Hemorrhage is a potential complication that can occur during and after surgical procedures. Hemorrhage refers to the loss of blood from the body due to damage to blood vessels. It is a serious condition that can result in significant damages, up to and including wrongful death if healthcare providers fail to recognize it in time, or fail to follow the standards of care prudently and reasonably to manage it.
What Types of Hemorrhage are Common in the Hospital Setting?
Hemorrhage can be classified based on the type of blood vessel that is affected. The types of hemorrhage include arterial, venous, capillary, and mixed hemorrhage.
Arterial hemorrhage is the most serious type of hemorrhage as it can result in rapid and significant blood loss. This is due to the pressure gradient in the arteries as compared to that of the venous system. Blood that is leaving the heart has a much more force behind it, and a tendency to “spurt”, whereas blood that is returning to the heart does so against gravity and with much momentum lost and a tendency to “ooze”. Therefore, venous hemorrhage is slower and can result in a lower volume of blood loss. Capillary hemorrhage involves bleeding from tiny blood vessels (more like “leaking” than “oozing” or “spurting”) and is the least severe form of hemorrhage.
What Causes Hemorrhage?
Hemorrhage can be caused by several factors including technical factors, patient-related factors, anesthesia-related factors, and medication-related factors. Each of these factors has potential to be traced to healthcare provider negligence, and should be examined in any case where hemorrhage is the core factor in life-altering damages or unexpected death, especially in the post-op period.
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Technical Factors
Technical factors that can result in hemorrhage include incorrect surgical technique, inappropriate use of surgical instruments, and damage to blood vessels during surgery. An attorney looking to investigate factors contributing to intraoperative hemorrhage should carefully inspect the intra-operative report for indications that the patient’s instability began on the table. This can include indications in the surgeon’s, anesthesiologist’s, or operating room nursing staff’s documentation that a “bleeder” may have been undetected or mismanaged. Inconsistencies between the reports can be telling. A case reviewer familiar with these types of reports, such as an operating room nurse consulting expert can identify discrepancies or suspicious or telling wording, which may indicate that an incident was improperly dismissed or downplayed, with negligence to patient safety or overall medical negligence creating a professional liability.
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Patient-related factors
Patient-related factors such as coagulation disorders, hypertension, and diabetes can certainly increase the risk of hemorrhage. This is why it is incumbent upon the medical professional to collect a thorough medical history on the patient and to follow standards of care to take steps to mitigate patient-related risks for a bleed. If there is documentation that a provider was made aware of a particular medical history and that medical history was not taken into consideration, the provider may be held liable for their failure to customize the treatment plan to the needs of the patient, resulting in catastrophic outcomes.
Proper management or mitigation of patient-related risk factors can include proper administration of blood products or close monitoring and/or management of the blood pressure during the procedure and in the immediate post-operative period. The blood pressure is related to the force with which the blood leaves the heart, so management of the blood pressure can reduce the likelihood of a burst vessel in the first place, as well as to reduce the volume of blood lost before the body can restore homeostasis.
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Anesthesia-related factors
Anesthesia-related factors such as inadequate anesthesia or the use of anticoagulants can also cause hemorrhage. A case reviewer familiar with the standards of care regarding dosing and titration of anesthesia and associated anticoagulant therapy, such as a nurse anesthesia consulting expert (NACE), can properly assess the contribution of this factor to the outcome of hemorrhage.
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Medication-Related Factors
Medication-related factors, such as the use of non-steroidal anti-inflammatory drugs (NSAIDs) can increase the risk of bleeding. A thorough patient history, including medications that the patient has been taking–both prescription and non-prescription–is part of the medical provider’s responsibility. If a patient is on a heparin derivative such as Lovenox (enoxaparin) or oral anticoagulant such as Coumadin (warfarin), standards of care should be followed regarding how soon non-emergent surgery can be performed following the last administration of these medications. A legal nurse consultant or nurse practitioner medical legal consultant (NP-MLC) can quickly investigate the most recent administration of any medications affecting bleeding and can review the pre-surgical admission history for completeness or red flags. They can also identify whether documentation exists to corroborate proper patient education about when the patient should have abstained from taking these medications at home.
Understanding Homeostasis and the Clotting Cascade
Homeostasis is the body’s dynamic process of maintaining internal balance and equilibrium in response to environmental changes. When it comes to blood clotting, the process of achieving homeostasis involves a “cascade” of events. Disruption along the continuum of any of the elements of this cascade can promote prolonged bleeding.
