Failure to Diagnose Aortic Aneurism Resulting in Death
The De la Rense Case
A. Brief Summary:
A patient with numerous risk factors for an aortic aneurism was brought to a hospital emergency department by ambulance with clear, classic signs of an aortic aneurism. A radiologist who read a chest x-ray taken in the ER recommended that a CT scan be performed to determine whether the patient had an aortic aneurism. This recommendation was ignored by the Defendants. The patient died the next day from an aortic aneurism.
B. Background on the Medicine:
An aortic aneurism is an enlargement (dilation) of the aorta to greater than 1.5 times its normal size. It occurs when a weak spot in the wall of the aorta begins to bulge. This can occur anywhere in your aorta. Having an aneurysm increases the risk of an aortic dissection which is a tear in the lining of the aorta, shown in the image below.
Everyone will agree that an aortic dissection is a medical emergency requiring immediate treatment. Treatment may include surgery or medications, depending on the area of the aorta involved and the extent of the aneurism. If the dissection ruptures and is not quickly treated, it will lead to death from internal bleeding. Therefore, it’s an understatement to say that “time is of the essence” when diagnosing and treating an aortic dissection.
With regard to its signs and symptoms, as an aneurism enlarges, it can produce a sudden onset of intractable chest, abdominal and/or back pain, difficulty breathing, and weakness. Risk factors include coronary artery disease, atherosclerosis (hardening of the arteries), smoking, a prior history of aortic aneurism, and an age between 60 and 80.
Everyone will also agree that the only way to conclusively rule in or rule out an aortic aneurism/dissection is to perform an MRI or CT scan because physical exams and x-rays cannot detect them. On May 5th, at 7:40 am, a female patient - with a history of coronary artery disease, atherosclerosis, smoking, a prior history of aortic aneurism, and age 75 – came to the hospital emergency department, by ambulance, with complaints of intractable, 10/10 chest pain radiating into her back with constant heaviness which began “last night. ” An emergency room physician (“the ER Doctor” Defendant) examined the patient for a few minutes and ordered spine and chest x-rays; however, before any x-rays were even taken, as the ER Doctor noted, he diagnosed the patient with “intractable back pain secondary to degenerative disk disease and osteoarthritis.”
D. Facts of the Case:
Shortly after the ER Doctor’s brief exam, while the patient was still under his care in the ER, a radiologist reviewed the spine x-rays, issued a report noting that there was nothing abnormal about the spine and did not recommend any additional imaging studies to look at the spine as the source of the pain. At the same time, the radiologist who reviewed the chest x-ray noted that an “underlying aneurism cannot be entirely excluded” and issued a report with the following diagnosis: Despite the spine x-rays being negative and despite the radiologist’s recommendation for a CT scan to evaluate the aorta as the source of the pain, the ER Doctor, who is not a radiologist, played Russian roulette with this patient and chose not to order a CT scan. Instead, the ER Doctor, who testified that a dissecting aortic aneurism was on his differential diagnosis, gambled with this patient’s life, decided that his physical exam and his reading of the chest x-ray was sufficient to rule out an aortic aneurism, and turned the patient’s care over to an internal medicine physician (“the Internal Medicine Doctor” Defendant).
“Persistent tortuosity and prominence of the ascending and descending aorta. Findings are similar to prior study however, the[y] appear slightly more prominent. Recommend CT of the chest for further evaluation of the aorta as a source for the patient’s pain.”
Going off of the ER Doctor’s diagnosis - that an old compression fracture was causing the pain - prior to performing his own evaluation, the Internal Medicine Doctor ordered a pain consult to be performed by an anesthesiologist/pain management physicians (“the Pain Management Doctor” Defendant).
The Pain Management Doctor saw the patient around 11:00 am. In his deposition, the Pain Management Doctor testified that he assumed a CT scan had already been performed, as recommended, and that an aortic aneurism/dissection had already been ruled out (since that is an emergent condition that he expected to be ruled out in an ER). According to his deposition, the Pain Management Doctor thought he was simply asked to evaluate the patient to determine whether a Kyphoplasty or some other pain treatment would help the spine issue that was presumed to be causing her pain. Therefore, to determine whether a spine procedure was indicated and at what vertebral level, the Pain Management Doctor ordered a thoracic spine MRI (not of the chest as recommended by the radiologist). And since the Pain Management Doctor did not believe he was evaluating a medical emergency, the MRI wasn’t ordered on a stat basis but instead ordered for the next day.
Moving forward, a little after the noon hour, the Internal Medicine Doctor, who is now the attending in charge of the patient’s care, examined the patient. In his note, the Internal Medicine Doctor recorded that the patient was in tears, unable to move, had pain in her lower thoracic and upper lumbar back areas, and was begging him to help her back pain. The Internal Medicine Doctor “diagnosed” the patient with “intractable back pain” (he assumed from an old compression fracture). The Internal Medicine Doctor also noted that the Pain Management Doctor had been consulted and ordered an MRI. Like the ER Doctor and the Pain Management Doctor, the Internal Medicine Doctor ignored the radiologist’s finding of an abnormal aorta and ignored the radiologist’s recommendation to perform a CT scan to determine if the aorta was the source of the pain.
