Failure to Diagnose Acute Renal Failure Resulting in Untimely Death
The Dugorski Case
Case Summary
This case involved an emergency room physician who failed to recognize and appreciate a patient’s signs of acute renal failure. Instead, the physician treated the patient for COPD (chronic obstructive pulmonary disease) and discharged the patient home without diagnosing and treating the acute renal failure.
The following day, the patient’s PCP recognized the emergency room physician’s failures and instructed her staff to contact the patient and inform him that he appeared to be in acute renal failure and required further treatment. The staff at the PCP’s office negligently failed to communicate the PCP’s urgent message to the patient. The negligence of the emergency room physician the PCP, and her staff led to the patient suffering a cardiac event and, ultimately, an untimely death.
The Medicine
Acute renal failure occurs when the kidneys suddenly become unable to filter waste products from an individual’s blood and become unable to balance fluids and electrolytes in the body.
Acute renal failure can be a life-threatening condition if not properly managed or treated, and patients who have preexisting renal disease are particularly sensitive to the effects of diminished renal perfusion (i.e., poor kidney function). Further, patients who have acute renal failure in the presence of low urine output and increased creatinine have a higher mortality rate and greater risk of complications.
A prolonged QTc interval is an irregular heart rhythm that is associated with an increased risk of torsade de pointes, which is a lethal arrhythmia. A prolonged QTc in the setting of acute renal failure puts an individual at even more risk of a sudden cardiac event.
The management of acute renal failure and a prolonged QTc is imperative and should be done in a hospital setting in order to properly and efficiently regulate the body’s fluid and electrolyte levels in addition to an individual’s heart rate. If the renal failure is significant enough, hemodialysis may be required to allow the kidneys to heal.
Case Details
On March 18, 2021, Timothy Dugorski, a 70 year-old husband, father, and grandfather was taken via EMS to the emergency department with complaints of shortness of breath that had been gradually worsening over the previous three days. Additionally, Mr. Dugorski was not voiding (unable to urinate) as of the same day. Mr. Dugorski was seen by the Defendant emergency room physician after presenting to the hospital. Mr. Dugorski had a complex medical history that included chronic kidney disease and COPD, however, these conditions did not prevent him from living an active and meaningful life.
Upon presentation to the emergency department, Mr. Dugorski was examined by the Defendant, and bloodwork was performed along with a chest X-ray and an EKG. Mr. Dugorski’s labs showed abnormal results that included an increased BUN, decreased serum calcium, and a creatinine of 5.5 mg/dL. These levels indicated acute renal failure in the setting of chronic kidney disease.
Mr. Dugorski’s EKG showed that he had a prolonged QTc interval, and his X-ray found cardiomegaly with mild bibasal opacities. Despite these abnormal findings, the Defendant physician diagnosed Mr. Dugorski with COPD exacerbation and treated him as such.
During his deposition, the Defendant ER physician testified that COPD exacerbation did not explain all of Mr. Dugorski’s abnormalities. Despite not having an explanation for Mr. Dugorski’s abnormal findings, the Defendant ER physician discharged Mr. Dugorski home after treating him for COPD exacerbation with no inquiry or investigation into his renal or cardiac concerns. The ER physician also did not consult with a nephrologist regarding Mr. Dugorski’s acute renal failure or his electrolyte abnormalities, and he did not consult with a cardiologist regarding his abnormal EKG. Further, the ER physician did not consult with Mr. Dugorski’s primary care physician, who was well informed of his medical history.
The Defendant ER physician documented that his clinical impression of Mr. Dugorski was COPD exacerbation, and his differential diagnosis included COPD exacerbation, viral illness, pneumonia, pneumothorax, and pulmonary embolism. Acute renal failure was not listed anywhere in his documentation. Rather, the ER physician documented that Mr. Dugorski’s labs were unremarkable. Mr. Dugorski’s urinary output was not considered or addressed while he was in the emergency department, which the ER physician testified would have been helpful information to have while treating Mr. Dugorski and would have caused him to consider his renal dysfunction further. However, the ER physician did not consider Mr. Dugorski’s renal dysfunction to be significant and discharged him home with a diagnosis of COPD exacerbation and a prescription for prednisone, a drug that can precipitate uremia or exacerbate electrolyte abnormalities in a patient with chronic kidney disease.
After being discharged from the emergency department, a note was transmitted to Mr. Dugorski’s PCP’s office stating, “Follow up needed for ED Note”. Mr. Dugorski’s PCP was also a Defendant in this case. The PCP had been treating Mr. Dugorski for around 15 years.
