anticoagulation ("blood thinner") therapy intravenously with the drug Heparin, and switched to the oral anti-coagulant Coumadin which she took for six months: All standard therapy.

The psychological evaluations of this patient for her back pain noted that she had a large emotional (psychological) component to her pain.

The hospital #1, departed from the standards of care for safe intravenous devices by not changing it for four days and significantly increased the risk for this patient developing her left arm thrombophlebitis. Although she may be more sensitive to pain then most people, they took this patient as they found her, including her frailties, and caused her negligent injury.

Her admitting Physician, Dr. #1, who ordered the intravenous line and morphine (MSO4) pump for her patient controlled analgesia (P.C.A.), and the Anesthesia Pain Service Doctor #2 both should have noticed that the nurses failed to change the IV site, and arranged for it to be moved to her other arm. Therefore they had some responsibility for which they too were negligent.

The subsequent care was good. No increase in clotting (abnormal coagulation) was noted by a series of comprehensive laboratory tests. She was taking the female estrogen hormone Premarin at 1.25 milligrams per day, a moderate to low dose, and although she was a nonsmoker, and although the problem was her arm and not leg, I believe it increased that risk. I question why it was not temporarily stopped or the dosage reduced after the arm vein clotting problem developed.

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The defense will contend that she had and has disabling back problems that overwhelm any left arm pain issues, and that almost all of her persisting pain is psychological, and not on a physical basis. However, even if that were true, this emotionally fragile patient had a well-documented thrombophlebitis in her left forearm that was obviously painful within two days after that IV was discontinued. How does it affect her arm now?

In my opinion, the Hospital, each Nurse caring for this patient after the first day, Dr. #1, and the Anesthesia Pain Service and its Physician departed from the accepted standards of care causing her prolonged injury. Obtain the Hospital's own protocols as they existed during her stay, concerning intravenous needle/catheter management and frequency for change. Also, obtain their latest protocols on that issue.

I suggest that the patient be evaluated by a local Clinical Psychologist with courtroom experience for any residual emotional (psychological) damages. Administration of standardized tests such as the M.M.P.I. (Minnesota Muliphasic Inventory) which have been given to millions of people would further support that opinion before a jury.

I would suggest the following Experts in this order: Infectious Disease, Nursing, Anesthesia/Pain Therapy, and a Physician of the same specialty of Dr. #1. They are available pursuant to our Contract.

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Nurse fails to follow the doctor's orders and feeds post-operative patient too soon, who then vomits and aspirates (breathes it into her lungs), and develops pneumonia.

After any major abdominal surgery, especially involving removal of the stomach and multiple surgical connections (anastomoses) between areas of the intestinal tract, it is a general surgical principle not to feed such a patient until the surgeon is satisfied that there is no leakage at the suture lines, and that the temporary paralysis (ileus) of the intestinal tract has passed. This is best assessed by the passage of gas (flatus) per the rectum. That gas is mostly from swallowed air.

In this case, the 80-year-old female patient had an abdominal mass, which was correctly believed to be most likely a form of stomach cancer. She underwent extremely major surgery, very skillfully performed by Dr. #1. At surgery he correctly had to remove her entire stomach, and because of what had clinically appeared to be invasion by this tumor, had to also remove the middle third of her large intestine (transverse colon), the distant half of her pancreas, and the adjacent spleen (because its blood supply was too close to the tumor), and then had to use the small intestine (jejunum) to create a pouch ("J") to replace the stomach and suture it directly into the esophagus (food pipe), reconnect the small intestine continuity, as well as the continuity of the large intestine. At the conclusion of the surgery, Dr. #1 helped to position the "stomach" (NG: naso-gastric) suction tube into this "J" shaped jejunal stomach replacement.

The patient was ordered to have nothing by mouth (NPO), and that order was negligently violated by a nurse the evening of 9/22, five days after surgery. The patient drank some milk, ate two graham crackers, subsequently vomited at night and aspirated some of this food into her lungs causing aspiration pneumonia.

According to the hospital records, a contrast (Gastrografin) x-ray study was performed on the morning of 9/22, and Dr. #1 and the Radiologist noted that the esophagus and small intestine sutured areas were functioning properly and that there was no leakage. Dr. #1 correctly removed the NG tube at 11:48 am and noted: "If doing well tomorrow to start clear liquids." That evening a nurse gave her the milk and crackers.

The patient or family claim that she was heavily sedated, and that led to an increased risk of her aspiration. The Nurses' notes show that she was alert and even out of bed for a few days before this incident. The medication records note that on 9/22 she was never sedated, and that she had no significant pain. She received 2 milligrams of morphine (a relatively small to moderate dose) at 0400, 0800, 1200, and 1630. At 2200 she received 1 milligram. On 9/23, because of more pain she received 3 milligrams at 2400 (midnight), 5 milligrams at 0320, and 2.2 milligrams at 0710.

