Epidural Hematoma After Colectomy [Anesthesiologist Text Messages Subpoenaed]

A 72-year-old woman developed repeated episodes of diverticulitis.

She was serving as a Peace Corps volunteer in Morocco, but returned to the US due to these episodes.

During her workup, it was noted that she had previous DVTs and PEs.

Further testing revealed that she had antiphospholipid syndrome.

The patient was started on Lovenox.

After consultation, a sigmoid colectomy (done by Dr. T, colorectal surgeon) with abdominal wall reconstruction (done by Dr. C, general surgeon) was scheduled for November 17, 2017.

The patient took her last dose of Lovenox 50mg the day prior to the surgery.

On the day of surgery, Dr C (general surgeon) discussed an epidural with the patient.

Note that the language in the excerpts below was written by the plaintiff attorney, so there is the potential for inflammatory bias in his writing.

A thoracic epidural was done by the anesthesiologist, Dr. S.

The surgery itself was uncomplicated.

The patient was continued on subcutaneous heparin 5000u q8hrs postoperatively.

She was admitted to the floor.

The initial post-operative period (11/17 and 11/18) was uncomplicated.

On POD#2 (11/19) she began to report discomfort in her back. As she only had pain at that point, it was not felt to be a major issue during morning rounds.

However, by that afternoon, the patient had developed weakness and sensory changes in her legs.

The nurse called the surgery intern, Dr. Kre, but the calls were not returned.

She next called the anesthesia resident, Dr. Kry, who came to see the patient.

The anesthesia resident documented a normal exam around 4pm.

He texted Dr. S, the attending anesthesiologist. The text messages were later subpoenaed during the lawsuit and are shown here:

The anesthesia resident Dr. Kry asked the nurse and surgery team to let him know if anything changed.

Within an hour, the patient’s weakness had worsened.

The nurse requested a PT consult, and the physical therapist documented 0/5 strength in her legs at 5pm.

The surgery intern was notified several times, but did not come see the patient.

Nobody updated the anesthesia team.

A nurse paged the surgery intern (Dr. Kre) at 3:03am. The family was at bedside. They were very concerned about her paralysis and asked to see the doctor.

The nurse documenting that Dr. Kre was “refusing to see pt”.

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By the next morning, the patient had an episode of fecal incontinence as well.

2 additional surgery residents saw her while pre-rounding, and noted the incontinence and 0/5 strength in her legs around 5am, but took no immediate action.

The anesthesiologists (both attending Dr. S and resident Dr. Kry) saw her during their rounds at 6am.

They were surprised to find her with no movement in her legs, because no one had updated them since the previous afternoon.

They stopped the epidural and decided to wait a few hours to see if symptoms improved.

Their documentation from that morning is shown here:

The patient’s care was signed out to another anesthesiologist, Dr. F.

Dr. F evaluated her a few hours later to see if stopping the epidural had helped.

It had not.

Dr. S texted Dr. F about imaging studies. Dr. S felt that CT may be best, but Dr. F ultimately felt that MRI would be better as the definitive study.

He ordered thoracic and lumbar MRIs at 11:17am. They were initially entered as a routine study, then later changed to STAT.

The MRIs were started at 14:47.

Results showed a massive epidural hematoma extending from T3-T10, and she was taken back to the OR for decompression that evening.

She recovered some movement and sensation in her legs but has severe impairments in her activities of daily living and has permanent incontinence.

The patient contacted a law firm and sued both anesthesiologists (Dr. S and Dr. F), the general surgery attending (Dr. C), and the hospital.

The allegations against all plaintiffs were shown here. Only some are relevant to the anesthesiologist.

The plaintiff’s anesthesiology expert witness wrote the following opinion:

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The defense hired numerous experts including an anesthesiologist who wrote this opinion:

The plaintiff offered to settle the case for $10,000,000 from all plaintiffs combined.

After negotiations, they could not reach an agreement.

