Use Staff for Pre-Procedure Instructions – But Also Verify

Though physicians may expect that staff will assist in properly instructing a patient on preparing for a procedure, the physician will still be responsible for those instructions having been carried out.

A 49-year-old data analyst was referred to a pain management practice by an orthopedic surgeon after an MRI showed degenerative joint disease from C 2-3 to T 1 and severe bilateral foraminal stenosis at C5-7. When Dr. PM, a pain management anesthesiologist, evaluated the patient and reviewed the MRI, he felt that the patient’s stenosis would result in neurological deficits that could lead to disability.

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That patient’s written history signed by Dr. PM included an entry of his new patient taking 800 mg of ibuprofen three times a day. Dr. PM and the patient discussed performing a cervical epidural steroid (CES) injection and according to custom and practice, Dr. PM would have discussed with the patient the risk of headaches, soreness, and bleeding.

The gentleman later testified that Dr. PM did not tell him to stop the ibuprofen before the contemplated CESI or that failing to do so would increase the risk of bleeding. He also testified that no staff person at the pain management center advised him to stop ibuprofen use before the procedure. Medical records contain no documentation of any such advice or instruction by anyone on that first visit.

A chart entry signed by Dr. PM on the day of the CESI listed the patient’s current medications as ibuprofen, turmeric, ginger, and boswellia. The consent form signed that day by the patient and Dr. PM confirmed that the patient had been advised of possible complications including bleeding, infection, tissue or organ damage, and anesthesia or medication reaction. Neither that consent form nor any other document addressed any need to stop medications prior to the procedure.

The procedure performed that day went uneventfully and Dr. PM’s report noted that on aspiration, no blood or CSF was noted. After completing the procedure, however, the skin at the site “seemed to be oozing blood more than usual.” Pressure on the site stopped the bleeding and an adhesive bandage plus five minutes of ice appeared to keep the site dry. Dr. PM noted: “Patient was inquired as to why he may be bleeding more than usual [and] at this time he admitted to us that he has been taking an excessive dose of ibuprofen up to eight pills a day regularly, practically overdosing on ibuprofen.”

Dr. PM instructed his patient that if he developed any symptoms related to bleeding at the site, including pain, numbness, or weakness, he should inform him and go to the ER immediately. Dr. PM kept the patient for 20-30 minutes after the procedure, confirmed that aftercare instructions were given, and discharged him in good condition.

The patient drove back to work, but about an hour later he felt a sharp pain in his mid-back. Unable to sit straight, the patient called his wife to take him to the hospital emergency room. The ED physician noted the patient was alert, oriented X3, cranial nerves intact 2-12, and had normal speech with no motor or sensory deficits. A spine MRI that evening showed a large posterior epidural collection from C3 to T3 likely attributed to a hematoma and resulting in severe spinal cord compression.

Two hours later, the patient underwent laminectomies at C4-T3 to remove the epidural hematoma and foraminotomies at C5-C8. The surgery resolved his acute pain and the patient was discharged two days later.

The patient sued Dr. PM alleging that Dr. PM should have advised him to refrain from taking ibuprofen prior to the cervical epidural injection. The complaint further alleged that Dr. PM negligently proceeded with the epidural injection “despite full knowledge that plaintiff was taking high doses of ibuprofen” and that upon seeing the patient bleeding from the injection site, Dr. PM should have arranged for the patient’s transportation to a hospital instead of releasing him to return home. The patient’s lawsuit alleged residual and continuing pain from the episode. The legal dispute resolved informally prior
to a trial.

Without written support, a physician’s verbal advice on identified risks — and reliance on staff to carry out specific pre-procedure instructions — will be subject to “he said/she said” disputes. And should a medical record instead show a patient on the day of a procedure taking a contra-indicated medication, the percentages for a successful defense plummet.  

Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to gownby@CAPphysicians.com.