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When a patient presents with a medical problem, a physician has to consider not only how to treat the problem at had but whether the proposed course of treatment may adversely affect another medical condition the patient has. Often times patient’s present with complaints that can be surgically treated. However, in addition to the risks inherent with anesthesia, some patients might have other medical conditions which make surgical treatment more risky. This is especially true with older patients who often have high blood pressure or heart abnormalities. When faced with these types of patients, a physician should take special efforts to assess whether surgery is the best course of therapy in light of the heightened risks the patient may be exposed to.
An anesthesiologist in Pennsylvania was recently found negligent for going forward with an elective surgical procedure on a patient with a well-known history of coronary heart disease, by-pass grafts, stroke, diabetes and hypertension. In that case, the patient presented for routine elective hip surgery on June 25, 1996. The patient suffered a cardiac arrest and died approximately twenty-four hours after the surgery. The patient’s wife filed a wrongful death suit against the anesthesiologist, the nurse anesthetist, and the hospital.
At trial, the plaintiff claimed that the anesthesiologist failed to perform a complete pre-surgical evaluation, which would have revealed that the decedent suffered from unstable angina. The plaintiff claimed that her husband’s surgical procedure should have been cancelled or at the very least postponed until her husband’s health was optimized. The plaintiff was also critical of the anesthesiologist for failing to utilize an invasive cardiac monitor during the surgery. Throughout the course of the trial the plaintiff stressed the ease and cost-effectiveness of cardiac monitoring.
The defendants argued that the decedent suffered from numerous medical conditions which made him a high risk surgical candidate. The defendants claimed that the decedent accepted the risk of death inherent in the procedure by electing to undergo the surgery in light of his health problems. However, by acknowledging that the decedent was a high risk patient, the defendant may have given credence to the plaintiff’s argument that surgery should have been cancelled. The jury found the anesthesiologist was 100% negligent and that the nurse anesthetist and hospital were not negligent. The jury awarded the estate of the decedent $750,000.
In Massachusetts, there is a wrongful death action pending against an orthopedic surgeon and an internist regarding a patient who died during their post-operative hospitalization following surgery. In that case, the decedent had a history of deep venous thrombosis, pulmonary embolus, and atrial fibrillation. The decedent’s clotting times were being routinely monitored and he was also treated with a Greensfield filter and Coumadin. The decedent got in a car accident and damaged the prosthetic that had previously been surgically implanted in his right hip. The orthopedic surgeon advised the decedent that he needed to have the prosthetic surgically repaired. Keeping in mind the other medical conditions the decedent suffered from, the surgeon consulted with an internist to have the decedent medically cleared for surgery. After evaluating him, the internist determined that it was okay to proceed with surgery as long as the decedent continued to be anti-coagulated with a blood thinner either orally or intravenously. The surgeon decided to continue given the decedent Coumadin, which would put him at a lower risk of bleeding post-operatively.
During the course of his hospitalization post-operatively, the decedent experienced an episode of low blood pressure. The surgeon again consulted the internist. Since the decedent was at risk for suffering a pulmonary embolism, the internist considered that diagnosis when evaluating the change in his condition. Inevitably, the internist determined that the hypertension was caused by fluid loss and treated him with IV fluids to which he responded. At the time the internist evaluated the decedent, he did not administer any tests to rule out a pulmonary embolism as the cause of the drop in blood pressure. The decedent was eventually transferred to the transitional care unit of the hospital for rehabilitation and a vascular surgeon was consulted to assess whether he had venous insufficiency in his legs. Shortly after the vascular surgeon performed the consultation, the decedent became short of breath and sustained a cardiac arrest. Resuscitation efforts were unsuccessful.
The decedent’s wife has likewise filed a lawsuit arguing that her husband was a high risk patient who was not properly monitored. The plaintiff argues that her husband died from a pulmonary embolism because he was not sufficiently anti-coagulated and that the orthopedic surgeon and the internist failed to order a simple radiology test to diagnose this condition in a timely manner. This case has not yet gone to trial.
In both these cases, the physicians were faced with patients who needed surgery to treat the symptoms which they presented with. However, the patients’ complicated medical histories put them at a potentially higher risk for complications if surgery was performed. When faced with patients like this, physicians must fully assess and discuss the risks of surgery with the patient. If a specific precaution seems to be indicated, physicians should develop a treatment plan that includes medical clearance for surgery. In many instances, this will require consultations with other medical specialists. If a non-invasive, inexpensive medical test provides some diagnostic value in assessing whether a patient should be cleared for surgery and a physician chooses not to order such a test, the physician should fully document the basis of their decision. Physicians should be mindful to continue monitor high risk patients for complications both during the procedure and post-operatively after the patient has been cleared for surgery. Physicians should also take extra efforts to obtain informed consent from a patient and should not rely on the routine consent forms for patients who are at increased risks. Physicians should provide a detailed written consent form advising of the risks inherent in the procedure and the additional risks inherent in the patient’s pre-existing medical conditions. Physicians should keep in mind that if a patient’s life is in danger by an elective surgery, proceeding with the surgery could constitute a deviation from the standard of care.
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