Therefore the lawsuit continued progressing, and a trial was scheduled.

The defense filed a motion asking the judge to prevent the plaintiff from mentioning or displaying the text messages at trial.

Prior to a ruling on the text messages, it appears that both sides reached a confidential settlement.

Court records do not indicate which of the defendants actually paid the settlement.

MedMalReviewer/Anesthesiologist Analysis:

1. The text messages are the most inflammatory part of this case. Even though they reflect the anesthesia team actively discussing the patient’s exam and imaging options (as opposed to outright neglecting her like the surgery team), there were enough dismissive comments thrown in that it was a bad look for the defendants. This might seem a bit backwards, but there is a real risk that the jury would feel more angry at the anesthesia team for making fun of her (despite at least attempting to do the right thing) than the surgery team who just completely neglected her but wasn’t recorded saying anything hurtful. Sometimes perception is more important than facts.

2. I’m not saying you can’t ever text about a patient’s care, but you should do so with the understanding that everything you write in a text can be subpoenaed. Even if you delete the text messages, they are still recoverable. Your cellphone company stores these records in a database for years, and they will immediately be provided to the attorneys when subpoenaed. It’s not hard for them to get copies of all your personal texts over a period of months or even years, and read through every one of them. I know a lot of doctors who are very flippant about texting because it makes life a lot easier, but you need to be extremely careful. Making a phone call instead may be a preferrable option, given the cellphone companies don’t record your conversations. However, using your personal phone for a call still opens up the possibility of a subpoena of your cell records. Instead of getting a copy of the text messages you wrote, they’ll get a list of every ingoing and outgoing call, and how long it lasted. I’ve seen cases in which the plaintiff tried to argue that two doctors only spoke for a short period of time, and that they couldn’t possibly have had a full discussion about a case. Email is not safe either. They might even pull your social media usage while you were on shift, even if totally unrelated to the case. Using hospital-provided phones for verbal conversations is probably the safest, followed by internal messaging software like Epic’s Secure Chat. The hospital actually controls the databases, as well as when the data gets deleted (unlike leaving it up to a cellphone company that stores data for years). Most hospitals have policies that result in messaging data being deleted at ~30 days. This gives them enough time to do HR investigations if needed, but they can also delete data soon enough that it’s gone by the time a lawsuit could be filed. The legal rules about discovery are very complicated and nuanced, with variable results in different cases, but you should know that there’s at least a possibility that they can pull any communication data they want.

3. The anesthesia team was sabotaged to some degree. Even the plaintiff acknowledged that the anesthesia resident had asked the nurse and surgery team to let him know if anything changed. They never did so. I’m guessing that the request to notify anesthesia if anything changed did not get passed to the overnight nurse. The night nurse was then so caught up in her frustration with the surgery intern that she didn’t think about contacting anyone else. Hospital staff members may have difficulty grasping the idea that the surgeons are focused on surgical complications, and that the epidural is a secondary concern to them. I don’t necessarily think the standard of care required rounding on her again in the evening (the anesthesia resident might have been too busy or off shift), but in a patient reporting worsening neuro symptoms, it may have been a wise idea for the anesthesiology resident to be more proactive with repeat exams. Trust nobody, expect sabotage.

4. There is a lot of blame to be passed around here, but the PT also shares some liability in my opinion. He evaluated the patient about an hour after the anesthesiology resident documented 5/5 strength in the legs (reasonable minds may have some degree of skepticism about this exam). The PT then documented 0/5 strength, and proceeded to…. tell nobody. Maybe he assumed that it was just due to the therapeutic effect of the epidural, like multiple doctors did. Maybe the anesthesia resident note wasn’t in by that point. Or maybe the PT was afraid of being belittled (“What do you mean she’s paralyzed, I was just in there an hour ago and she had normal strength!”). But whatever the reason, it’s a bad look for everyone involved that the exam decompensated that fast and nobody did anything.