Course Menu

Live Chat

chat live with aihcpHave questions? Join us on "live chat" online now! One of our advisors will be happy to assist you and respond to your questions.

LN 450 Examination with Case Study

LN 450 Examination
Legal Nurse Consulting
Dominick L. Flarey, PhD, MBA, RN,BC, CNAA, LNC-CSp.
Instructions: This is a 7 question exam consisting of essay questions. This is NOT a self-grading exam.

You must have read and studied the reading materials (cases) in order to successfully complete this examination. All answers are essay type. I am not looking for quantity, but rather “quality” in your responses. This examination is graded on a pass/fail basis. Please be sure that you have read and reviewed the examination case study (link inside of the classroom), before you answer these questions. Please review the information inside the classroom related to submitting your responses to the examination.

If you have any questions, please contact me. Good Luck !!

1. Are there other “defendants” in this case ? If you were advising the attorney in this case, who might you advise that he also name in this law suit ( besides Dr. SMITH ) ? If you have identified other defendants, please explain why and what theory of negligence you are basing your decision on.

2. What are the strengths in this case ? Please advise the attorney where there are strengths that will make this case a good meritorious case for litigation. Help him understand why he might have a good chance of recovering for damages to his client.

3. What are the weaknesses in this case that your attorney client needs to be aware of? Why are they weaknesses ? Where and why may the defense attorney’s have a good argument against the allegations of negligence on the part of their clients?

4. Who was negligent in the care of this patient? Why ?

5. Did the client sustain injuries/damages? If yes, what were they?

6. Can “causation” be easily demonstrated in this case? Why?

7. Do you have any other recommendations for your attorney client regarding this case? Explain.

This is the case study for the examination for LN 450. You are to study this case presentation. The examination consists of questions that require essay-type responses. All examination questions are directly related to this case presentation. The examination will be graded on a pass/fail basis.

NOTICE: this case presentation is stirctly confidential . Names and places, etc have been changed to protect confidentiality. This case presentation is copywritten. It is a violation of copyright to reproduce this case study in anyway or allow any other individuals to review or study it. You may NOT disseminate this case study to any persons . Only you, the student, are authorized access to it via the LNC classroom which is secured and password protected. Violation of this notice may result in legal actions by the author.

I. CASE SUMMARY

Theme: This case concerns client, JANE DOE, a 24 year old female, Gravida 6, Para 4, with 2 missed abortions. This client presented to Dr. SMITH’S office on 7-12-94 with a request for evaluation for a voluntary sterilization. She subsequently underwent the voluntary sterilization procedure at General Hospital on 2-6-95. A pathology report following the procedure demonstrated that the tissue submitted for the left fallopian tube was smooth muscle tissue. Apparently the client was informed of this 17 days post-operatively, by Dr. SMITH. Apparently Dr. SMITH warned the client not to have unprotected sexual intercourse until a salpingogram could be done to verify if the left fallopian tube was opened. On 7-31-95 the client presents to a hospital emergency room and had a Beta HCG which was positive, indicating likely pregnancy. This was followed up with an ultrasound which confirmed an intrauterine pregnancy. The client then went on to have an abortion. She now brings a claim for negligence in performing the voluntary sterilization and a claim for wrongful conception.

On 7-12-94 this client was seen by Dr. SMITH in his office for evaluation of a requested voluntary sterilization. She was referred to Dr. SMITH from her primary care physician, Dr. PACE. On 10-17-94 she has signed the proper consent form for voluntary sterilization at Dr. PACE’S office. (The law requires at least a 30 day waiting period from the date of consent to the date of the surgical procedure).

The patient was scheduled for surgery at General Hospital on 7-18-94 and again on 7-20-94. Both times the patient was a “No Show.” I believe the patient did not show for these scheduled times because a consent for voluntary sterilization was not signed. The law requires at least a 30 day waiting period from the date of consent to the date of the surgical procedure. This consent expires 180 days after signing. As such, the “no shows” were justified.

The patient was scheduled for pre-admission work-up and testing at General Hospital on 1-9-95; she did not show for this appointment. She was rescheduled for 1-11-95, and again did not show up for this appointment. The medical records do not answer the question as to why the patient did not show up for these pre-admission, pre-surgical testing appointments.

