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Excessive opioids blamed for respiratory arrest
A MIDNIGHT VISIT TO THE HOSPITAL prompted by abdominal pain, nausea, and vomiting led to a diagnosis of acute pancreatitis and secondary conditions in a 67-year-old woman. She was admitted to the intensive care unit (ICU) and given pain medication, including Demerol, morphine, and a fentanyl transdermal patch, despite the fact that she was opioid naïve, with no tolerance to strong opioid-based medications. A black box warning for fentanyl specifies that it should not be administered to opioid-naïve patients for acute or short-term pain.
During her stay in the ICU, the patient received increasing amounts of pain medication. On the third day, a physician prescribed almost 10 times the dose given on the previous day. The patient subsequently suffered respiratory arrest, resulting in brain damage that left her with no short-term memory and in need of full-time care.
PLAINTIFF’S CLAIM Excessive administration of opioids caused respiratory arrest and brain damage.
THE DEFENSE Respiratory arrest resulted from the patient’s underlying illnesses, not opioid overdose. The patient did not show typical signs of overdose, such as slowed heart rate and decreased breathing, and was, in fact, agitated up to the time she went into respiratory arrest.
VERDICT Confidential Missouri settlement.
COMMENT I’m seeing many malpractice suits involving the prescription of opioids. Caution and due diligence are essential.
A rising PSA, but no evaluation
A 59-YEAR-OLD MAN received a prostate-specific antigen (PSA) score of 2.0 in 2003. In 2006, his score was 5.26. His primary care physician didn’t evaluate him for prostate cancer.
A year later, the patient complained of frequent, slow urination. A digital rectal examination revealed a hardened, nodular prostate. The patient’s PSA was 209. A biopsy showed stage 4 terminal prostate cancer. Computed tomography and bone scans of the abdomen and pelvis indicated metastasis to lymph nodes and bones. The patient wasn’t a candidate for surgery or radiation.
PLAINTIFF’S CLAIM The patient had been diagnosed with benign prostatic hypertrophy in 2005 and 2006, but had received no further evaluation. A biopsy should have been performed in 2003, at the time of the initial PSA test. If the cancer had been diagnosed and treated with radiation then, the patient’s condition wouldn’t have become terminal.
THE DEFENSE No information about the defense is available.
VERDICT $500,000 California settlement.
COMMENT We may disagree with the assessment that more aggressive evaluation would have been lifesaving. Nonetheless, the lack of follow-up and discussion with the patient makes for a very unfortunate situation.
A hemorrhoid…or something else?
WHILE GIVING BIRTH TO HER SECOND CHILD, a 35-year-old woman sustained a second-degree vaginal tear that required repair. The physician who performed the repair noticed a large hemorrhoid and told a nurse midwife to have it evaluated with a possible gastroenterological consult to rule out a mass. The next day, another doctor and midwife examined the patient. They agreed with the patient to defer a gastroenterology consult and have the patient follow up with her primary care physician in a few weeks.
When the patient saw her primary care physician 3 weeks after delivery, her exam revealed no hemorrhoids; she was instructed to call back if the hemorrhoids recurred. The hemorrhoids didn’t recur, and the patient didn’t follow up with her primary care physician.
During the next 4 years, the patient received care from her gynecologist that didn’t include rectal examinations. Five years after delivery, the patient went to her primary care physician complaining of rectal bleeding with bowel movements. The physician found no external hemorrhoids but noted a rectal mass.
He referred the patient for a gastroenterology consult and biopsy, which revealed intramucosal adenocarcinoma. A computed tomography (CT) scan of the chest showed a nodule in the lower lobe of the right lung, which was suspected to be a metastasis. An abdominal CT scan and a positron-emission tomography scan indicated likely liver metastasis. A liver biopsy confi rmed adenocarcinoma.
The patient underwent chemotherapy and chemoradiation followed several months later by abdominal perineal resection, left lateral segmentectomy of the liver, cholecystectomy, and appendectomy. At the time of the settlement, she was doing well and receiving no cancer treatment.
PLAINTIFF’S CLAIM The primary care physician should have followed up on the rectal finding, which would have led to earlier diagnosis and treatment of the cancer.
THE DEFENSE The finding made at the time of the delivery was a simple hemorrhoid, which went away after delivery. The absence of symptoms for 4½ years indicated that the cancer couldn’t have been present at the time of delivery. The diagnosed cancer was in a different place than the original hemorrhoid.
VERDICT $1 million Massachusetts settlement.
COMMENT The folly of the failed hand off. One of the most common root causes of litigation is poor communication that results in a bad outcome. How many lives could be saved simply by phone calls between physicians?