The morning after Mr. Dugorski presented to the emergency department, the PCP received the message and reviewed his ED Note from the previous day. After reviewing the note and recognizing Mr. Dugorski’s condition, at 8:37 a.m. on March 19, 2021, the PCP authored a note to her staff to advise Mr. Dugorski’s wife that she reviewed Mr. Dugorski’s ER record, and he appeared to be in acute renal failure with a rise in his creatinine to 5.5. She further documented that she believed Mr. Dugorski should have been admitted to the hospital for hydration, and he should either be taken back to the ER for further treatment or provided lots of fluids to rehydrate over the weekend.
On March 19, 2021, a Certified Medical Assistant in the PCP’s office took responsibility for completing the task as instructed by the PCP and called Mr. Dugorski at 9:37 a.m. At the time the CMA called, Mr. Dugorski was sleeping, so his wife answered the phone. It was well known at the PCP’s office that Mr. Dugorski’s wife was very involved in Mr. Dugorski’s medical care and often attended doctors’ appointments with him and was regularly provided with his medical information. It was for this reason that the PCP specifically stated in her note to her staff to advise Mr. Dugorski’s wife about Mr. Dugorski’s emergent condition. This is also why on two separate occasions, Mr. Dugorski executed authorizations permitting the PCP’s office to release information regarding his medical care to his wife.
During her deposition, the CMA testified that prior to calling Mr. Dugorski, she checked in the office’s internal system to see if she was authorized to provide medical information to anyone other than Mr. Dugorski, and she did not see Mr. Dugorski’s wife as someone who was authorized to accept medical information on Mr. Dugorski’s behalf. Therefore, when the CMA called and Mrs. Dugorski answered, in contradiction to the PCP’s instruction, and in violation of the authorizations executed by Mr. Dugorski, the CMA failed to provide any of the information as instructed by the PCP. The CMA testified that she never saw the authorizations executed by Mr. Dugorski, and had she seen those prior to calling, she would have provided the information to Mrs. Dugorski. The CMA also testified that she understood acute renal failure to be an emergent condition, but she chose not to tell Mrs. Dugorski that Mr. Dugorski was in acute renal failure because she mistakenly did not believe she was authorized to do so.
Importantly, March 19, 2021 was a Friday, and the PCP’s office closed at 12:00 p.m. on Fridays. However, that information was not relayed to Mrs. Dugorski during the phone call with the CMA. The CMA failed to provide any pertinent information to Mrs. Dugorski, but rather simply told her to have Mr. Dugorski call the office back. For the next 2 ½ hours, no one from the PCP’s office attempted to call Mr. Dugorski again nor made any effort to ensure that the pertinent medical information as noted by the PCP was provided to the Dugorskis.
Mr. Dugorski called the office back shortly after 12:00 p.m., but unbeknownst to him, the office was closed. Therefore, Mr. Dugorski never received the message that he was in acute renal failure and should return to the ER as instructed by the PCP.
The following day, on March 20, 2021, Mr. Dugorski woke up experiencing some shortness of breath. Mr. Dugorski put on his oxygen and felt well enough to walk downstairs to use the bathroom. Upon reaching the bathroom, Mr. Dugorski called out for his wife before suffering a sudden death. He was pronounced dead by EMS upon their arrival. Mr. Dugorski’s acute renal failure was listed as an underlying cause of his sudden death.
In summary, the ER physician discharged Mr. Dugorski despite clear signs of acute renal failure in addition to cardiac issues that put him at even more risk of suffering a sudden death. Mr. Dugorski’s PCP recognized the ER physician’s error in discharging Mr. Dugorski and attempted to intervene and get Mr. Dugorski the treatment he required. However, due to a breakdown in communication and a failure to provide Mrs. Dugorski with pertinent medical information regarding Mr. Dugorski’s health, Mr. Dugorski was never informed that he was in acute renal failure and required further treatment. As a result, Mr. Dugorski suffered an unfortunate and untimely death.
A common theme in the cases we handle is to try to blame the patient for the ultimate outcome. This case was no different. The Defendants in this case, including the PCP who was not present in the emergency department, attempted to create a narrative that Mr. Dugorski was pushing to be discharged from the emergency department, despite no documentation to support that claim. The record clearly demonstrates that the ER physician felt comfortable discharging Mr. Dugorski from the ED despite his clear signs of acute renal failure that required further evaluation and treatment.
As for the PCP’s defense, there simply was none. She recognized that Mr. Dugorski was in acute renal failure and knew that something needed to be done. However, due to her failure to communicate this information to Mr. Dugorski, she was negligent and contributed to his untimely death.
Result
Shortly before trial, the parties reached an agreement to settle the case for a substantial amount.