Hospitalist expert witness advises on hospital discharge procedures

A hospitalist expert witness opines on a case of a patient with a hepatic abscess who was discharged from a hospital without adequate care. This case involves a fifty-five-year-old male patient with a past medical history of obesity and hypertension. The patient presented to the emergency department with a one week history of right upper quadrant abdominal pain. An abdominal CT scan was performed which revealed a lesion on the patient’s liver. A gastroenterologist reviewed the patient’s scan and described the lesion as vascular in character. At the time of diagnosis, the lesion was biopsied and found to be nonmalignant. The patient underwent a hepatic angiogram with embolization. During the procedure the lesion was diagnosed as a hemangioma with necrosis and hemorrhage. Following the procedure, the patient experienced loss of appetite which was never regained. He was discharged from the hospital despite the fact that he was not feeling well. The treating physician advised the patient that there was nothing more that could be done for him. Unhappy with this dismissal, the patient sought a second opinion at another hospital. After further evaluation the patient was diagnosed with a hepatic abscess. He required a right hepatic lobectomy and cholecystectomy which resulted in intraoperative hemorrhage warranting resuscitation and intubation.

Question(s) For Expert Witness

1. Have you ever cared for a patient postoperatively who underwent a liver angiogram with embolization?

2. Did this hospital performing this procedure practice adequate post-operative care in this patient?

3. If not, what further testing and measures should have been performed?

Expert Witness Response E-005297

It appears that the patient should have received more thorough care in the original hospital he initially presented to. However this could only be confirmed after reviewing the patient’s complaints at the time of discharge, his oral intake, pain levels and the reason why the physicians treating him believed that he was stable enough for discharge despite his protests. If the patient’s condition warranted further evaluation at the time of discharge and there was clear evidence of this in his medical records, discharging the patient would be a breach of the standard of care. Care must be taken not to discharge a patient who is not completely stable. Furthermore, it is difficult to assess whether or not the patient received the appropriate post-operative care. This would be absolutely critical. During the course of my career, I cared almost exclusively for hepatic patients, of which many were post embolizations as was this case for this patient.