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Case
A 29-year-old patient, 5 years pregnant and 4 years postpartum, had her first antenatal visit at 10 weeks to her last menstrual period (LMP). She has a history of four previous vaginal deliveries, three of which were term and uncomplicated, and one where she had a stillborn fetus with trisomy 18 and multiple fetal anomalies. She gave birth at 36 weeks under circumstances. Her last pregnancy had significant gestational hypertension, but otherwise her pregnancy and delivery were uneventful.
Her medical history was notable for migraine with aura and varicose veins in her left leg. She had no history of hypertension (other than gestational hypertension mentioned above) and no history of diabetes within or outside of her pregnancy. She denied her history of blood clots and there was no family history of them either. She had been using oral contraceptives prior to her current pregnancy and had no outbreaks. She was a non-smoker. Her body mass index was 45 kg/m2.
During her first prenatal visit at 9 weeks and 4 days of pregnancy, she noticed morning nausea but was able to tolerate food without difficulty. Upon reviewing her system, she reported that she had no sleep disturbances or shortness of breath. She hasn’t had any recent trips or long car rides and was able to climb stairs like she used to. However, she said morning sickness reduced her activity level and she ended up lying in her bed for several hours. She also complained of worsening pain in her legs, and she had long-standing varicose veins that made it difficult for her to walk, stand, or put pressure on her legs, but she noticed that the symptoms in her left leg had become noticeably worse the previous day. It got worse, she said. She described a “throbbing pain up and down” in her left leg.
On physical examination, the patient was not in significant pain. She spoke in complete sentences and there was no choking in her voice. Her vital signs were within normal limits, her blood pressure was 116/64 mmHg, and her heart rate was 76 beats per minute (bpm). Her weight was 273 pounds. Her heart had a steady rate and rhythm, her abdomen was soft and nontender, and her lungs were bilaterally clear. Her pelvic examination was normal and revealed an appropriately enlarged uterus. Examination of her extremities revealed swelling in both of her legs, with her left leg being larger than her right leg. No erythema was observed and no palpable cords were identified.
Bedside transvaginal ultrasound revealed an intrauterine pregnancy. Head-hip length measured her to be 9 weeks 4 days, and LMP supported gestational age. Fetal heart sounds were recorded in her 150s and no maternal adnexal masses were seen.
Patients were given a prenatal education packet, prenatal testing instructions, and a formal first trimester ultrasound examination. Because of the patient’s symptoms and leg edema on examination, she also ordered an emergency Doppler ultrasound of the lower extremities. Healthcare provider documentation included physical examination findings, including differential diagnosis of the cause of symptoms and potential next management steps. Whether the Doppler ultrasound of the legs is within normal limits.
The patient underwent a laboratory test in the examination room on the first floor of the clinic and then left the clinic building. As she was walking across the parking lot to the hospital to get an ultrasound of her lower extremities, she felt unwell and sat on a bench on the sidewalk. She was then seen falling off a bench and people in her street called 911.
Arriving paramedics found her initially unconscious. Her heart rate was 131 bpm and her oxygen saturation was 75% on ambient air. Blood pressure could not be measured and the patient was noted to have a weak radial pulse but a good carotid pulse. Intravenous access for hydration was established, an oxygen mask was secured, and the patient regained consciousness. Her blood pressure was 166/122 mm Hg and her heart rate was 153 bpm. The patient was rushed to the emergency department (ED) of the hospital across the street.
At the emergency department, the patient complained of dyspnea and abdominal pain. She was very excited and could not follow her complete instructions. She said she felt dizzy and nauseous before sitting on her sidewalk bench, but she did not remember falling or responding to 911. Although she was receiving supplemental oxygen, she was clutching at her mask due to her agitation.
Vital signs were remarkable with blood pressure 172/99 mm Hg and heart rate 160 bpm. The oxygen saturation of the non-rebreather face mask was 90%. Physical examination revealed bilateral lungs to be clear on auscultation and labored but symmetrical breathing. Cardiac examination revealed a regular rhythm with no extra heart sounds. Both radial and femoral pulses were weak. The patient was able to move all four limbs. The lower limbs had marked edema, which was greater on the left than on the right. Bedside ultrasound demonstrated no free fluid in the abdomen, confirming an early intrauterine pregnancy. An ultrasound examination of the lower extremities was planned.
The femoral line was placed and the lab was drawn. Shortly thereafter, the patient became unresponsive and was noted to be grinding his teeth and biting his lips. Her pupils were fixed and dilated. Her blood pressure at this point was 148/106mmHg and her heart rate was 54bpm. She was immediately intubated and her airway was cleared.
Within minutes, she went into pulseless electrical activity (PEA) cardiopulmonary arrest. Cardiopulmonary resuscitation (CPR) was initiated. The differential diagnosis at this point was pulmonary embolism, intracranial hemorrhage, seizures, toxicosis, or unknown cause. Ultrasound examination of the lower extremities revealed a superficial venous thrombus. The deep venous system could not be completely evaluated. Tissue plasminogen activator (tPA) was administered because pulmonary embolism (PE) was considered more likely than intracranial hemorrhage. Despite best resuscitation efforts, the patient remained under PEA arrest and was pronounced dead after 50 minutes of cardiopulmonary resuscitation. An autopsy revealed that the cause of death was PE in the right main pulmonary artery.
review
The case was reviewed by the plaintiff’s medical experts. Key documentation during her prenatal visit listed several risk factors for venous thromboembolism. Her health care provider considered deep vein thrombosis in the differential diagnosis and ordered an emergency Doppler lower extremity ultrasound. Her obstetrician noted that her condition was stable and that she did not require urgent transfer to the emergency department. Her obstetrician was unaware that the patient had become unresponsive outside the clinic building.
The documentation and response by the emergency room physician was appropriate, especially regarding the rapid change in her condition. It was noted that thorough documentation was carried out immediately after the patient was declared dead, which was considered appropriate under the circumstances.
After extensive review, it was determined that although this is a rare but tragic result of a very morbid condition, the documented care met the applicable standards of care. Therefore, no medical negligence suit was filed.
discussion
Lack of adequate and appropriate documentation is often cited as the root cause of medical malpractice actions. This case shows how proper documentation can avoid a negligence lawsuit. Documentation included pertinent historical and clinical information, and a complete and thoughtful physical examination was performed with appropriate differential diagnoses, including the actual diagnosis. Appropriate clinical and imaging tests were ordered in a timely manner. The response in the ED was appropriate and was managed in a timely and competent manner with appropriate documentation. Therefore, the reviewers concluded that the health care provider acted reasonably under the circumstances and within the applicable standard of care. If documentation was incomplete and not timely, allegations could be made that the patient’s complaint was not taken seriously or the seriousness of the patient’s condition was not recognized, and subsequent delays in treatment could result in the patient’s death. may have led to. The documentation addressed these concerns.
It was noted that ED provider records were primarily made after the patient had died. Noting the seriousness of the situation and the extreme condition of the patient, documentation immediately after the event was permitted. Timely documentation is critical to proper patient care and to avoid subsequent litigation in the event of adverse outcomes. Physicians and healthcare professionals are also encouraged to debrief with nursing and support staff after acute events to ensure consistent documentation by all involved.