66yo F admitted to hospital w/ high grade neuroendocrine endometrial Ca on 3/13/23.
PMH: DM II, HTN, hyperlipidemia, all controlled with meds.
HPI: endometrial Ca suspected on CT scan A-P; uterine biopsy confirmed high grade
neuroendocrine endometrial Ca.
03/13/23
TAH-BSO w/ PLND.
Operative report describes skeletonizing both uterine arteries, applying Zeppelin clamps at the level of the internal os, using bipolar ligasure to cauterize and transect further transection with Mayo scissors, and securing the pedicles with 0 Vicryl sutures.
Vaginal cuff formation with Heaney sutures at the angles and figure-of-eight sutures “in the middle”. EBL 350cc. Surgical pathology showed Stage I uterine ca confined to the endometrium. Patient stable post-op on 3/13/23 (POD#0) in PACU on Toradol, oxy PRN, acetaminophen and ibuprofen for pain, and SQH q12 AD. Discharge to floor late at night.
03/14/23
Patient had been followed by PGY II throughout evening on 3/13/23 (POD#0) in PACU and on the floor during 3/14/23 (POD#1). PGY II saw the patient on the floor on 3/14/23 (POD#1) at 0556.
03/14/23 @ 04:42.
CBC w/ HGB 11.3. No other CBCs done until after patient codes later in the day at approximately 21:22.
Vital signs show normal systolic BPs with diastolic BPs in the 50-60s at the following times: 0550 – 0824 – 1352 – 1907.
03/14/23 @ 12:05
Gyn-onc attending #2 saw the patient at approximately 1205 and wrote an addendum to
the resident’s note in which she describes “borderline” UOP and BPs 140s-150s/60s. She notes post-op HGB at 11.3. She describes a net fluid imbalance of 1976ml with intake 2921ml and output 945ml. She notes fluid bolus was given and directs monitoring output
via foley. Also directs continued monitoring of BP with restarting antihypertensive meds if BP “improve[d]”. She also notes scant VB on pad and scant blood “stains” on abdominal dressing.
03/14/23 @ 14:25
Patient seen by PGY III at 14:25. She noted that she had been called by RN to “assess incision” because there was “red blood” on bandage. She estimated that the bandage was “30% saturated with blood”. PGY III inspected the abdominal midline incision and found that there was a “small amount of red blood” seen on the lower part of the incision compared to that morning; she wrote that there was no active bleeding. PGY III’s A/P includes “slightly increased strikethrough” on the bandage but there was “no active bleeding” from the incision. RN noted at 1452 that the patient had a “saturated dressing”; she made the “MD aware”. There are no more narrative progress entries in the chart by either a physician or nurse until 2001 that evening.
03/14/23 @ 19:50
BP drops to 91/51.
03/14/23 @ 20:01
PGY II is paged by the RN to see the patient. He notes that the patient complained of dizziness when she got up from bed to sit in a chair. She complained about the “room spinning and seeing floaters”. Patient stated that dizziness subsided but related that the “room appears darker”. She complained of nausea but did not vomit. Her BP at that time was 91/51. She was noted to be “diaphoretic”. Exam revealed that the vertical abdominal incision had a minimal amount of “drainage at the middle point” and the extremities had “asymmetrical edema”. PGY II’s assessment was “likely vasovagal” episode. He noted “FSG elevated”. Further assessment showed BP 104/60, HR 109 and O2 sat 100%. PGY II directed that VS be monitored in 30 minutes, 500cc fluid bolus, and, if the patient complained of dizziness again, to do “EKG and labs” to “r/o cardiac etiology”.
03/14/23 @ 20:16
BP 104/60.
03/14/23 @ 21:00
According to the patient’s husband, he arrived at approximately 2100, found the patient c/o severe LBP, she was "clammy", and appeared "drowsy". He saw patient’s abdominal dressing was “wet with red blood”. She was crying, saying "it hurts", and asked him to hold her.
03/14/23 @ 21:22
BP 82/26 at 21:22 shortly before the patient coded.
Patient goes into cardiac arrest, a code was called, and she was intubated and underwent CPR. She went in and out of cardiac arrest/PEA/V-tach during 2122 - 2304. Asystole prolonged for 20> minutes x2. A stat CBC at 2233 showed severely low H&H; HGB at 7.0 and HCT at 25.8, and ABGs showed patient severely acidotic c/ lactic acidemia. Patient goes in and out of asystole, PEA and v-tach throughout this interval. No pulse is recorded except with brief episodic returns to a pulse at variable intervals during 21:22 – 23:04.
03/14/23 @ 23:04
ROSC.