On 1-31-95 the client underwent pre-surgical testing. At that time a BETA-HCG (Qualitative) was done and was negative. Other routine laboratory assessments were also done. It is interesting to note some of the results of these tests. Her hematocrit was slightly decreased (there is no mention of this in the chart by any physician), and her urine analysis was 1+ for blood with few bacteria, 3-5 white blood cells, 3-5 red blood cells, few epithelial cells, and many mucus strands. I see no evidence of an assessment or treatment for the hematuria or a work-up to rule out a urinary tract infection. The physician who reviewed this report (if it was reviewed) would probably say he did not treat this condition because the client was either: 1) asymptomatic, or 2) there were no leukocytes found in the urine. I believe this assessment would be questionable and that a prudent physician would have at least obtained a culture of the urine to rule out an infection.

On 2-6-95, the patient underwent voluntary sterilization: Mini laparotomy, Bilateral and Partial Salpingectomy. Dr. SMITH performed the surgery, and was assisted by DR. DO GOOD. The patient underwent general anesthesia. The operative report details: “………. The left cornu was manipulated up into the wound. The left lobe and tube being identified by its fimbriated end, was purchased with two Babcock clamps. The mesosalpinx opened with the bovie and the tube was double ligated with 2-0 silk suture and the intervening portion of the tube is excised, removed from the field and submitted for gross and microscopic examination. There was no bleeding. The sutures were cut.” She then underwent a normal course of recovery from the procedure. There were no apparent complications from the procedure post-operatively. The patient was discharged the same evening in satisfactory condition.

The pathology report for gross and microscopic examination revealed the following:

A = rt tube
B = lf tube

“A- the specimen consists of a pinkish soft tubular structure measuring 2 x 0.8 cm.”
“B- the specimen consists of a narrow segment of firm cord like tissue measuring 1.5 x 0.6 cm. The specimens are sectioned and totally submitted.”

“Sections labeled B- initial sections demonstrated fibrous connective tissue with blood vessels. Distinct oviduct lumen was not noted. Recuts, however demonstrated focal area showing crushed mucosal structures which suggest oviduct lumen. This area is somewhat distorted.”

The pathologist, Dr. JONES states on his report: “Tissue said to be left tube labeled B- smooth muscle tissue with distorted lumen at one periphery- noted in recuts suggesting portion of left oviduct- partial salpingectomy. In light of this distortion noted in recuts labeled B other follow-up studies should be performed to verify complete bilateral partial salpingectomy.”

Seventeen days post-operatively (2-23-95) the client was seen in Dr. SMITH’S office. Wound assessment showed normal healing without evidence of infection. Dr. SMITH documents that based on the pathology report, he recommends that the client undergo a HSG (hysterosalpingogram) to confirm the occlusion of the left tube. He documents that he stressed the importance of this test and that the client should not engage in any unprotected intercourse until the results of this test were revealed. According to Attorney CREW, the client is stating that the issue of unprotected intercourse was not mentioned to her. Also, Dr. SMITH documents that “we will order an HSG and follow-up thereafter.”

On 7-31-95, the patient presented to the emergency room of General Hospital. She underwent testing for possible pregnancy. A Beta HCG was positive and a HCG Quantitative was 11,834 which indicated a pregnancy of 2-3 months. On the same day, an ultrasound was ordered– revealing an intrauterine gestational sac. In his office notes of 8-1-95, Dr. SMITH documents: ” ……..we had suggested that she get a hystersalpingogram performed. We strongly suggested that she have this study performed but it has not been performed.” He also documents that he discussed the risks, benefits and hazards of abortion.

On 9-6-95, the patient presented to the UNIVERSITY HOSPITAL for a “second opinion” regarding the intrauterine pregnancy. The medical records do not demonstrate if the client was a self-referral to the UNIVERSITY HOSPITAL, or if some physician referred her for a second opinion. The assessment and evaluation at the UNIVERSITY HOSPITAL confirmed via ultrasound the presence of an intrauterine pregnancy. On this date, it was noted that her last menstrual period was 6-20-95, and the estimated gestational age is 11 1/7 weeks. Physical exam revealed an enlarged, non-tender uterus, which is consistent with pregnancy.

