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Internists must consult a urologist to treat this serious condition Contact Now

Failure to treat hydronephrosis leads to permanent kidney damage

Internists must consult a urologist to treat this serious condition

Surgeons like to spend time in the operating room, but many of them are uncomfortable in providing post-operative care. In fact, rather than handling it themselves, some surgeons leave it up to a nurse practitioner (NP) or physician’s assistant (PA).

Inattentive surgeons who aren’t engaged in providing proper follow-up care create needless danger for the patients. This type of risky medical care sometimes extends over into the services provided by hospitalists or internal medicine physicians who manage the overall care of hospitalized patients after surgery.

Both of these are issues that were at play in an appeal that was recently disposed of by Houston’s Fourteenth Court of Appeals. The case is styled Samiran Kumar Das, M.D. v. Yvonne Hester, No. 14-19-00596-CV, In the Fourteenth Court of Appeals. You can read the court’s opinion here.

The facts of that case began with the patient having a laparoscopic hysterectomy. Laparoscopic surgeries are popular in comparison to traditional surgeries because they are minimally invasive. While performing the laparoscopic procedure, the surgeon accidentally damaged the patient’s ureter, a vessel that carries urine from the kidney to the bladder.

The standard of care requires the surgeon to recognize and correct this type of error. Unfortunately for this woman, though, the surgeon did neither. In fact, even though the following day the patient had abnormal lab values, the surgeon didn’t investigate them or order diagnostic tests. The most relevant lab values were a decrease in urinary output and increase in creatinine levels, both of which are signs of a kidney problem. Instead of working up this clear problem, the surgeon discharged the patient later that day.

Within two days, the patient was back at the hospital emergency room (ER) because of shortness of breath and leg swelling. Her blood pressure had plummeted, and her heart rate was very high. Her overall clinical picture was consistent with severe septic shock and multi-organ system failure. Septic shock is an advanced stage of sepsis, which itself is a systemic inflammatory response to an infection.

Fortunately, the ER team recognized her dangerous condition and jumped into action. They secured her airway by placing a breathing tube down her throat, in a procedure called intubation. They started her on medications called vasopressors, which stabilize blood pressure by constricting the blood vessels. She was admitted to the hospital under the care of attending physician Samiran Kumar Das, M.D., an internal medicine doctor.

An attending physician coordinates the overall care for hospitalized patients. They order consultations with doctors in other specialties, as needed, and carry out diagnostic testing. Attending physicians often specialize in internal medicine or are hospital-based physicians called hospitalists.

While caring for this patient, Dr. Das ordered consultations with several other physicians, including an infectious disease specialist. The infectious disease consultant discovered that the patient had an acute kidney injury.

In the medical malpractice lawsuit, the plaintiff alleged that Dr. Das, as the attending physician, never followed up with the infectious disease doctor’s finding of the patient’s acute kidney injury. The plaintiff’s medical expert believed that Dr. Das breached the standard of care by failing to order a consultation with a urologist, a physician with specialized training to diagnose and treat kidney injuries.

To meet the tort reform preliminary expert report requirements of Texas Civil Practice & Remedies Code Section 74.351, the plaintiff served reports by a board-certified urologist and a board-certified obstetrician/gynecologist. Both of the experts wrote opinion letters that Dr. Das was negligent. Dr. Das responded by objecting to the experts’ qualifications and opinions.

The Fourteenth Court of Appeals rejected all the arguments by Dr. Das.

As an initial finding, the court found that the report by the plaintiff’s urology expert explained that hydronephrosis, the swelling of the kidney because of backed up urine, caused the patient’s kidney injury and is a condition that’s outside the scope of practice for internal medicine physicians. Therefore, the urology expert explained, the standard of care requires an internist to consult with a urologist for the diagnosis, management, and treatment of the condition.

The urology expert explained that he was familiar with the standard of care for identifying and treating obstructions of the ureter, which can cause hydronephrosis, hydroureter (dilation or swelling of the ureter because of backed up urine), and permanent kidney damage.

The defendant objected to the urology expert’s qualifications and standard of care testimony because he wasn’t a general internal medicine physician coordinating multi-level care. In rejecting this argument, the appellate court concluded that the defendant had the wrong focus. The court noted that the dispositive issue isn’t the defendant physician’s area of expertise, but rather the expert’s familiarity with the illness, injury, or condition involved in the claim.

Upon concluding that the expert was qualified, the court went on to analyze the urologist’s expert opinions. Once Dr. Das, the internist, was made aware by the consulting infectious disease doctor that this patient had hydronephrosis and hydroureter, the standard of care required the internist to do three things:

• Verify that there was no obstruction preventing urine from passing from the kidney through the ureter to the bladder.

• Consult with a urologist to investigate the cause and extent of a possible injury to the ureter.

• Inform the patient as to the need for a follow-up visit with a urologist.

The expert concluded that Dr. Das did none of these things, in violation of the standard of care. As a result of Dr. Das’s failure to identify and treat the cause of the patient’s hydronephrosis, the patient developed permanent kidney damage.

The Fourteenth Court of Appeals’ order overruled all objections and found that the plaintiff’s urology expert report was sufficient to show that the case had merit to proceed.

If you’ve been seriously injured because of poor internal medicine, urology, or hospital care, then contact a top-rated Houston, Texas medical malpractice lawyer for help in evaluating your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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