She claims she was awakened by a Nurse for that late evening snack (at what time?). Her vital signs (blood pressure, temperature, pulse, respiratory rate) were taken on 9/22 at 1200, 1600, 1930 (7:30 pm), and 2400.

The only times she received any significant morphine (for pain) were at 2400 and 0320.

A Dr. #2 telephoned an order for nausea medication at 9:22 pm, and it appears to have been given at 2155 (9:55pm). Thus it would appear that her "snack" and resulting nausea occurred at least eight hours after the NG tube was removed when the liquid she swallowed for the contrast x-ray revealed good function of the reconstructed upper intestinal tract, and when she was NOT sedated, and was receiving a very reasonable dose of narcotic medication based on her age, weight, type of surgery, and response to that medication over at least two days. Never did they note any sedation, even with the higher doses from midnight (after a moderate dose) and at 0320.

On 9/19 at 0515 the nurse's notes show that, less than two days after surgery was completed, she was "passing flatus" and had positive bowel (intestinal) sounds: "+BS." Her intestinal tract was working. There was no obstruction.

On 9/23 at 0110 her abdomen was soft, had very hypo-active (decreased) bowel sounds, she was not passing gas, and she complained of some nausea.

On 9/23 at 0635 she had a congested cough, and "states she passed some gas this a.m." By 1830 she had labored respirations and needed an oxygen mask to keep her blood (arterial) oxygen levels in a safe range. She had also been started on potent intravenous antibiotics.

According to the "graphic chart," her respiratory rate at midnight on 9/22 and for two days prior was at the upper limit of normal at 20. On 9/23 at 0750 it was elevated to 27, and at 1145 was 28. Her temperature, which was less than 100 degrees in the proceeding days, jumped to 102 at 0750.

Her chest x-ray, taken on 9/10 prior to admission to the hospital, was normal. On 9/17, immediately after surgery, there was some congestion in the bottom (base) of her left lung and the right side was "clear." On 9/23 there were changes in her right lung "most consistent with pneumonia." It was worse on 9/25, and unchanged on 9/27. However, clinically she was rapidly improving. Her respiratory rate returned to 20 on 9/28. The oxygen mask was used for a short period of time, followed by nasal oxygen, then room air.

On 9/27 she was able to walk "to the hall and back." On 9/28, Dr. #3, the Pulmonary Disease Specialist, noted her significant recovery, that she had no history of smoking (which is why she did so well), and: "I feel finishing a course of therapy in 7-10 days should help her resolve this problem nearly completely."

The tumor was an unusual form of cancer, a nodular and diffuse non-Hodgkin's malignant lymphoma, rather than the more fatal gastric (stomach) carcinoma (cancer). I do not know her current condition.

She was fed a high calorie intravenous solution (TPN: Total Parenteral Nutrition). Her first weight recorded was noted on 9/18 to be "60.4 kg on admission." The last recorded weight on 10/1 was 62.6 kg (138 lb), and on admission to the rehabilitation hospital was 138.8 lb on 10/2. The family claims that she lost 25 lb. That is not true. That major operation will decrease her ability to digest food and consume three large meals per day in the absence of her stomach. The removal of one-half of her pancreas will decrease the digestive enzymes, although oral supplements can usually overcome that problem. Her insulin dependent type 2 diabetes will probably be worse with the loss of much of her pancreas.

It is amazing that she did so well at her age from this most radical of abdominal surgeries. It may be hard to distinguish her "weakness" from the effects of the surgery and nerve damage to the lower part of her legs from her diabetes, from the effects of the aspiration pneumonia.

Upon admission to the rehabilitation hospital, they noted that her muscle strength in all extremities was a "4" out of a possible "5," which is very good for her age and two weeks after surgery. Her lungs were "clear to auscultation" (listening with a stethoscope).

If there is any lung damage, it can best be assessed with pulmonary (lung) function tests ordered by her doctor, or a pulmonary disease specialist. If that is basically normal, and if a follow up chest x-ray is unchanged from the one prior to surgery, then there would be no permanent lung damage from the nurse's negligence.

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The defense would contend that it only prolonged her hospital stay for one or two days (paid by Medicare), and that the rehabilitation hospitalization was needed to recover her strength from the operation, and not from pneumonia, since she needed no special lung therapy.

They will also contend that the vomiting may have occurred hours after she sipped some milk, and that it was from the one quart per day of saliva produced daily, and may have occurred when she was in pain, requiring the indicated 3 milligrams of morphine at 2400 on 9/22 when her pain was 3-4 out of a maximum of 10, or after 0320 when she received the indicated 5 milligrams of morphine for a pain level of 4 (during which they noted she was not sedated). Thus they will try to claim it was an unfortunate aspiration event, not directly related to some sips of milk and a graham cracker, especially after she had an uneventful Gastrografin x-ray swallow study the morning of 9/22, followed by the removal of the NG suction tube at 11:48 by Dr. #1.