Excessive opioids blamed for respiratory arrest
A MIDNIGHT VISIT TO THE HOSPITAL prompted by abdominal pain, nausea, and vomiting led to a diagnosis of acute pancreatitis and secondary conditions in a 67-year-old woman. She was admitted to the intensive care unit (ICU) and given pain medication, including Demerol, morphine, and a fentanyl transdermal patch, despite the fact that she was opioid naïve, with no tolerance to strong opioid-based medications. A black box warning for fentanyl specifies that it should not be administered to opioid-naïve patients for acute or short-term pain.
During her stay in the ICU, the patient received increasing amounts of pain medication. On the third day, a physician prescribed almost 10 times the dose given on the previous day. The patient subsequently suffered respiratory arrest, resulting in brain damage that left her with no short-term memory and in need of full-time care.
PLAINTIFF’S CLAIM Excessive administration of opioids caused respiratory arrest and brain damage.
THE DEFENSE Respiratory arrest resulted from the patient’s underlying illnesses, not opioid overdose. The patient did not show typical signs of overdose, such as slowed heart rate and decreased breathing, and was, in fact, agitated up to the time she went into respiratory arrest.
VERDICT Confidential Missouri settlement.
COMMENT I’m seeing many malpractice suits involving the prescription of opioids. Caution and due diligence are essential.
A rising PSA, but no evaluation
A 59-YEAR-OLD MAN received a prostate-specific antigen (PSA) score of 2.0 in 2003. In 2006, his score was 5.26. His primary care physician didn’t evaluate him for prostate cancer.
A year later, the patient complained of frequent, slow urination. A digital rectal examination revealed a hardened, nodular prostate. The patient’s PSA was 209. A biopsy showed stage 4 terminal prostate cancer. Computed tomography and bone scans of the abdomen and pelvis indicated metastasis to lymph nodes and bones. The patient wasn’t a candidate for surgery or radiation.
PLAINTIFF’S CLAIM The patient had been diagnosed with benign prostatic hypertrophy in 2005 and 2006, but had received no further evaluation. A biopsy should have been performed in 2003, at the time of the initial PSA test. If the cancer had been diagnosed and treated with radiation then, the patient’s condition wouldn’t have become terminal.
THE DEFENSE No information about the defense is available.
VERDICT $500,000 California settlement.
COMMENT We may disagree with the assessment that more aggressive evaluation would have been lifesaving. Nonetheless, the lack of follow-up and discussion with the patient makes for a very unfortunate situation.
A hemorrhoid…or something else?
WHILE GIVING BIRTH TO HER SECOND CHILD, a 35-year-old woman sustained a second-degree vaginal tear that required repair. The physician who performed the repair noticed a large hemorrhoid and told a nurse midwife to have it evaluated with a possible gastroenterological consult to rule out a mass. The next day, another doctor and midwife examined the patient. They agreed with the patient to defer a gastroenterology consult and have the patient follow up with her primary care physician in a few weeks.
When the patient saw her primary care physician 3 weeks after delivery, her exam revealed no hemorrhoids; she was instructed to call back if the hemorrhoids recurred. The hemorrhoids didn’t recur, and the patient didn’t follow up with her primary care physician.
During the next 4 years, the patient received care from her gynecologist that didn’t include rectal examinations. Five years after delivery, the patient went to her primary care physician complaining of rectal bleeding with bowel movements. The physician found no external hemorrhoids but noted a rectal mass.
He referred the patient for a gastroenterology consult and biopsy, which revealed intramucosal adenocarcinoma. A computed tomography (CT) scan of the chest showed a nodule in the lower lobe of the right lung, which was suspected to be a metastasis. An abdominal CT scan and a positron-emission tomography scan indicated likely liver metastasis. A liver biopsy confi rmed adenocarcinoma.
The patient underwent chemotherapy and chemoradiation followed several months later by abdominal perineal resection, left lateral segmentectomy of the liver, cholecystectomy, and appendectomy. At the time of the settlement, she was doing well and receiving no cancer treatment.
PLAINTIFF’S CLAIM The primary care physician should have followed up on the rectal finding, which would have led to earlier diagnosis and treatment of the cancer.
THE DEFENSE The finding made at the time of the delivery was a simple hemorrhoid, which went away after delivery. The absence of symptoms for 4½ years indicated that the cancer couldn’t have been present at the time of delivery. The diagnosed cancer was in a different place than the original hemorrhoid.
VERDICT $1 million Massachusetts settlement.
COMMENT The folly of the failed hand off. One of the most common root causes of litigation is poor communication that results in a bad outcome. How many lives could be saved simply by phone calls between physicians?
