In this medical malpractice case, Janine Kelly (fictitious name), a 66-year-old woman went into the hospital for a colon resection after a colonoscopy showed she had a malignant tumor. She expected to be in the hospital for 3-4 days, and to return home to her previous level of functioning. She was alert, cooperative, calm, had full range of motion, and a strong hand grasp and leg movement.

Surgery began about 12:00 PM and ended about 3:00 PM. The surgeons encountered a lot of bleeding during the operation. It took several attempts with sutures to finally control the bleeding, which totaled 1200 cc of blood loss. The patient was given 4 units of blood.

In the recovery room, the patient was awake and could move her arms and legs when requested to do so. She was asked to rate her pain. She rated it as 8; the nurse injected Dilaudid 1 mg by intravenous push. (Dilaudid is one of the strongest pain relievers on the market.) At 3:40 PM, the patient’s artery was stuck to obtain blood to test for blood gasses. (Punctures of arteries are exquisitely painful due to the nerve endings that surround the artery.) At 3:45 PM, the patient’s femoral vein in her groin was stuck to obtain blood. At 3:50 PM, Ms. Kelly rated her pain as 10 at that time, the highest possible pain. She was given an intravenous injection of Fentanyl, a narcotic.

The patient left the recovery room at 5:15 PM. She was awake and could move her arms and legs when requested to do so.

Intensive Care Unit 5:45 PM-7:45 PM
Ms. Kelly’s level of awareness was evaluated when she arrived in the intensive care unit. She spontaneously opened her eyes. She obeyed commands. (Commands are requests such as “Open your eyes”, or “Squeeze my hand.”) She could not speak due to the presence of the endotracheal tube. She could purposefully move her arms and legs and had full strength. displayed her heart rate and rhythm.

At 6:00 PM, Ms. Kelly was pulling on her IV lines, attempting to remove the endotracheal tube in her mouth, and pulling on her tubes and drains. Wrist restraints were put on each wrist to tie her hands to be bed frame. This prevented her from doing anything for herself, such as scratching her nose, turning over, or writing a note. The critical care nurse documented the patient had obvious signs of pain. She was given Fentanyl 25 mcg by intravenous push at 6:00 PM.

A nursing note was written at around 7:00 PM which summarizes the hour of 6:00 PM to 7:00 PM states three doctors were in and inserted a triple lumen catheter and an arterial line. A triple lumen catheter was inserted into the patient’s upper chest in the right subclavian area. This procedure involves injecting the skin with Xylocaine to numb it, covering the chest with drapes, and piercing the skin with a needle to insert a long tube that is threaded along the subclavian artery to a point close to the heart. A painful arterial stick to insert an arterial line was also performed.

At 6:10 PM, the patient was assessed as needing more pain medication. She was given Fentanyl 25 mcg by intravenous push.

At 6:20 PM, the patient was assessed as still being in pain. She was given Fentanyl 25 mcg by intravenous push for pain.

At 6:40 PM, the patient was again in need of pain medication. She was given Fentanyl 25 mcg by intravenous push.

At 7:00 PM, the cardiac monitor displayed a slow pulse rate in the 40s. Ms. Kelly was given an intravenous dose of Atropine to increase her heart rate. It had little effect. The patient was not responding to painful stimulation. She was given Narcan to reverse the pain relieving effects of the Fentanyl. A dose of Epinephrine was given to stimulate her heart. There was little response.

At 7:15 PM, the code sheet shows the patient had no pulse or heart rate. Chest compressions were given. The plan was to re-explore the patient’s abdomen on an emergency basis.

Surgery 7:45 PM – 8:35 PM
Ms. Kelly’s preoperative diagnosis was “acute abdomen, bleeding post hemicolectomy.” The surgeons saw the entire small bowel was dead, black, and purple. A massive small bowel resection was completed. Ms. Kelly did not wake up after her surgery. A “medical futility” note written that evening around 10:45 PM noted the patient was cold with a body temperature of 91.4°; she was bleeding from all sites and had a hemoglobin below recordable data. (An earlier hemoglobin was 3.7.) The patient expired at 11:23 PM.

When the defense claimed the patient had no pain and suffering, the plaintiff attorney pointed to the report Med League’s nurse prepared, a portion of which is in this blog post. The judge agreed the patient experienced pain and suffering and the case was settled.

Med League legal nurse consultants prepare Federal rule of evidence 1006 summaries/pain and suffering report of medical records that detail the care and treatment of patients. Call us for assistance.