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Act on your observations

01 May 2009

The right of Sandy Anthony to be identified as the author of the text of this work has been asserted by her in accordance with the Copyright, Designs and Patents Act 1988.

Mr W was a 39-year-old clinically obese mechanic with four children. He had been experiencing biliary colic and other symptoms suggestive of gallstones, which were confirmed by ultrasound scan. His GP referred him to a consultant upper GI surgeon, Mrs Y, for treatment. Mrs Y discussed treatment options with Mr W, who agreed to the recommended procedure of a laparoscopic cholecystectomy.

Apart from some difficulty in placing the second trocar due to a thick abdominal wall, the surgery was uneventful and, space being limited in the recovery room, Mr W was returned to the ward soon after recovering consciousness. On his arrival at the ward, he seemed restless, but his vital signs were normal. Mr W’s restlessness persisted and he complained of mild abdominal discomfort. Nurse N, detecting a slight tachycardia and noting that he had not passed urine, was concerned.

She bleeped Dr T, a junior doctor, and asked him to come and examine the patient. Dr T arrived on the ward ten minutes later. He palpated Mr W’s abdomen and, finding no alarming signs, reassured Nurse N that there was no cause for concern, but to maintain regular observations.

An hour later, Nurse N again bleeped for assistance, this time contacting Dr H. She told him that Mr W had become increasingly restless, that he had passed no urine since returning from theatre three hours earlier, his pulse rate had increased to 110 bpm and his diastolic blood pressure had fallen to 70mmHg; his skin was cool and clammy and his respirations seemed shallow and rapid. Dr H attended immediately. He examined Mr W and concluded that the patient was suffering from possible infection and postoperative pain, for which he prescribed antibiotics and analgesics.

Half an hour later, Mr W vomited and became unrouseable; his blood pressure was unrecordable and his pulse rapid and thready. He was resuscitated with IV fluids and an urgent laparotomy was performed. A large amount of blood was found in the abdominal cavity. Before the cause of the bleeding could be located and repaired, however, Mr W suffered a cardiac arrest and attempts to resuscitate him were unsuccessful. Postmortem examination revealed a laceration to the portal vein.

Expert opinion

Experts who examined the case were agreed that both Dr T and Dr H should have considered the signs of haemorrhagic shock and investigated more thoroughly. Dr T did appear to have searched for an alternative explanation for Mr W’s symptoms and signs, but he had made no note in the patient’s records at the time, so it was unclear what his thinking process had been.

The claim was settled for a high figure, which reflected the fact that Mr W had been the only provider for his wife and children.

Learning points

  • Postoperative tachycardia is a red flag for haemorrhagic shock. By the time it has reached 100bpm, the patient may already have suffered a 15% to 30% blood loss. Early intervention is therefore crucial.
  • Postoperative haemorrhage is a well-recognised complication of surgery. Its occurrence is not necessarily a sign of negligence, but failure to recognise it and act in a timely manner is. Any signs of “shock” in a patient who has recently undergone surgery should be taken seriously, investigated urgently for haemorrhage, before considering other explanations such as postoperative pain or sepsis.
  • If Dr T and Dr H had listened more carefully to Nurse N’s concerns and looked at the observation charts, they might have been more aware of the seriousness of Mr W’s condition. Nurse N might also have been at fault for not reporting her observations and concerns clearly enough. AA good model for nurse/doctor communications is SBAR (Situation, Background, Assessment and Recommendation), which has been found to reduce the number of adverse incidents resulting from poor communication.
  • Good documentation is essential to assess the evolution of a patient’s condition. In a hospital environment, it is likely that many different professionals will be dealing with one patient, so access to up-to-date information is vital.
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