INFORMATION EXCHANGE:
MAINTAINING AWARENESS THROUGH THE STAGES OF MEDICAL TREATMENT

Daniel R. Santola

Powers & Santola, LLP
39 North Pearl Street
Albany, New York 12207
518-478-6616
jpowers@powers-santola.com

Most patients unconditionally entrust their well being to the care and treatment of their doctors. These dedicated professionals have completed eight years of advanced education, served an internship, completed a residency program and almost all are certified by their peers to be competent with in their respective specialties. They are trained in the use of the most sophisticated technologies and have access to the most advanced medical equipment available on Earth. But the more specialized medicine becomes the more we should recall the old adage that a chain is only as strong as its weakest link. On some occasions, the life or death of a patient may depend, not upon advanced medically techniques, but upon much simpler factors such as basic communication among the various health providers.

Recently, we represented a young woman in a medical malpractice lawsuit brought against her primary care physician, a gastroenterologist (GI specialist), the HMO they both worked for and an emergency room doctor employed by a local hospital where she was sent. This was a vibrant young woman, blessed with an 11 year old daughter and a loving husband who came as close to death as is humanly possible, yet survived. When her heart stopped beating and she was classified as clinically dead, she described for the jury, in vivid detail, what happened. She was some distance from her bed as she watched the doctors desperately trying to resuscitate her. Then, she saw a beautiful LIGHT to which she was drawn. As she approached the light, she found herself waiting in a long line. Despite the beauty and serenity she experienced, she eventually noticed the line was not moving. She thought that maybe it was God’s way of telling her it was not her time to die. It was then that she decided to return to her hospital bed. A decision, she testified, she would later regret.

In medical terminology, she needed full cardio-pulmonary resuscitation after heart and lungs completely shut down from septic shock secondary to toxic mega colon. Multiple surgical procedures were required to remove her colon, fit her with a bag outside of her body to collect waste and several procedures to cut away the dead tissue in her abdomen as she healed. Her husband described that for several days her body bleed so much that they put a large pan under her bed to catch the blood dripping from her bed. She was transfused with over 400 units of blood. Her doctors said they were actually pumping in the replacement blood as fast as it was bleeding out from the gaping open wound in her abdomen, which had to be left open due to the massive infection present. She went through months of rehabilitation, but still suffers from the enormous physical and emotional scars she has been left with. Most importantly, she can never return to the former life she had known. Gone is the ability to go back to her job at the local Community College, which she loved. The quality time and special mother- daughter activities she spent with her child were abruptly ended. Whenever she left the house she had to meticulously plan her route according to the location of the ladies room. The once active circle of friends dwindled down to one, her husband, who still is and forever will be there for her. The real tragedy is that all of this suffering could have been avoided if a simple, non intrusive test, costing less than $20.00, had been given.

Not surprisingly, each of the doctors who were sued had their own rational for why he or she did not order this one test despite subjecting her to what one doctor called “The Medical Mode.” Her odyssey began in the early fall when she was prescribed the commonly used antibiotic Augmentin for an upper respiratory infection. She was given the customary warning to call if she experienced an upset stomach or diarrhea. The day after starting the Augmentin she called the doctors office with complaints of diarrhea. Her doctor took her off the Augmentin and replaced it with another antibiotic. The diarrhea stopped but returned again in mid December, this time it was accompanied by bright red blood. Alarmed by the new development, she called her doctor and was given an appointment in early January. After examining her patient, the doctor diagnosed the cause of her condition to be hemorrhoids. She prescribed Anusol HC suppositories and advised if the symptoms continued to return in 3 weeks. However, only 9 days later, the plaintiff returned to the doctor’s office with continued complaints of rectal bleeding and bloody diarrhea. This time, the doctor felt there was something going on which required immediate evaluation. She first ordered some blood test and instructed the patient to drop off a stool sample at the HMO’s laboratory the next day. Additionally, she called on one of her partners, who has a sub-specialty in the field of gastroenterology, and explained that the patient needed to be seen immediately and could not wait the normal one to two weeks for an office appointment. The GI specialist agreed to see the patient the next day. Unbeknownst to the patient or the GI specialist, the primary care doctor, when filling out the paper work for the lab to do the stool culture, checked every box corresponding to various tests that could be done on a stool sample but one, the one for a c-diff tox screen. After dropping off the stool sample at the lab the patient went straight to the GI specialist’s office. The lab, primary care doctor and the GI specialist were all in the same one story building housing the HMO.