Excessive opioids blamed for respiratory arrest
A MIDNIGHT VISIT TO THE HOSPITAL prompted by abdominal pain, nausea, and vomiting led to a diagnosis of acute pancreatitis and secondary conditions in a 67-year-old woman. She was admitted to the intensive care unit (ICU) and given pain medication, including Demerol, morphine, and a fentanyl transdermal patch, despite the fact that she was opioid naïve, with no tolerance to strong opioid-based medications. A black box warning for fentanyl specifies that it should not be administered to opioid-naïve patients for acute or short-term pain.
During her stay in the ICU, the patient received increasing amounts of pain medication. On the third day, a physician prescribed almost 10 times the dose given on the previous day. The patient subsequently suffered respiratory arrest, resulting in brain damage that left her with no short-term memory and in need of full-time care.
PLAINTIFF’S CLAIM Excessive administration of opioids caused respiratory arrest and brain damage.
THE DEFENSE Respiratory arrest resulted from the patient’s underlying illnesses, not opioid overdose. The patient did not show typical signs of overdose, such as slowed heart rate and decreased breathing, and was, in fact, agitated up to the time she went into respiratory arrest.
VERDICT Confidential Missouri settlement.
COMMENT I’m seeing many malpractice suits involving the prescription of opioids. Caution and due diligence are essential.
A rising PSA, but no evaluation
A 59-YEAR-OLD MAN received a prostate-specific antigen (PSA) score of 2.0 in 2003. In 2006, his score was 5.26. His primary care physician didn’t evaluate him for prostate cancer.
A year later, the patient complained of frequent, slow urination. A digital rectal examination revealed a hardened, nodular prostate. The patient’s PSA was 209. A biopsy showed stage 4 terminal prostate cancer. Computed tomography and bone scans of the abdomen and pelvis indicated metastasis to lymph nodes and bones. The patient wasn’t a candidate for surgery or radiation.
PLAINTIFF’S CLAIM The patient had been diagnosed with benign prostatic hypertrophy in 2005 and 2006, but had received no further evaluation. A biopsy should have been performed in 2003, at the time of the initial PSA test. If the cancer had been diagnosed and treated with radiation then, the patient’s condition wouldn’t have become terminal.
THE DEFENSE No information about the defense is available.
VERDICT $500,000 California settlement.
COMMENT We may disagree with the assessment that more aggressive evaluation would have been lifesaving. Nonetheless, the lack of follow-up and discussion with the patient makes for a very unfortunate situation.
A hemorrhoid…or something else?
WHILE GIVING BIRTH TO HER SECOND CHILD, a 35-year-old woman sustained a second-degree vaginal tear that required repair. The physician who performed the repair noticed a large hemorrhoid and told a nurse midwife to have it evaluated with a possible gastroenterological consult to rule out a mass. The next day, another doctor and midwife examined the patient. They agreed with the patient to defer a gastroenterology consult and have the patient follow up with her primary care physician in a few weeks.
When the patient saw her primary care physician 3 weeks after delivery, her exam revealed no hemorrhoids; she was instructed to call back if the hemorrhoids recurred. The hemorrhoids didn’t recur, and the patient didn’t follow up with her primary care physician.
During the next 4 years, the patient received care from her gynecologist that didn’t include rectal examinations. Five years after delivery, the patient went to her primary care physician complaining of rectal bleeding with bowel movements. The physician found no external hemorrhoids but noted a rectal mass.
He referred the patient for a gastroenterology consult and biopsy, which revealed intramucosal adenocarcinoma. A computed tomography (CT) scan of the chest showed a nodule in the lower lobe of the right lung, which was suspected to be a metastasis. An abdominal CT scan and a positron-emission tomography scan indicated likely liver metastasis. A liver biopsy confi rmed adenocarcinoma.
The patient underwent chemotherapy and chemoradiation followed several months later by abdominal perineal resection, left lateral segmentectomy of the liver, cholecystectomy, and appendectomy. At the time of the settlement, she was doing well and receiving no cancer treatment.
PLAINTIFF’S CLAIM The primary care physician should have followed up on the rectal finding, which would have led to earlier diagnosis and treatment of the cancer.
THE DEFENSE The finding made at the time of the delivery was a simple hemorrhoid, which went away after delivery. The absence of symptoms for 4½ years indicated that the cancer couldn’t have been present at the time of delivery. The diagnosed cancer was in a different place than the original hemorrhoid.
VERDICT $1 million Massachusetts settlement.
COMMENT The folly of the failed hand off. One of the most common root causes of litigation is poor communication that results in a bad outcome. How many lives could be saved simply by phone calls between physicians?