Bacterial infection worsened after discharge from hospital – Defense Verdict

The defendant general surgeon operated on plaintiff, a 59-year-old male, on May 27, 2010. Plaintiff presented with cholelithiasis and acute cholecystitis. He underwent an urgent laparoscopic cholecystectomy that was converted to an open procedure after his gallbladder ruptured, spilling a large amount of purulent bile into the abdominal cavity. The purulent bile in the operative field was cleaned out by the general surgeon via copious irrigation with warm saline. During the laparoscopic procedure and prior to the gallbladder rupture, the defendant obtained a fluid culture of gallbladder fluid. Intraoperatively, a gram stain result was called to the operating room, indicating the presence of gram positive and gram negative bacilli. The open portion of the procedure was complicated and lengthy, lasting approximately four hours, during which plaintiff was intermittently hypotensive despite aggressive hydration.

Post-operatively, plaintiff spent the first night in the ICU due to tachycardia, where he was continued on Unasyn (ampicillin), an intravenous antibiotic that had been started by the surgeon upon plaintiff’s initial presentation to the hospital. Plaintiff’s white blood count, BUN and creatinine began to rise after surgery. On the evening of the first post-operative day, plaintiff was moved from the ICU to the floor. He was afebrile, but his BUN was high at 22, his creatinine was high at 1.57 and his white blood count was high, at 13.7. Plaintiff was ambulating, eating and improving clinically. He was continued on intravenous Unasyn.

On May 29, 2010, the second post-operative day and the day of discharge, plaintiff’s BUN was higher at 41, his creatinine was higher at 1.71 and his white blood count was higher at 15,800. Clinically, plaintiff had little discomfort, was eating and voiding well, was ambulatory and requested to go home. At discharge, plaintiff was switched from intravenous Unasyn to an oral antibiotic equivalent, Augmentin, at 500 mg three times per day.

Moments, after the mid-day discharge, initial sensitivity results of the gallbladder fluid culture became available in the hospital chart. These indicated the presence of Citrobacter Freundii, a bacteria resistant to ampicillin, and thus resistant to the Augmentin prescribed for plaintiff at discharge. Plaintiff left the hospital with a prescription for Augmentin, which was filled that afternoon. In the early morning hours the next day, plaintiff became extremely ill with complaints of progressive abdominal pain and weakness. He was taken to the hospital by ambulance, where he was noted to be severely hypotensive and tachycardic. Plaintiff’s condition severely worsened and he required intubation. Plaintiff remained intubated for weeks and was treated for severe sepsis. He was ultimately transferred to two other hospitals, where his recovery was difficult and slow. During the following months, he developed a sacral decubitus ulcer.

At trial, plaintiff’s general surgery expert testified that plaintiff’s condition—most notably the rising BUN, creatinine and white blood counts—prior to the May 29, 2010, discharge was consistent with an infection that should have been recognized. Plaintiff’s general surgery expert testified that it was negligent for the defendant surgeon to discharge plaintiff without first confirming from culture and sensitivity results that oral Augmentin covered all bacteria present in the gallbladder fluid that had contaminated the operative field. Plaintiff’s surgery expert testified that plaintiff developed severe sepsis due to a lack of response to the culture and sensitivity results. Plaintiff’s treating plastic surgery expert testified concerning the development of plaintiff’s sacral decubitus and the treatment he endured relative to that injury.

The defendant’s general surgery experts and infectious disease expert testified that the standard of care allows a surgeon to treat a patient’s clinical picture and that a surgeon is not required to obtain culture and sensitivity results prior to discharge, even when there is possible contamination of the operative field. They opined that it was appropriate to give broad-spectrum antibiotics and to discharge the patient when the clinical picture warranted. They opined that the patient’s rising BUN, creatinine and white blood counts in this case were not unexpected given the intraoperative hypotension, as well as plaintiff’s history of diabetes and kidney disease. These lab results were not necessarily consistent with a blossoming septic infection. On causation, they testified there was no blood culture or other confirming evidence that Citrobacter Freundii, which was shown by sensitivity results as resistant to Augmentin, was actually responsible for the septic infection plaintiff developed.

After a four-day day trial, the jury deliberated for approximately four hours before returning a verdict in favor of the defendants.

[15-T-157]

Type of action: Medical malpractice
Injuries alleged: Severe septic shock
Court: Halifax County Circuit Court
Case no.: CL12000339-00
Tried before: Jury
Judge: David A. Melesco
Date resolved: Sept. 17, 2015
Special damages: $476,794 in medical expenses; no past or future lost wages sought; no future medical expenses sought
Demand: $1,000,000
Offer: None
Verdict or settlement: Defense verdict
Attorneys for defendant: Elizabeth Guilbert Perrow and Daniel T. Sarrell, Roanoke
Defendant’s experts: Kent W. Kercher, M.D., general surgeon, Charlotte, North Carolina; Donald M. Poretz, M.D., infectious disease physician, Annandale; Daniel G. Turgeon, M.D., general surgeon, Reston
Plaintiff’s experts: Joseph V. Boykin, Jr., M.D., plastic surgeon, plaintiff’s treating wound care physician, Richmond; Garry D. Ruben, M.D., general surgeon, Silver Spring, Maryland
Insurance carrier: The Doctors Company