03/14/23 post-23:04
Sometime post-2304, patient was emergently brought to the OR by gyn onc attending #2 assisted by a fellow and PGY II. Exploratory laparotomy found 2500cc hemoperitoneum w/ active bleeding from right uterine artery and the right side of the vaginal cuff. The right uterine artery was suture ligated and the vaginal cuff was reinforced with sutures for hemostasis. Patient was given 1l LRs, 2u PRBCs & 1u FFP in the OR.
3/15/23 (POD#2)
Post-op, the patient was sent to the SICU and remained intubated and on pressors due
to hemorrhagic shock with acute respiratory failure, severe lactic acidosis, elevated liver enzmes, elevated BUN and creatinine, hyperkalemia (multi-organ failure). CVVH for the renal failure. She was given additional volume with 2u PRBCs and 3u FFP due to declining H & H; e.g., HGB 9.8, HCT 31.3, and PLT 139 on 3/15/23 (POD#2). Cause of declining H & H & Plt is unknown.
03/16/23 (POD #3)
The patient became asystolic, was coded x40 minutes, and died.
Files:
Q: Were there additional labs ordered prior to the patient coding ?
A: None.
Q: Did any physician note increased abdominal tenseness or girth ?
A: Yes, Exam by some goes from NT-ND in early am to mod distended & approp tender at 1425. Some docs, like att gyn onc, there is no exam at all. No exam when patient w/ BP 91/51 at 2007.
Do you believe there might have been medical error?
When a post-operative patient becomes hypotensive it is incumbent on the medical staff to assess for possible bleeding. At minimu, a CBC should have been ordered. If a large drop in hgb was noted compared to the morning, this would prompt rapid evaluation for the bleeding source.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The description given here for securing the vascular pedicles is within standard of care. The bleeding most likely began sometime after the morning of POD 1.
What makes you a good expert for this case?
I have performed thousands of hysterectomies by laparotomy. I work on a busy service and we are presented with postoperative hypotension fairly often and I am well versed on evaluating these patients.
How often do you encounter cases similar to this one in your practice?
Probably two-three times a month we evaluate for post- op hypotension. Identifying significant bleeding occurs about 4 times per year. Some of those cases require immediate return to the operating room and some can be handled by embolization.
Do you believe there might have been medical error?
The mere fact that no other lab test were run during this patient’s postoperative phase,,when clearly one of the differential diagnosis had to have been bleeding, This after a complicated Oncology case, shows a clear lack of understanding of the possible processes, this patient may be undergoing. The lack of any notation of a physical exam of the patient’s abdomen, coupled with decreased urinary output, again demonstrates poor medical care and lack of understanding of the process of differential diagnosis. It is exasperating to read that a resident concluded that a vagal episode occurred in a postoperative patient complaining of hypovolemic symptoms without considering an internal abdominal bleed..
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Obviously, upon undergoing the second surgery, the fact that there was bleeding within the abdomen, demonstrates that the uterine artery in question was not clearly ligated to the point where this patient would’ve had a smoother postoperative course.
What makes you a good expert for this case?
I’ve been in practice as a general gynecologist for 34 years. I worked in the hospital training residence alongside of working with general surgeons and GYN oncologists. Over the years, I have faced many issues such as this where the issue of an internal bleed always was a consideration in the list of differential diagnosis, especially when the patient is within a 24 hour postoperative window. as such, my teachings and experience have always been to go beyond a simple cursory exam of the patient, and to order lab tests as necessary and to be hyper vigilant,
How often do you encounter cases similar to this one in your practice?
I would say 1-4 per month of varying degrees.. The need to return to the OR occurs about one per month,
Do you believe there might have been medical error?
03/14/23 @ 20:01 This was the critical time, the patient showed clear signs of shock which may have been ignored by the second year resident because the patient's post-op hemoglobin earlier in the day was 11.3. However, bleeding is known to occur at a longer interval following this type of surgery, and the resident should have been suspicious. I have listed the duties that were neglected below. To miss the signs of shock and not provide the appropriate care is below the standard of care expected.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The second year resident had a duty to the patient when called at 2001 as follows: 1. Suspect shock due to intrabdominal blood loss in this post-op pateint with low blood pressure and elevated heart rate. 2. Summon a more senior resident if unsure what to do 3. Call the attending physician / surgeon/ immediately with update on patient condition 4. Get a STAT hemoglobin and check coagulation factors (rule out DIC) 5. Order a pelvic ultrasound or CT scan, whichever would be quickest, to look for post-op bleeding 6. Immediately type and cross blood for transfusion (at least 2 units) 7. Notify the OR of the unstable patient and possible need for surgery
What makes you a good expert for this case?
I have reviewed over 200 cases for a medical-legal opinion both for plaintiff and defense I have practiced for 30+ years I take care of patients like this one
How often do you encounter cases similar to this one in your practice?
frequently We do surgery every week and often need to rule out postop bleeding
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