Surgical providers have a duty to assess baseline lab values that affect bleeding prior to performing surgery. These include platelets, prothrombin time (PT) and partial thromboplastin time (PTT), among other evaluative factors. Depending on the emergent nature of the surgery, if surgery is undertaken despite an unsafe balance of these values, when it would have been reasonable or prudent to wait or to intervene to better balance them, surgeons may be held liable for damages associated with preventable hemorrhage. Hospital protocols may exist that outline standards of care to mitigate these risk factors such as administration of vitamin K, protamine sulfate, or plasma, which contains human clotting factors.
A nurse practitioner consulting expert (NPCE), such as a surgical nurse practitioner, familiar with the intricacies of the clotting cascade can be an asset to the litigation team investigating cases of intraoperative or postoperative hemorrhage because they can call out whether the surgical team proceeded with surgery when waiting or intervention would have been prudent due to the patient’s less-than-ideal physiology.
A legal nurse consultant or nurse practitioner consulting expert (NPCE) case reviewer familiar with the flow of cases through the surgical suite may also be able to read between the lines when production pressure contributed to a surgical team proceeding with surgery on a patient despite clear warning signs that the patient was at risk for hemorrhage. Such consultants would know which records to request during the discovery process to corroborate these suspicions, in order to attribute to the hospital corporation as a whole due accountability as a potential defendant.
Symptoms and Signs of Hemorrhage
Intraoperative
An attorney reviewing a surgical case of hemorrhage to determine merit should engage a consultant familiar with the sometimes subtle indicators of potential blood loss, and where these are documented both in the intra-operative and in the postoperative period. Common signs of a “bleeder” on the table include a steady or sudden drop in blood pressure accompanied by a steady or sudden increase in heart rate This classic combination of vital sign observations is due to volume loss and a compensatory mechanism by the heart in an attempt to increase the net cardiac output.
Other observable signs in the operating room may be pale skin and decreased urine output (patients under general anesthesia will have a urine catheter).
Postoperative Monitoring for Hemorrhage
During postoperative care, dropping blood pressure and increasing heart rate can also be observed. A patient may report dizziness or lightheadedness, nausea, or a racing heart. If post operative staff are not following standards of care to monitor the vital signs at appropriate frequencies, this may be missed.
In addition, the nursing staff may note the formation of a hematoma (which looks like a growing–often firm–lump under the skin generally accompanied by bruising) A nurse’s physical assessment may also note an unusual quantity or character of drainage from the surgical site. Early recognition and prompt treatment are critical to prevent significant blood loss, its associated complications, damages, or death.
When such observations are documented without associated responses (such as notification of the on call provider, application of firm direct pressure, evaluation of bloodwork to identify appropriate pharmacological response, administration of and notification of appropriate medication antidotes, administration of IV fluid, whole blood or blood products to restore volume and replenish clotting factors, administration of oxygen where appropriate, body positioning to promote blood flow to vital organs, or the activation of a hospital rapid response team) hospitals and personnel may be held liable for failure to follow standards of care that contributed to a poor outcome. In some cases, immediate additional surgical intervention (emergency repair surgery) must be undertaken to restore homeostasis.
The observations listed above will generally not be found in the physician’s progress notes. Consequently, they are commonly missed by physician reviewers who are unfamiliar with the types of details that can be found in other parts of the medical record, with which legal nurse consultants and nurse practitioner consulting expert (NPCE) reviewers are intimately familiar. (After all, nurses are the ones who generally produce these aspects of the medical record). This is one example of how physician reviewers often fail to point out the liability of the nursing staff (i.e. of the hospital itself); and how doctors may be quick to chalk the incident up to statistics, when, in reality, faster recognition and response would have resulted in a much different outcome for your client.
Conclusion
Hemorrhage is a serious surgical complication that can result in lifelong damages up to and including wrongful death. It is a complication that surgeons and perioperative staff must be alert to at all times to avoid liability. It can occur due to several factors, many of which are preventable or subject to mitigation by the hospital staff, including technical factors, patient-related factors, anesthesia-related factors, surgical errors, and medication-related factors. It is the duty of the healthcare team to follow standards of care to promote early recognition and prompt management of hemorrhage to prevent catastrophic outcomes. Contact us today for more information.