Time after time, I’m confronted with the problem of doctors treating a computer screen instead of the patient. Yesterday, that’s exactly what I was thinking as I took the deposition of a Waco, Texas general surgeon in a medical malpractice wrongful death case.
The facts underlying that case are sad. An elderly lady who lived independently was suffering from gastric reflux and saw a surgeon. The surgeon diagnosed her with a hiatal hernia. The hiatus is a hole in the diaphragm where the esophagus connects to the stomach. A hiatal hernia is a condition where an organ in the abdomen (like the stomach or colon) squeezes or herniates through the hiatus and into the chest.
In my client’s case, she had what’s described as a Type IV paraesophageal hiatal hernia, which means that small parts of both her stomach and colon were trapped (incarcerated) in the hiatus. She was admitted to Providence Health Center, which is located at 6901 Medical Parkway, in Waco, Texas, for a laparoscopic minimally-invasive hiatal hernia repair surgery.
This type of surgery is pretty easy to understand. The surgeon’s goal is to basically pull down the stomach and colon to the correct position below the diaphragm. In my client’s case, the surgeon also did a gastropexy, which means that he stitched the stomach and placed it so it would not re-herniate.
While the surgery itself looked straightforward, during the next two days, this lady’s condition quickly went south. She had breathing problems, heart irregularities, and lab values and vital signs that pointed to an infection.
Another surgeon, a partner of the original one, was responsible for seeing her during the two important post-operative days. The second surgeon became concerned about the possibility of the patient developing sepsis and decided to do some testing.
When I deposed the second surgeon, she explained that sepsis is part of an infection and inflammatory process. She testified that surgeons know that the most likely cause of sepsis in a patient who recently had a hiatal hernia surgery is a perforation of the esophagus, stomach, or colon.
What is an esophagram or barium swallow study?
The surgeon ordered an esophagram to investigate whether the patient had a perforation that was causing an infection and possibly sepsis. An esophagram is often called a barium swallow study. Esophagrams or barium swallow studies are used for a lot of reasons, mainly to investigate problems in the movement of the esophagus, to see if there is a stricture or obstruction preventing flow from the esophagus into the stomach, or to identify a perforation of the esophagus.
To do this type of study, the patient is asked to swallow a contrast agent, and then a radiologist uses a standard x-ray machine to follow the contrast through the esophagus and into the proximal stomach. If the study was ordered because of suspicion of a perforation, barium shouldn’t be used because if it leaks into the abdominal cavity, it can cause a nasty infection. Instead, a water-soluble contrast agent should be used. That’s exactly what happened in my client’s case, which was appropriate.
The importance of using the correct radiology study
What isn’t appropriate though, according to our surgical expert, is using an esophagram to rule out a perforation of the stomach or the colon. In a hiatal hernia surgery, the surgeon is manipulating and moving the esophagus, stomach, and, in my client’s case, the colon. This physical stress and pressure could damage any of those organs.
While an esophagram would be an appropriate first radiology study to look for a perforated esophagus, it’s less reliable to look for a stomach gastric perforation, and completely useless to rule out a perforation of the colon.
Instead, the standard of care requires the surgeon to order CT scans of the chest, abdomen, and pelvis—in other words the whole gastrointestinal (GI) system from the esophagus down to the pelvis. CT scanning technology is much more sensitive to identify excess fluid and air bubbles in the chest or abdominal cavity, which are signs of a perforation.
Plus, unlike an esophagram, a CT scan can identify the exact source of a perforation, which is helpful to let the surgeon identify what needs to be repaired.
Treat the patient, not the radiology images
When it comes to treating post-operative patients—and anyone else, for that matter—it’s important for physicians to both order the right study and to keep going until they find an answer.
While it was okay for the surgeon to start with ordering an esophagram, it certainly was inappropriate for her to stop there. CT scans were absolutely necessary to rule out a perforation. Unfortunately, the surgeon stopped before ruling out a perforation and sepsis.
By the next day, the patient’s condition had plummeted. The surgeon noted in the medical records that she had septic shock, a life-threatening condition that was causing her organs to shut down. Finally, they ordered a CT scan. It showed a large 2 cm perforation in her stomach. At her deposition, the surgeon testified that the location of the perforation was precisely in that part of the stomach that was involved in the hiatal hernia surgery.
The surgeon agreed that it was a surgical emergency, and she needed to get back to the operating room promptly. At that point, they did everything they could for her, but it was simply too late. By failing to order the right test, and by failing to treat the patient rather than the computer screen, this patient was left with a hole in her stomach that was leaking contents into her abdomen and causing a festering infection.
She never came back from the surgery and passed away the next day.
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Robert Painter is a 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 against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2018, by H Texas as one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.