The GI specialist took a medical history from the patient and scheduled her for a colonoscopy to be performed the next morning. Immediately after the colonoscopy was performed, the GI specialist informed the patient that she did not find any polyps, cancer or other abnormality except for the presence of some redness adjacent to the rectum that was most likely caused by the persistent diarrhea. She further recommended that the patient undergo an upper GI series which was scheduled for the next week. In addition, the GI specialist set up an appointment to meet with the patient in two weeks, at which time all test results, including those ordered for the stool sample by the primary care doctor, would be available. With the assistance of the test results, a diagnosis could then be made and a treatment plan developed according to the GI specialist.

The next week the patient did have an upper GI series performed at the local hospital as scheduled. At the completion of the test she was told by the radiologist who performed the test that it was normal. But, the very next day, a Friday, the patient experienced severe abdominal pains on top if her continuing bloody diarrhea. She called her primary care doctor that day and was told to come right in to be examined. The patient complained to her doctor that it seemed like the more tests she was having the worse she was getting. This, the doctor said, was called being in “The medical mode”. The doctor diagnosed her condition as a thrombosed hemorrhoid, and prescribed nitroglycerin suppositories and Darvocet for pain relief. She was instructed to call on Monday if she was no better.

Over the weekend her symptoms not only continued but became significantly worse. On Monday, the patient called the doctor twice from work and waited for the return call until she felt she needed to leave before she could no longer drive herself home. Her doctor eventually returned the call shortly just after the patient left work for home. Upon learning of this the doctor then called the patient home. The patient’s husband answered, explaining his wife had not yet arrived home. The doctor instructed him to go to the pharmacy and pick up a new prescription for hydrocodone, a stronger narcotic for the pain, and Anucort for the hemorrhoids. Also, she directed that the patient was to stay out of work for three days and get as much rest as possible. The husband relayed the information to his wife when she arrived home and picked up the new medication as directed.

The next day, a Tuesday, the patient took the new medication and stayed on the couch all day, but did not get any relief from her symptoms. On Wednesday morning, the husband called the doctor and told her how his wife was not getting any better and that she needed to be hospitalized. In response, the doctor said the only way for her to be admitted to the hospital was to bring her back to the HMO offices to be seen by one of her partners or to go straight to the Emergency Room. The husband decided not to waist any time and took her to the local hospital. She was examined in the ER, given IV fluids, potassium and routine blood test were ordered. After several hours in the ER, the patient was told by the hospital doctor that she did not need to be admitted and she see should call her regular doctor for further treatment.

What she was not told, and never learned until the trial began to unfold, was that the ER doctor, upon being informed that the blood test he ordered came back with an abnormally high liver enzyme value, called the patients primary care doctor to alert her to his findings and asked what she wanted him to do with the patient. In fact, there were 3 separate calls from the ER room to the doctor’s office. The first was not returned, but the remaining 2 were returned by yet another doctor in the HMO who was “on call” for the patient’s primary care doctor. The ER phone logs recorded that the ER was told by the on call doctor for the HMO to send the patient home and instruct her to continue her follow up treatment with her doctors at the HMO offices. Later that evening the ER doctor faxed a copy of the ER records to the patient’s HMO. This report was received at the HMO, but never read by any doctor.

After being discharged, the plaintiff’s condition spiraled downward into a state of delirium. Barely able to remain conscious, she spent most all of the next day, Thursday, on her couch, unable to remember any of the day’s events. On Friday morning, her husband once again called her primary care doctor, stating that her conditioned worsened and that she was now mentally “not with it.” He was instructed to immediately send his wife back to the ER and the doctor would make arrangements to have one of her partners come down to see her. The patient was taken by ambulance to the ER arriving at 8:00 AM . Although called several times from the ER, no one from her doctor’s office came until after 5:00 pm. Eventually, she was admitted to the floor and after a CT scan was done her GI doctor was finally called in for an evaluation. After arriving at the hospital that evening and within minutes of seeing the CT film her GI doctor realized the patient had a toxic mega colon and needed emergency surgery and intensive care. Arrangements were made for transfer to a regional Trauma center, since the local hospital was not equipped to handle this level of critically ill patient.

Within minutes of her transfer to the trauma center, she was diagnosed with the end stages of pseudomembranous colitis that had progressed to the point of causing severe swelling and death of the colon, spilling its contents into the abdomen causing a massive infection. The pseudomembranous colitis in turn was due to the untreated c-diff infection the patient had over the previous months.

