The Kaller Case
This case illustrates the harm that is caused when members of the healthcare team fail to clearly communicate.
Mrs. Kaller, 62 years old, presented to the emergency room of Hospital A with severe abdominal pain. Lab work was ordered which revealed a very high amylase and lipase level, indicative of acute pancreatitis. She underwent a CT Scan of the Abdomen which also showed a possible small bowel obstruction. Hospital A diagnosed Mrs. Kaller with Acute Pancreatitis and recommend her to be transferred by ambulance to Defendant Hospital B for a higher level of care. The transfer diagnosis from Hospital A was documented as Acute Pancreatitis.
The treatment for acute pancreatitis consists of three parts:
- Aggressive fluid replacement
- Monitoring of urine output
- Pain management.
Mrs. Kaller arrived at Defendant Hospital B and was taken to the emergency room. The Defendant Emergency Room Doctor assumed that the Defendant General Surgeon was caring for the patient, and so the Emergency Room Doctor never saw the patient, never ordered any treatment for her, never treated her with aggressive fluids, never monitored her urine. Mrs. Kaller sat in the emergency room for approximately 5 hours before any actual treatment was ordered for her. Defendant General Surgeon assumed that the ER would have given Mrs. Kaller fluids and would have began monitoring her urine output. Unfortunately, this was not the case.
During her time in the emergency room, Mrs. Kaller had a CT Scan of the Abdomen performed. This CT scan showed that there was no small obstruction at all. The radiologist that read this CT Scan called Defendant General Surgeon and advised him over the phone that there was no obstruction – and so, the only diagnosis Mrs. Kaller had was Acute Pancreatitis.
After five hours, a small amount of fluids was ordered for Mrs. Kaller and she was admitted to the telemetry floor of Defendant Hospital B. Here she came under the care of a nurse. Due to poor communication between doctors and the nurses, the nurse thought Mrs. Kaller was admitted for a small bowel obstruction. The Nurse was not aware of her acute pancreatitis diagnosis. Defendant General Surgeon never told the Nurse that her only diagnosis was Acute Pancreatitis. For her entire shift, the Nurse thought the patient was there for a completely different reason. The small amount of fluids ordered for the patient ran out, however the Nurse did not notice that until hours later when she final replaced the empty bag of fluid with another. During her time in the hospital, Mrs. Kaller was not producing urine – a sign that she was not receiving enough fluids. Again, this went unnoticed for many hours. Mrs. Kaller’s symptoms progressively worsened throughout her time at Defendant Hospital B.
Defendant General Surgeon finally saw that the patient was worsening and transferred the patient to Hospital C for a higher level of care. During the ambulance ride to Hospital C, Mrs. Kaller had a cardiac arrest. Mrs. Kaller subsequently passed away from Hypovolemic Shock and Severe Pancreatitis.
Unfortunately, due to the lack of communication among doctors, nurses, and hospital departments at Hospital B, Mrs. Kaller did not receive the treatment she needed, which ultimately caused her death.
This case was resolved on the first day of trial for a 7-figure settlement.