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.
Judgment for the Defense MVA Leads to Fetal Demise
A pregnant woman at 32 weeks gestation presented in the ER severely injured after a motor vehicle accident (MVA). Upon the patient’s arrival in the ER, the nurses quickly found a fetal heartbeat and performed an ultrasound, through which they identified fetal movement before moving on to care for the mother. Upon examination, a CT showed the patient had an extensive pneumothorax (i.e., collapsed lung). Physicians put a chest tube in, validated placement, and sent the mother up to Obstetrics for further evaluation. When the patient arrived on the Labor and Delivery unit, no fetal heartbeat was found and it was apparent that a placental abruption had occurred. The patient immediately went into surgery and was found to have a 70% placental abruption, a couvelaire uterus, a retroperitoneal bleed, and a posterior rent in the uterus at the level of the fetal head.
The baby would have survived if the abruption had been diagnosed upon the patient’s arrival in the ER and if she had been sent up to Labor and Delivery for an immediate cesarean delivery.
Standard of care dictates that the first responsibility of the clinicians is to treat and stabilize the mother. Even if they had known about the placental abruption, the clinicians would have needed to treat the mother first, since the patient’s condition was severe and life-threatening. Furthermore, without a chest tube, the patient would not have been able to survive a cesarean delivery procedure.
In addition, the baby had already suffered extensive damage from the MVA, which likely resulted in significant brain damage. The physicians responded quickly and appropriately, attending to the damage to the uterus from the trauma. The mother did not suffer any permanent injury, and had no future complications from these injuries.
APS worked with the attorneys and experts to develop a visual strategy that would help explain to the jury in detail how the physicians appropriately managed the situation by responding quickly to mother’s rapidly declining condition, stabilizing the mother and then attending to the 32-week fetus.
We began with a presentation of the mother’s condition, showing the initial CTs taken in the ER and creating film enhancements outlining the massive pneumothorax.
We then focused more specifically on the details of this case, illustrating the size and position of this 32-week fetus.
Following this introduction, we went on to show the injuries that were sustained from the MVA. Based on the operative reports and documentation, we demonstrated the extent of injury. The findings included:
A 70% placental abruption, as drawn in a progress note by an attending physician
A retroperitoneal bleed
A posterior rent in the uterus at the level of the fetal head
Blood found in the colonic gutters
The illustrations helped identify where bleeding occurred and how the rent in the posterior uterus likely developed due to the impact of the fetal head during the accident.
We went on to illustrate a couvelaire uterus, a condition stemming from trauma-induced placental abruption, whereby blood from the placenta invades the uterine muscle and eventually extends into the peritoneal cavity.
This combination of illustrations helped the defense successfully explain:
The severity of the injury sustained by the mother
The severity of the injury involving the 32-week fetus
The timely and appropriate response of the physicians, given the entire situation
The injury to the fetus was fatal and unfortunately irreparable for the physicians involved in the mother’s care. The physicians responded quickly to stabilize the mother, after which they expediently attended to the fetal situation. The physicians’ care prevented the mother from suffering any permanent injury, and she subsequently had no complications in future pregnancies.
After a short period of deliberation, the jury found in favor of the defense.
“Your ability to refine the illustrations in a timely fashion was crucial. We were able to both project them and use the boards on an easel, close to the jury when preferable, as decided by the witness. My client looked at the finished product and said: ‘That’s it! That’s what I saw at surgery.’”
—Attorney, Stephen Ryan, Marshall, Dennehey, Warner, Coleman & Goggin, King of Prussia, PA