She was depressed in the hospital. The emotional trauma of her pneumonia, extra oxygen needs, and any residual posttraumatic stress disorder can best be assessed by a local clinical psychologist who could administer psychological tests, such as the Minnesota Multi-Phasic Inventory (MMPI). It may be difficult to separate the issue of cancer and the major operation from the pneumonia episode.

I have no medical record concerning her draining abdominal wound. It is not uncommon for the severed and sutured end of the pancreas to leak, even though Dr. #1 properly tied off (ligated) the pancreatic duct and sutured the cut end of the gland closed with silk sutures. A wound infection, especially with the large intestine surgery (it contains fecal germs), is also a known and unpreventable risk of this operation.

To proceed with the issue of negligence I suggest that you authorize us to have these records reviewed by one of our Nurse Experts. Then, after pulmonary (lung) function studies and follow up x-rays (copies) and the preoperative and postoperative x-rays (copies) are obtained, you can authorize us to have these record reviewed by one of our Pulmonary Disease Experts.

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Confused, demented, sedated, disoriented 80 year old patient was hospitalized for surgery for a broken (fractured) hip, and after surgery was not properly restrained, fell out of bed, and fractured her other hip.

According to the records, the patient was 80 years of age, tripped at home, and was admitted to the hospital with a fractured left hip. After stabilization, she was taken to surgery on May 8, by Dr. #1. She had a resection of the femoral head that was fractured and replacement with a prosthesis. This was with the "endoprosthetic bipolar replacement." According to the x-ray reports, the operation was properly done.

Following this operation, the patient had difficulty with her lungs and had to be intubated (an endotracheal tube placed in the windpipe). A Pulmonary consultant, Dr. #2, managed that aspect of her care properly.

On the evening of May 8, at 20:30, the nurses' notes show that the patient was resting quietly and "wrist restraints in place to bilateral wrists, circulation intact and unimpaired." A similar nurses' note was recorded at 21:00, at 21:15, and at 22:15, just before the patient was transferred to the surgical intensive care unit. I was unable to find any physician's order for soft wrist restraints during this part of her care.

Some hospitals have standing orders (automatic routine procedures) that nurses follow, or have automatic nursing standards that allow nurses to apply soft wrist restraints when indicated. In some hospitals, they can apply the soft wrist restraints, but it then requires the physician to be contacted for an order to be written.

In addition to the use of soft wrist restraints, which is quite restricting, patients can also be placed in a Posey jacket, which is like a straight jacket with the arms freed, and the jacket is tied to the bed from behind. This allows the patient limited mobility, depending upon how tight the Posey restraint is pulled down to the bed.

When patients are confused, the hospital is required to protect the patients from harm, which includes falling out of bed, or climbing out of bed and falling thereafter.

According to the records, the patient was doing well within the few days following the hip operation.

The first orders for wrist restraints that I can find in the records occurred at 2:59 a.m. on May 14. It says, "restraints -apply: soft ties to wrist - prn (as indicated). Follow restraint protocol". This was the telephone order of Dr. #3. Then, on May 14, at 9:14 a.m., there is a further order to restrain with the soft wrist restraints, which follows a hospital format, as noted on the restraints order dated May 14, at 08:45. It allows the nurses to use their judgement to release the restraints if the behavior checked off is absent. The behavior checked off here was to use the restraints during "episodes of confusion resulting in potential or actual injury to self. . ."

In the doctors' progress notes from May 13, it appears to state, "realizes her confusion today." On May 14, it notes, "very confused. Fell last night. X-rays ordered." That x-ray documented a fracture of the right hip, and she was properly taken to surgery by Dr. #1 on May 14, for an open reduction and internal fixation of the intertrochanteric fracture of the right hip. A hip screw and plate were used to reduce the fracture and maintain it in position. X-rays confirm that the operation was correctly done.

Usually, elderly patients are more confused at night, and one of the procedures utilized is to leave a night light on in the room. I cannot tell if this was done or not from the records.

Furthermore, the side rails need to be elevated and the bed placed at the lowest level so that if the patient should get out of bed or fall out of bed, their fall to the floor is reduced. It appears from the records that the side rails were elevated and the bed placed in the lowest position.

According to the nurses' notes, on May 11, the patient was noted to be confused and disoriented at times. This was 16:00. At 20:00 (8:00p.m.), it says, "confused -- most of the time."

On May 12, at 8:00 a.m., noon, and 4:00 p.m. (16:00), the three recordings under the "neurologic" section show that the patient was "confused, disoriented to place and time." Despite that, no Posey restraint or wrist restraints were requested by the nurses, or ordered by the physicians.