The client then presented to the Women’s Center in ANYTOWN, FLORIDA for a termination of the pregnancy. The patient underwent the abortion on 9-9-95. A counselor at the center documents that the client is upset on arrival. The center’s assessment via crown-rump length revealed the fetus to be 12 weeks. There was fetal motion detected and fetal cardiac activity observed. The abortion was performed and gross examination of fetal tissue revealed the four major components present. No tissue was sent to a laboratory for further examination. The procedure completed was a Vaccum Currettage. All consents for this procedure were signed appropriately.

The client was then seen by Dr. COUCH in ANYTOWN, FLORIDA On 5-6-96 she underwent another procedure of elective sterilization- Laproscopic Tubal Sterilization, and Dilitation and Curretage. This was performed by Dr. COUCH at the COMMUNITY Osteopathic Hospital. The operative report dated 5-6-96 documents that while under general anesthesia, and via laproscopy, Methylene Blue was instilled through the tubes. “Free flowing blue dye was seen through the left tube.” (This indicated an opened, patent left fallopian tube- demonstrating that the tube had never been ligated). The left tube was then ligated, and Dr. COUCH re-ligated the right tube. A dilatation and curettage was also performed. The patient was discharged in satisfactory condition. There was no apparent incidents or complications during or after this procedure.

II. MISSING RECORDS

The following records from General Hospital are missing:

1) Physician orders
2) Admissions record and conditions of agreement form
3) Anesthesia Consent Form
4) Anesthesia Record
5) Operating Room Record
6) Recovery Room Record
7) Pre-operative History and Physical Examination
8) Nurses Notes- both pre-operative and post-operative
9) Discharge Instructions given to the client
10) Nursing Discharge Sheet
11) Documentation of Anesthesia pre and post-operative assessment
12) Pre-operative Checklist
13) Discharge Progress Report

III. POSSIBLE TAMPERING OF MEDICAL RECORD

This is in reference to the one page record (copy) from Dr. SMITH’S office which contain documentation of three patient visits by the client ( on 7-12-94; 2-23-95; and 8-1-95). If you look at the copy… in the left upper hand corner just preceding the capitalized and underlined header SURGICAL CONSULTATION, there is noted a complete, blackened circle on the page. This has been produced on the copy from the copier machine. This would represent a paper hole punch on the original document. So one can conclude that the original document has one paper punch hole. This is very suspicious. This blackened circle is lined appropriately on the page for a standard format of three-hole punch. My suspicion and question is: WHERE ARE THE OTHER TWO PAPER PUNCH HOLES? Some thoughts to consider: 1) the other two holes do not appear because they have been hidden by attached paper over the original document. The second and third set of notes by Dr. SMITH may have been dictated at a later time and pasted over the original notes. 2)The second possibility is that Dr. SMITH uses paper with only a one hole punch. I confess that I have never seen paper with a one hole punch. I also do not understand why a company would even create paper with a one hole punch in the left upper corner. I believe this possibility is very weak. 3) the original document is formatted with two-hole punch at the top. This is very unlikely for two reasons: 1) where is the other top paper punch hole?, and if so, 2) the left paper punch hole is not aligned correctly for two hole punch format at the top of the page.

RECOMMENDATION: Request to see the original. If there are any suspicions, then refer this original to a Forensic Document Examiner. If there is then evidence of tampering, you have this case won.

IV. STANDARDS OF CARE

In my evaluation of this case, I have assessed it against the following standards of care:

A. A reasonably prudent surgeon who has been trained in a surgical procedure has a duty to the client to perform the procedure safely and correctly.

Evaluation: The surgeon performed below the standard of care in this case. Smooth muscle tissue was resected in place of the tissue of the left fallopian tube. This resulted in maintained patency of the left fallopian tube. Thus the procedure for which the surgeon had a duty to perform in this case was not performed due to negligence. “Even though sterilization procedures are not guaranteed as totally reliable, there is a common assumption the failure reflects negligence.” (Borten M., Friedman, E. Legal Principles and Practice in Obstetrics and Gynecology, Vol. II. Year Book Medical Publishers Inc. Chicago, 1990, p.174.

