This tragic case involved a 31 year-old mother of two who had a miscarriage with her third pregnancy. She was seen by defendants on three separate occasions, December 6th, 7th and 8th of 2006. Her miscarriage was diagnosed and each she came in she had worsening symptoms of vaginal bleeding, nausea, vomiting, and abdominal tenderness. She was at high risk for severe bleeding, clotting and infection because of her past medical history and medications. Each time she was sent home without definitive treatment for her miscarriage. In her last visit, no laboratory studies were ordered to assess her body fluid status. Instead she was given a prescription for Cytotec, a drug which causes uterine contractions, and was instructed to return in a week.
The next day, December 9, 2006, our client passed out at her home. An ambulance arrived quickly, attempted resuscitation, and transported her to another hospital. Initial labs there revealed she had a life-threatening hemoglobin level of 4.4. Plaintiff was diagnosed with severe anemia and hypovolemia from acute blood loss and systemic infection caused by her retained products of the miscarriage. She suffered brain injury from lack of oxygen as a result of her arrest and was rendered a spastic quadriplegic.
Our claim was that plaintiff was at high risk pregnancy for bleeding, clotting and infection and required hospitalization. If she had been hospitalized on December 7th or 8th, a timely D&C would have been performed, her anoxic injury would have been prevented.
PERTINENT PRIOR MEDICAL AND SOCIAL HISTORY
Plaintiff and her husband had two children, ages 7 and 5. Plaintiff graduated from Minnesota High Technology Institute where she was trained as a medical technician. She was saving money to take the state licensure exam. In the meantime, she worked for a collection agency.
In March of 2006, Plaintiff was diagnosed with Lupus. An MRI showed that she had suffered a prior heart attack and stroke. She had stents placed and the discharge records established that all of her symptoms had resolved. Plaintiff did have a period of rehabilitation, but her cardiologist’s records demonstrate that she quickly returned to cooking and cleaning independently and walking daily with no pain. Her physicians were concerned she was at increased risk of blood clots and she was placed on a number of medications including Immuran, Coumadin, Plavix, Plaquenil, Zocor and aspirin therapy.
TREATMENT AT ISSUE
1. December 6, 2006
Plaintiff was pregnant and began spotting the morning of December 4, 2006. She continued to bleed and at about 11:30 p.m. the night of December 5, 2006, she went to the emergency room. Plaintiff remained in the ER the early morning of December 6, 2006 and had some spotting but her hemoglobin and hematocrit were within normal limits. An abdominal ultrasound revealed a “blighted ovum”, meaning it there was no fetus was non-viable. The physician noted no active bleeding, a closed cervix and mild uterine tenderness. Defendants sent plaintiff home with instructions to be seen by her OB/GYN in two to three days if she had not passed tissue or to report back to the ER if she had nausea, vomiting or increased bleeding of more than a pad an hour for over three hours.
2. December 7, 2006
Plaintiff was taken to the ER at 12:30 AM the early morning of December 7, 2006, about 24 hours after her first visit, because she had been bleeding heavily, “soaking her clothes,” since 8:30 PM. She complained of nausea and vomiting and was too light-headed to stand up to have her orthostatic blood pressures taken. The emergency physician performed a physical examination and noted moderate pelvic pain and copious amounts of bright red blood in her vagina. The physician cleaned the blood and several clots out of her vagina. Plaintiff was immediately started on an IV of normal saline because she was hypovolemic. Her hemoglobin and hematocrit were slightly low. Plaintiff was then typed and cross matched for blood products as well. The emergency room physician then consulted with an OB/GYN.
We argued the defendants’ reliance on these lab values was misplaced. Plaintiff had been bleeding heavily in the hours just prior to coming to the ER. An overall decrease in the hemaglobin or hematocrit would not likely be reflected in these initial labs. Further, she was likely dehydrated because of her nausea and vomiting which resulted in the labvalues being artificially high.
Plaintiff continued to bleed, although the OB stated she was not actively bleeding when she saw her and was no longer dizzy or vomiting. The OB felt plaintiff was stable and offered her the option to be hospitalized or to go home and return to the clinic on Friday, thirty hours later. Plaintiff did not want to stay in the hospital if it was unnecessary and went home. Ironically she was discharged with instructions to return if she had severe cramps, bleeding, felt faint or vomited repeatedly, the very symptoms that had brought her back to the ER in the first place.