Under the "psychosocial" section of the patient care notes that are typed, at 16:00 on May 12, it says, "Affect: confused most of time." On that day, the patient only took 25% of her dinner, less than usual.

In the handwritten patient care notes, at 20:00 on May 12, it says, "confused to time and place." On May 13, at midnight, 4:00 a.m., 8:00 a.m., and noon and at 20:00, it says the patient was confused, she was disoriented. On May 13, the patient was incontinent of urine at times, which is the first note of such a problem in the records.

Under the "musculoskeletal" section, on May 13, at 20:00, it says, "patient confused and crosses legs." This is contraindicated following a hip operation. In the "psychosocial" section for that entire day, it notes the patient was confused.

Despite all the above, no restraints were requested or ordered.

On May 13, at 22:59, under the "safety" section, it says, "bed low/locked, bell in reach, side rails up, instructed to call for assistance." This is by a Nurse whose initials are #1. However, you cannot instruct a confused patient to call for assistance.

Under the handwritten patient care notes on May 13, at 09:00, the nurses state that the patient was "pleasantly confused." She received physical therapy. She was short of breath (SOB), and oxygen was applied. This was a new complaint. At 00:00, it says that she was confused. She had no complaints of pain at that time.

That patient care note, as all of them in the records, have a stamper plate in the upper right hand corner. However, the next page, which appears to be a continuation of the above notes, even though the bottom two lines on the previous page are blank, does not have a patient stamp on that right upper corner. This should be investigated.

Then, at 01:20, it notes that when the rounds were made, the patient was found nude sitting near the bathroom door. It notes the side rails were still up. With the assistance of two people, she was able to ambulate without complaints of pain at that time. They noted that the right and left lower extremities were intact neurovascularly. They noted there was no shortening or external rotation of the legs, which is usually seen with a hip fracture.

They notified the Physician at 01:45, and orders were written for soft restraints to be used as needed. At 02:00, it notes that the soft elastic restraints were applied.

At 02:45, they noted that the patient was out of the soft restraints and somehow was able to rise up or pull herself free from the restraints, and she was found pulling her torso over the side rail of the bed. The restraints were reapplied, and the patient was complaining of pain in the right hip. Despite that, apparently no physician was notified until later that morning when the hip x-ray was obtained and showed a fracture of the right hip.

In my opinion, since this patient showed episodes of increasing confusion in the previous days, they should have notified the Pysician who should have ordered a Posey restraint or soft wrist restraints. As an alternative, they could have arranged for a sitter, by the hospital or the family, to be at the patient's bedside continually to protect the patient from injury. None of this was done, and in my opinion, that is a departure from the accepted standards of care of Hospital #1, as well as the attending Physicians. All the physicians seeing this patient, including the orthopedic surgeon and the others, had a duty, in my opinion, to note her confusion and order appropriate restraints. Furthermore, the nurses had a duty to contact the treating physicians, who may not have read the Nurses' notes, and notify them that there was a problem and request that an order be written. Also, they could institute restraints on their own, and then request a physician's order to support that action of the n urse.

Based upon their documentation, it would appear the patient did not fracture her hip when she climbed out of bed at 01:20, but after the wrist restraints were not properly applied, the patient injured her hip during that subsequent episode that was documented at 02:45.

The patient was also sedated and receiving narcotic pain medication. That, plus her age of 80, plus her history of dementia, lung problems, previous fainting episode that required hospitalization during Easter, and her fall at home that precipitated the admission with the hip fracture, all should have required the patient to be properly restrained, particularly in the evening, when these patients are prone to become more disoriented. She had increasing urinary incontinence, was eating less, and was more confused. All this is well-documented in the records.

In my opinion, all the above would require appropriate bed restraints, which should have been at least the Posey jacket restraint. In my opinion, the proper use of that jacket restraint, or the proper use of soft wrist restraints, would have prevented the subsequent fracture from occurring.

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Through discovery, obtain all of the standing orders of these physicians, as well as the hospital standing orders and nursing standards that the Hospital promulgated and were in effect during that time, with regard to the use of restraints.

The Defense would argue that the fracture was identified, she underwent successful surgery, and it only extended her hospital stay a small amount of time. Furthermore, this was paid for by Medicare insurance.

It would be important to document the current status of the mobility of the patient. She was going to be transferred to a skilled Nursing care facility, and was she ever able to be fully ambulated, having two hip fractures?

Because of her age, I would suggest you have a "day in the life" film taken to show the current status of the patient. I would also urge that a fast-track for trial be utilized because of her age and associated diseases.

In this case, I suggest that we first obtain the services of one of our Nursing Experts and then one of our Orthopedic Surgeons. You will have to conduct some discovery with regard to the standards I noted above, as well as deposing the Nurses that were in attendance during that night of May 13 and early morning hours of May 14.

We have these Experts available through our independent consulting staff.

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