“Failure of sterilization is not always due to the method itself. Misidentification of the pelvic structures is not always due to the method itself. Misidentification of the pelvic structures accounts for some. Generally, this means that the ring or the clip or the cautery was applied to the round ligament mistakenly identified as the tube. If this should happen, it is clearly not a fault that can be ascribed to the technique but rather to the operator. It is variously reported to occur between 1 per 420 and 1 per 1,548 cases, averaging about once in every 1100 procedures. Needless to say, it should never occur if the tube is properly identified.” (Borten M., Friedman E. Legal Principles and Practice in Obstetrics and Gynecology, Vol. II Year Book Medical Publishers Inc. Chicago, 1990. P. 178.)

B. There was a duty to warn the patient that the procedure may not be totally reliable.

Evaluation: The standard consent form that was used in this case, the which was signed by the client does not expressly state that the client understands that the surgical procedure is not always reliable and that pregnancy could occur. In fact, the consent which the client signed and which was also signed by Dr. SMITH states : “……. I explained to him/her the nature of the sterilization operation, the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it.”

Evaluation: In my opinion, this standard of the duty to warn was not adequately met. There is no documentation whatsoever that the client was fully warned that the procedure is not always totally reliable. I believe in the clients mind, immediately following the procedure she believed she was permanently, and irreversibly sterile.

Regarding preoperative consent: “The failure rate must be clearly stated so that the patient understands that sterilization in not 100% successful in all situations. No guarantee or implied guarantee should ever be given……..Thirdly, I believe its s critically important to inform the patient that any pregnancy that should occur in the future, in the event of sterilization failure, will most likely be an ectopic pregnancy. This constitutes informed consent in my opinion.” (Boten M., Friedman E. Legal Principles and Practice in Obstetrics and Gynecology, Vol. II Year Book Medical Publishers, Inc. Chicago. 1990; pp. 179-180.).

C. Community and National Standard: “Except for those done in conjunction with cesarean section or immediately following delivery, surgical sterilization is seldom done any longer in communities where translaparoscopic operative approaches are available.” Both the mechanical and electrical methods can be applied by way of the laproscope, making them the obviously preferable approaches, especially in this era of outpatient surgery.” (Boten M., Friedman E. Legal Principles and Practice in Obstetrics and Gynecology, Vol II. Year Book Medical Publishers Inc. Chicago, 1990; pp. 174-175.)

Evaluation: In my opinion, this community standard was breached. The surgeon performed a sterilization procedure on this client via entrance through the abdomen with clipping and suturing of the fallopian tubes. A Trasnlaparoscopic procedure is the new standard as there is less pain, and post operative complications. The translaparoscopic procedure done later by Dr. COUCH is an example of meeting this standard. Also, General Hospital did have at the time translaparoscopic equipment available. What would need to be determined is whether or not Dr. SMITH was properly trained and credentialed in the use of a laparoscope. Also, we would need an expert surgeon to discuss the differences in effectiveness between translaparoscopic surgery with coagulation and a conventional abdominal approach with suture tying.

D. The surgeon had a duty to warn the patient of the failed surgical procedure in a timely fashion and to instruct her that she was not sterile.

Evaluation: This duty to warn may or may not have been met. Investigation into the documentation and the discovery of tampering of the medical record will eventually determine whether or not this standard was breached.

E. The surgeon had a duty to order the hysterosalpingogram for the client to determine with great accuracy whether or not the left fallopian tube was patent and whether or not she was at risk of pregnancy.

Evaluation: This test can not be ordered by the client. A physician must order the test. Dr. SMITH had a duty to insure that this test was ordered for the patient. I find no documentation whatsoever that this test was ordered as it should have been done. Also, if the test had been ordered, and the client failed to have the test done as was suggested, the surgeon should have documented this.

Also, if the surgeon did in fact order the test, and the client did not show for the test, then the hospital or diagnostic facility in which the test was ordered would have had a duty to inform the surgeon that the patient failed to show up for the ordered test. If this were the case, then the hospital may be liable for failure to inform the surgeon.

If the hospital did inform the surgeon that the patient did not show up for the test, then I believe the surgeon had a duty to follow-up with the patient and discuss her reasons for not following through with the test and the possibility of pregnancy.

F. National Standard: Surgeon who perform gynecological surgical procedures should have completed a Residency in Gynecological surgery and be Board Certified in this specialty or board eligible.