Our experts were critical of the defendants for discharging plaintiff from the hospital. They testified plaintiff was at high risk for infection, bleeding or clotting and absolutely should have been admitted to the hospital for monitoring, additional consults and likely surgical intervention. The defendants should have been aware the lab values were artificially elevated and should have performed serial studies to determine plaintiff’s true hemodynamic state. Our experts felt that had additional labs been ordered they would have shown a clinically significant drop in hemoglobin.
3. December 8, 2006
Plaintiff continued to bleed over the course of the next day and a half. She mostly stayed in bed during this time because she was not feeling well. Plaintiff’s husband took her to her scheduled appointment with her OB on Friday morning at 10:00 a.m., thirty hours after her last ER discharge.
Her OB was aware that plaintiff had a history of “excessive vaginal bleeding” over the course of the last three days. She also reported soaking through a pad every three hours and had vomited that morning. Plaintiff now had tenderness over her “entire uterus and cervix”, was dilated 1-2 cms., and was actively bleeding. The OB saw tissue in the cervical canal and tried but was unable to remove the tissue. The OB did not run any laboratory studies, nor do any cultures but did place plaintiff on Cytotec, a medication which promotes contractions and told her return in a week.
Our experts were unanimous that this decision was below the standard of care. Our experts felt plaintiff’s increased uterine and cervical tenderness were clear signs of an infection from the fetal remains or dead tissue that had been in her uterus for some time. She had dilated which created an open pathway for pathogens or bacteria from the vagina. Further, plaintiff was on immune-suppressants which decreased her body’s ability to fight off infection. Plaintiff continued to have “excessive bleeding” and yet her OB did not order a hemoglobin or hematocrit. Our experts will testify that these lab studies were mandatory to evaluate this patient’s status. Our experts opined that labs that day would have shown a clinically significant decrease in her hemoglobin and hematocrit. Our experts testified strongly that in their opinion this patient should have been hospitalized, monitored and arrangements made for immediate surgical intervention.
D. December 9, 2006
Plaintiff had the prescription for Cytotec or Misoprostol filled that day. She remained in bed most of the night and next day and husband would periodically go in and check on her. On the afternoon of December 9, 2006, plaintiff collapsed in the hall.
911 was called and the ambulance arrived within five minutes. EMT personnel determined that plaintiff was in cardiac arrest- pulse-less and non-breathing. They began CPR, a large IV was started, epinephrine given and her heartbeat restarted. She was then transported to another area hospital.
Lab studies showed a critical hemoglobin of 4, CBC of 30,000, bicarb of 8, and elevated creatinine. 2 units of uncrossed match-blood to be given immediately and 4 units of cross-matched blood to follow. There was two 1 inch diameter pieces of “extremely foul smelling macerated tissue” which the ER physician removed from plaintiff’s vagina.
Plaintiff’s primary physician set forth in his History & Physical that plaintiff was in “septic shock,… most likely intrauterine infection…and patient” still had some retained products of conception. He also noted severe anemia due to acute blood loss and renal failure from blood loss and sepsis.
Our experts testified that had appropriate steps been taken on either the 7th or the 8thPlaintiff’s injuries would have been avoided. The treating physicians also felt that plaintiff continued to bleed and eventually developed severe anemia, hypovolemia and sepsis. This led to her cardiac and respiratory arrest and brain injury from lack of oxygen.
Defendants argued this was an unanticipated and catastrophic anti-phospholipid syndrome. Plaintiff had Lupus which can create increased risk of clotting and is one of the reasons our experts believe she needed to be admitted to the hospital. However, our experts and the key treating physicians felt that anti-phospholipid syndrome is a clotting disorder and plaintiff suffered from an acute bleed.
We had truly compelling and qualified experts. Our emergency room expert was a board-certified emergency medicine physician who works and teaches at the UCLA. She had written numerous articles on a variety of emergency room subjects and had co-authored a book on obstetrical emergencies. We also had obstetricians, one from the Woman’s Hospital in Houston, the other from Mercy Hospital in St. Louis, and a high risk specialist from the Beaumont Hospital in Detroit. Finally, we have a local hematologist.
Plaintiff was rendered a spastic quadriplegic. She has a sense of what is going on around her, but has no control of her arms or legs. She has a catheter, colostomy bag and feeding tube. There is no part of her daily care she can do herself. She is on numerous medications and needs PT to help with her contractures. Our life care plan put the cost of her future medical care at millions of dollars. However, the defendants had limited coverage.