Malpractice defense: Lung Infection vs. Chronic Pulmonary Embolism

In addition to my consulting work and writing the Health Business Blog, I’m chairman of the board of Advanced Practice Strategies, a medical risk management firm that provides litigation support for malpractice defense and an eLearning curriculum focused on enhancing patient safety. Here’s the Advanced Practice Strategies case of the month.To learn more send an email or call 877-APS-4500.

Judgment for the DefenseLung Infection vs.Chronic Pulmonary Embolism PLAINTIFF'S CLAIM:The plaintiff suffered premature death as a result of undiagnosed chronic pulmonary emboli (PE).  Despite persistent respiratory failure and diagnostic testing throughout her hospitalization that confirmed a deep venous thrombosis (DVT), the physicians did not start appropriate interventions, such as placing an inferior vena cava filter or proper doses of anticoagulation medication to treat and/or prevent further PEs from occurring.DEFENSE'S ARGUMENT:The plaintiff was a morbidly obese female patient admitted to the hospital in respiratory distress.  During this complex case, extensive diagnostic testing was performed to determine the source of the patient's respiratory issues, which her physicians identified as an infectious process.She initially presented with apparent worsening of an atypical pneumonia and was treated with antibiotics.  Her physicians also prescribed anticoagulation medications prophylactically to prevent clots from developing in her legs during her hospitalization.  At the beginning of her admission, a series of diagnostic tests to identify a DVT and/or PE were negative, including an ultrasound of her legs and a chest CT.  During her hospital stay, she spiked fevers to 103 °F and chest x-rays showed a probable new left lower lobe pneumonia.  She also developed respiratory failure with an unclear etiology.  Follow-up CTs were performed that showed the patient had diffuse, bilateral infiltrates consistent with pneumonia and acute respiratory distress syndrome (ARDS).Throughout her hospital stay, the patient’s symptoms were consistent with an infectious process. However, an autopsy revealed that the patient had massive pulmonary emboli within both lungs, pulmonary arteries, inferior vena cava, and the right side of heart.  The defense theory was that these findings were the result of an acute event and not chronic emboli that resulted in her cardiorespiratory arrest and death.There were findings that supported this theory: During her hospitalization, she had a lung biopsy that did not show chronic emboli. The CTs and x-ray films performed throughout her hospitalization were consistent with an infectious process and not a PE. Proper steps to anticoagulate the patient were taken at the time of her treatment, and placement of an inferior vena cava filter was not indicated.  The patient’s death was an unfortunate medical result that was not caused by negligence on the part of any of the defendant physicians.___________________________________________________________________VISUAL STRATEGY: APS worked with the attorneys, defendants, and experts to develop a visual strategy that would help explain to the jury the complex clinical picture seen by the defendants during the patient’s hospitalization and also at the time of her death.We began by creating a board on normal anatomy of the lungs with both illustrations and films.We also illustrated pneumonia and acute respiratory distress syndrome (ARDS) in the same format with both illustrations and films.  This helped to support the diagnosis of infection rather than chronic pulmonary embolisms as the etiology for her breathing distress.We enlarged the patient’s films onto boards to demonstrate the progression of the condition and to allow the experts to explain to the jury that what was seen on the films was more consistent with the appearance of infection rather than chronic pulmonary emboli.To support the diagnosis of an infection we illustrated blood and pus excreting from a tracheostomy tube.We put together a series of illustrations to show how a deep vein thrombosis (DVT) can form in the leg and how emboli can break off and travel up the bloodstream.We created a board that explained how a vena cava filter works, to educate the jury on location and function of the filter.As a follow up to the previous board, we also created an exhibit to show one complication that could have arisen if a vena cava filter had been placed during her stay.   Because she showed signs of infection throughout her stay, her doctors were concerned that a clot could become lodged in a filter and become grossly infected.We illustrated the massive in situ acute thrombosis to show what the defense believed caused her death.We enlarged the patient’s pathology slides of the pulmonary emboli found at autopsy.Finally, we created timelines to illustrate the constant care that the plaintiff received by multiple physicians throughout her hospitalization. Timeline 1 Timeline 2 This combination of illustrations helped the defense successfully explain that: The plaintiff’s condition at the time of her hospitalization was followed very closely and treated appropriately by the defendants. The defendant physicians did all they could with diagnostic testing to evaluate and treat the patient’s symptoms as they presented themselves. The plaintiff’s death was an unfortunate acute event that could not have been prevented. RESULT:The jury found in favor of the defense.Attorney John Mulvey called to share his defense verdict and give thanks:“I am very pleased with APS's work for this involved case. My client used every exhibit provided and he found not only does a picture equal 1000 words, but it was more like 10,000 words in this case. The images really helped my client teach and put him at ease for his testimony.This was the most Medical Illustration Exhibits that I have ever used in a single trial and I am very happy with the outcome. I can’t thank you enough for being so available to my clients, for additional boards while the trial was in session and for doing last minute edits to make the defendant feel completely comfortable and secure in his teachings to the jury.” --Attorney John Mulvey, Martin, Magnuson, McCarthy & Kenney, Boston, MA