When c-diff is timely diagnosed, the treatment is simple. In almost all cases the patient’s symptoms end within forty-eight to seventy-two hours after taking a medication called Flagil. After ten days of treatment with Flagil, up to ninety-five percent of patients are completely cured. C-diff is a common bacterium found in the human intestinal tract. It is so common that its very presence is sometimes described as normal. C-diff normally does not cause any problems because it is usually found in relatively small numbers. However, when the normal flora or bacterium that is necessarily present in our gut to digest food becomes disrupted, such as when one takes antibiotics especially Augmentin, the medication can kill off not only the bad bacterium, but the good as well. This allows the C-diff to multiply and proliferate in the vacuum created by the killing off of the good flora. When C-diff bacteria is present in high numbers, the toxin they produce have the ability to erode the human bowel.

At trial the focus was upon the primary care doctor’ s failure to consider, and test for, the presence of a C-diff infection, despite the plaintiff’s history, her complaints and increasing deterioration over the course of the three weeks in January. Although the doctor’s diagnosis of hemorrhoids might account for the blood it did not explain the patient’s diarrhea. The primary care physician argued that this medical problem unexplained diarrhea was out of her specialty and fell to her partner, the GI specialist. The GI specialist said that she was not the patient’s doctor but was acting only a consulting capacity to the primary care doctor. Furthermore, since the colonoscopy she performed was normal and she was never told that the patient developed abdominal pain which required an emergency office appointment and treatment with narcotics on that Friday, or that the patient continued to get worse over the weekend and ended up in the ER room on Wednesday. These were all factors that the GI specialist testified were important and that she would have expected the primary care doctor to inform her of. Both doctors from the HMO argued that in almost all cases of C-diff the cause is rooted in the administration of antibiotics within a few weeks of the onset of unexplained diarrhea. Since the patient had been given antibiotics in the early fall and did not come to the HMO until January, she must have gotten the c-diff infection from the bowel prep, given before the colonoscopy which could cause a flushing of the normal levels of bacteria from the colon leaving only the c-diff bacteria to run rampant. Since only a hand fill of the world’s research scientist had ever heard of c-diff being caused by bowel prep, no one could have expected the local doctors to think of this possibility. Anyways, the patient was last seen in the Emergency Room and if she needed to be admitted, it was the ER doctor who should have admitted her. The fallacy of this argument was exposed by the defendant’s own expert, who unwillingly, had written several times that while most cases of c-diff infection occur within a few weeks their is a notable percentage of cases where the onset of diarrhea will occur up to three months from the taking of the antibiotic and that he actually taught his residents that any patient who has unexplained diarrhea with in that time frame should be given a c-diff toxin screen test.

The ER doctor took the position that the patient had her own private physicians, one of whom was a specialist in GI problems, and her own doctors, who knew her much better, did not arrive at the correct diagnosis, how could anyone realistically expect an ER physician, whose job is confined to stabilizing patients in need of emergency treatment, to provide a correct diagnoses. Besides, he testified, we faxed to her doctors the relevant records that evening.

The hospital did indeed prove that they sent a copy of the ER records to the patient’s doctor’s offices. When asked about this, the GI physician testified that she had never seen the ER records and that if it was faxed to the office it would have been put in the primary care doctors mail slot to be review by that doctor who would then decide whether it needed to be sent over to her.

The primary doctor when confronted with the ER record, also said she never saw it. In defense, she testified that there were ongoing problems with regard to what was the procedure in the office for disseminating information like this. And, that it became so prevalent that she had complained about it to the HMO’s management on several occasions in the past, but nothing was done about it. What she did not have a credible answer for is why she simply didn’t tell her partner, who she saw on almost a daily basis, that the patient was getting sicker and sicker and was sent over to the ER for emergency treatment.

When the level of medical bureaucracy becomes so palpable that it hinders simple communication between doctors, we need to think about refocusing our approach to medicine. What good will the most advanced form of treatment achieve if one doctor cannot tell another, that the patient is indeed sick and needs to be treated.

Awareness and involvement are essential elements that we, the patients, must maintain. If we don’t understand what is going on, then the medical profession has not performed its duty to keep us informed. If we are properly informed we still must be mindful that underneath the illustrious reputations and the baffling technical jargon, care providers are only human and like anyone else prone to error.