Unraveling the Complexities of a Medical Malpractice Case: SIRS/Sepsis

Medical malpractice cases are among the most challenging for attorneys due to their complexity, involvement of medical intricacies, and stringent legal standards. Medical malpractice cases also involve highly technical medical issues that require a deep understanding of complex procedures and medical and nursing standards of care. To effectively argue a case, these details must be broken down and distilled into a digestible manner for all parties involved. ?

Here are several reasons why medical malpractice cases can be complicated:

1)???? Specialized knowledge of the medical or nursing issues at hand.

2)???? Expert testimony: Coordinating and presenting the right expert witnesses can be arduous.

3)???? High burden of proof: Must demonstrate clear evidence that the provider deviated from what a reasonable provider in the same specialty would have done under the same circumstances and connect the negligence to the injury.

4)???? Resource intensive: Requires high investment of time and financial resources such as expert witnesses, medical records, depositions, and possible trials.

5)???? Complexity of evidence: Explaining intricate medical details to juries with no medical knowledge is tricky. Simplifying without losing crucial information requires excellent communication skills. A legal nurse consultant can bridge the case's medical details and legal framework in such cases. In a recent case, I assisted an attorney-client in determining the deviations from the standard of care concerning delayed recognition and treatment of septic shock.

Case Study:

A 31-year-old wife and mother of two young children was admitted to a local hospital for a routine robotic-assisted laparoscopic gall bladder removal to treat her reoccurring gallstones after having her second child.? ?

At 10:00 AM, her gall bladder was removed, and surgeons noted there were no complications. Ms. X was admitted into post-operative care for monitoring. Approximately six hours after the surgery, at approximately 4:00 PM, the nurses documented that Ms. X had hypoactive bowel sounds, abdominal tenderness, a Foley catheter draining yellow urine, and a distended abdomen. The nurse administered 4 mg of Morphine every four to six hours on an as-needed pain, which alleviated her discomfort.

At 6:00 PM, the surgeon evaluated and noted that Ms. X's gastrointestinal system was functional and within normal limits, given her post-operative status. He ordered the nurse to continue to monitor her, administer pain medication as needed, and advance her diet and activity the following morning as tolerated. He anticipated her discharge within 24-48 hours. ?

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On postoperative day two, at 7:00 AM, the day shift nurse noted Ms. X to be in severe pain, rated 9/10 with abdominal distention [bloating], guarding, hypoactive bowel sounds, and not passing gas. Ms. X's vital signs were a blood pressure of 109/60, heart rate of 120, respiratory rate of 18, and temperature of 99.5 F. The nurse made rounds with her other patients for the day and then paged the surgeon at 9:30 AM to update him on her medical status. The surgeon called back at 11:00 AM and ordered Ms. X to start intravenous fluids and administer more pain medication as needed. ?

[No nursing or physician assessment between 7:15 AM and 1:00 PM]

[No nursing or physician assessment between 1:00 PM and 3:00 PM]

At 1:00 PM, the nurse administered intravenous fluids and medication. At 3:00 PM, nurses re-evaluated Ms. X after her medication administration and noted Ms. X to be diaphoretic [sweating]. ?Her vital signs were blood pressure of 99/50, heart rate of 130, respiratory rate of 24, and temperature of 101 F. Nurses paged the surgeon to inform him of her change in status. At 3:15 PM, the surgeon returned their call. He stated he would evaluate her personally when he finished his cases in the operating room. In the meantime, he ordered Tylenol and additional intravenous fluids. ?

The nurse immediately carried out the orders. At 3:20 PM, within approximately twenty minutes of administering intravenous antibiotics and fluids, Ms. X's vital signs became unstable, and a code blue [CPR] was called. After twenty-five minutes of life-saving measures, Ms. X was resuscitated and admitted to the ICU for further monitoring and treatment. ?Intensive care providers diagnosed Ms. X with septic shock, which cascaded into cardiac arrest.

After one week of intensive care unit medical treatment, Ms. X was diagnosed with an anoxic brain injury, and one month after the incident, she was unable to speak, walk, or care for her family. She required 24-hour care.

Background:

Systemic inflammatory response syndrome (SIRS) is an exaggerated defense response of the body to a toxic stressor (stress, infection, surgery, acute inflammation, or malignancy). SIRS with a source of infection is termed sepsis. Sepsis with one or more organ failures is called severe sepsis, and there is hemodynamic instability despite intravenous fluids.

Any of two criteria defines SIRS:

1)???? A body temperature under 96.8 or over 100.4 F

2)???? A heart rate greater than 90 beats per minute

3)???? A respiratory rate greater than 20 breaths per minute

4)???? A leukocyte count greater than 12,000 or less than 4,000 or over 10% of immature forms or bands

Almost all septic patients have SIRS, but not all SIRS patients are septic. Regardless, SIRS/Sepsis is time-sensitive, and early identification and treatment are the keys to a favorable outcome.

The standard of care for management early management of SIRS includes:

·?????? Securing the airway

·?????? Establishing vascular access

·?????? Early and aggressive intravenous fluids and antibiotics.

Ideally, routine laboratory studies, serum lactate, arterial blood gases, blood cultures, and imaging of suspected sources should be obtained; however, fluids and antibiotic administration should never be delayed.

The deviations from the standard of care for Ms. X included: ?

1)???? Failure to perform a timely assessment: The healthcare team overlooked vital signs indicative of a deteriorating condition, missing crucial windows for intervention.

a.????? Ms. X’s initial vital signs were a blood pressure of 109/60, heart rate of 120, respiratory rate of 18, and temperature of 99.5 F. Although they did not meet the SIRS criteria, it should have alerted the nurses to monitor Ms. X more closely. Approximately eight hours later, her repeat vital signs were a blood pressure of 99/50, heart rate of 130, respiratory rate of 24, and temperature of 101 F. There were no nursing assessments or repeat vital signs completed from 7:00 AM to 3:00 PM. This is a deviation from the standard of care.

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2)???? Delayed initiation of treatment protocols:

a.????? If proper assessments had been completed between 7:00 and 3:00 PM, Ms. X’s vital signs would have indicated she was not improving, but rather developing further signs of SIRS/Sepsis. ?The medical team could have initiated aggressive treatment earlier. This is a deviation from the standard of care.

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3)???? Failure to communicate: Miscommunication or inadequate reporting between the nurse and the surgeon contributed to the delays in identifying the severity of Ms. X’s condition.

a.????? Although the nurses paged the surgeon to inform him of Ms. X’s change in status, it was inadequately reported and not investigated further. Ms. X’s initial vitals showed a high heart rate and elevated temperature, which should have prompted the medical team to order lab work and imaging. This is a deviation from the standard of care.

A legal nurse consultant can create a comprehensive narrative and illustrate how delays or oversights in recognizing or treating SIRS/Sepsis impacted the client’s prognosis. In Ms. X’s case, a simple procedure became a devastating medical outcome.

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