Evaluation: This is a national standard and to a certain degree a community standard. Across the country, in most instances and in most health care organizations, surgeons are only granted clinical privileges for procedures they have been taught to perform in their residency programs and in which they are board certified or board eligible. In the allopathic institutions in the community, this standard has been met. In the osteopathic hospitals, traditionally, this standard has not been adhered to. Osteopathic hospitals are more known to grant privileges outside the scope of board certification when it can be shown that the surgeon has had some proper education and training in the procedure. This is all beginning to change.

Dr. SMITH is a general surgeon and to the best of my knowledge, he underwent a general surgical residency, not one in Gynecological surgery. More than likely he has privileges at General Hospital to do gynecological procedures, including sterilization procedures. It must be noted that recently, now under the auspices of SYSTEM’S HOSPITAL, Dr. SMITH’S privileges for gynecological procedures have been revoked.

This avenue needs much pursuit. It may be that General Hospital may be held liable for granting privileges in a specialty in which the surgeon did not have residency training. This makes your case much stronger.

Much needs to be found regarding this in the discovery process. Also, I would highly recommend an out of the area, Board Certified Gynecologist as an expert witness in this case.

GLOSSARY OF TERMS
1. Beta HCG (Qualitative): this is a test to measure the presence of maternal hormones in the urine. Qualitative means that we are just testing to see if the hormone is present. The presents of certain hormones indicates pregnancy. A Quantitative Beta HCG will tell us the amount of the hormone present and this allows one to determine the stage or month of pregnancy;.

2. Cautery: to burn. This term is used in this case to describe cautery of the tube. Meaning the tube was closed by a burning method.

3. Crown Rump Length: this refers to a measurement of the head (crown) of the fetus. It provides indication for how old the fetus is.

4. Dilatation and Curettage: (D&C): a surgical procedure in which the cervical opening to the uterus is dilated and tissue is scraped out. This tissue is then sent to the lab for microscopic examination.

5. Ectopic Pregnancy: this is a tubal pregnancy. When the fetus attaches in the tube and does not go into the uterus to implant itself. This is very dangerous as it frequently cases rupture of the fallopian tube and massive hemorrhage.

6. Epithelial Cells: tissue cells. In the urine, it generally means small amount of tissues cells from the bladder. It can be seen in conditions of bladder irritation, or in urinary tract infections.

7. Fallopian Tube: this is part of the normal female anatomy. It is a tubular structure, attached to the ovary and the uterus. Once an egg is released by the ovary, the egg goes into the tube; this is where fertilization begins when the egg has been penetrated by sperm. Following fertilization, the egg or ovum, descends the fallopian tube, enter through the duct and goes into the uterus where it attaches itself.

8. Gestational Age: the age (in months) of the fetus. Determined by measurements with ultrasound.

9. Gravida: mean the number of times a female has been pregnant.

10. Hematocrit: this is a blood test. It is a ratio of packed red blood cells to serum plasma. It may be low in cases of anemia or dehydration.

11. Hystersalpingogram: a test where dye is injected into the female pelvic organs to determine the presence of masses or the patency of the fallopian tubes.

12. Intrauterine Gestational Sac: the embryonic sac containing the fetus.

13. Laproscope: a type of equipment, advanced technology, used in surgical procedures. It allows the surgeon to visualize internal organs and parts and to do surgical procedures through the scope with just a small puncture wound on the outside of the skin, rather than incising the skin. Procedures can be done through the scope and biopsies taken as well as pictures and videos.

14. Leukocytes: are white blood cells. Seen in the urine of patients with a urinary tract infection.

15. Ligated: means “cut”.

16. Methylene Blue: a dye that is considered safe to the body. Used in procedures to determine patency of tube like organs and ducts, etc.

17. Mini Laparotomy: a surgical procedure in which the abdomen is entered into. The incision is smaller than a normal abdominal surgery.

18. Missed Abortion: a “miscarriage.”

19. Oviduct Lumen: related to the fallopian tube. An opening where the ovum can pass from the tube into the uterus.

20. Para: refers to the number of live births that a female has had.

21. Ultrasound: a radiographic procedure. Like an x-ray. Uses ultrasonic waves. In this case, an ultrasound is used to visualize the fetus in the uterus, to confirm the pregnancy, to see if the fetus is alive and moving. Also used to determine the age of the fetus.

22. Vacuum Curettage: a type of procedure used in abortions. In this procedure the fetus is destroyed and killed with a sharp, knife-like instrument and then the dismembered parts of the fetus are vacuumed or sucked out of the uterus.