Shortly thereafter, the patient was placed in the ICU due to her condition. Throughout the rest of the day and evening, nursing notes consistently document that the patient had dangerously low blood pressures, had constant, severe, acute lower back and abdominal pain (despite being treated with morphine), was very cold, was weak, and had to have oxygen supplied via nasal cannula (4 liters) due to shortness of breath.
The next morning, May 6th, the MRI did not take place as scheduled because the patient was unable to lay on her back and unable to sit still due to her unrelieved, unrelenting pain. At 9:00 am, a nurse documented that she tried to update the Pain Management Doctor about this issue and documented that the Pain Management Doctor did not answer her pages. The nurse also documented that the Pain Management Doctor’s pain clinic was updated on the same and that staff were also texting the Pain Management Doctor with no response. In the Pain Management Doctor’s deposition, he claimed to not recall being notified. In the Internal Medicine Doctor’s deposition, he testified that no one ever notified him that anesthesia (the Pain Management Doctor was also the head of anesthesia) did not come in or respond to sedate the patient and perform the MRI.
Moving back a few hours, a blood test at 5:38 am showed an abnormally low red blood cell count and abnormally low hematocrit and hemoglobin (“H&H”). This H&H unquestionably screams out that the patient was now bleeding internally which should have tipped any doctor off that the previous diagnosis of intractable back pain from a disc problem was incorrect.
In the Internal Medicine Doctor’s deposition, he tried to claim that after seeing the H&H results, around noon, he became concerned, and his diagnosis changed to an aortic aneurism/dissection; however, despite this testimony, the facts and records tell a completely different story. In fact, the Internal Medicine Doctor had to admit, inter alia, that his progress note from the 6th did not even mention the blood test results (“It should have”) or his alleged new life-threatening diagnosis (which “always get documented”). The Internal Medicine Doctor also had to agree that he didn’t do anything to have the patient transferred, to give blood products, or to get STAT imaging studies performed once he saw the H&H. In his deposition, to try and justify why he didn’t order a STAT MRI or CT scan for his new life-threatening diagnosis, the Internal Medicine Doctor testified that he “assumed” the previously ordered MRI was going to be done STAT because the patient was in the ICU. Yet when this issue was brought to the Pain Management Doctor’s attention in his deposition - he was the head of the Department of Anesthesia - the Pain Management Doctor testified that the Internal Medicine Doctor’s testimony makes “no sense”. In any event, no MRI was ever done.
Throughout the day on the 6th, the patient’s condition continued to deteriorate. Due to respiratory failure, she was eventually intubated and placed on a ventilator. Another blood test at 5:18 pm revealed critically low H&H values indicating that the internal bleeding was at a lethal point. Shortly before the patient’s death, a critical care doctor was consulted who reviewed the patient’s chart, including the original chest x-ray report, and diagnosed the patient with an aortic aneurism and aneurismal rupture. The critical care doctor also diagnosed acute anemia due to blood loss. Shortly thereafter, the patient suffered a respiratory arrest, a code was called, and the patient died. The patient’s two adult children were present. Notably, the Internal Medicine Doctor signed the Death Certificate and listed the cause of death to be “hemorrhage from abdominal aortic aneurism.”
The patient was Janet de la Rense, a widow. She was survived by her daughter, her son, 6 grandchildren, and 2 great grandchildren.
E. The Decedent:
She worked for over 40 years as a nurse in a variety of specialties including Pediatrics and Nursing Home Administration. At the time of her death, she lived independently and was very active. She drove herself on errands, to weekly church activities, and many Senior Center activities. She especially enjoyed gardening, in particular her house plants and flowers with which she adorned her yard and home. She was an excellent cook and took pride in sharing meals with family and friends. Janet was known in her church and neighborhood for having a listening ear to all who needed a friend. She did many handcrafts and sewing projects, including crochet, quilting, and beadwork, which were mainly shared as gifts with friends and family. She was also known for taking a carload of children to weekly church activities and teaching the Awana Club (she also authored numerous children’s Bible programs and lessons as well as short stories and poetry).
Due to the glaring negligence, the defense was essentially going to be that Janet was a 75-yeard old woman with several “co-morbidities” who would have needed a risky operation to repair the aortic aneurism even if it had been timely diagnosed. In other words, the defense was going to claim “no harm no foul. “
A few months prior to the scheduled jury trial, the case settled at a voluntary mediation for a substantial amount.
F. The Defense:
Due to the glaring negligence, the defense was essentially going to be that Janet was a 75-year old woman with several “co-morbidities” who would have needed a risky operation to repair the aortic aneurism even if it had been timely diagnosed. In other words, the defense was going to claim “no harm no foul.”
G. The Result:
A few months prior to the scheduled jury trial, the case settled at a voluntary mediation for a substantial amount.