WWYD? Hospital Negligence.

[J-rap]

My other-wise healthy, 88-year-old father came down with e-coli pneumonia.  He was extremely dehydrated and had very low blood oxygen.  He was taken by ambulance to the local hospital late morning, where they immediately put him on oxygen, antibiotics, and an IV for the dehydration.  Within just a few hours, he felt so much better.  At least at first.

 

They kept him on an IV for dehydration throughout the day and then all night.  But they never weighed him or kept careful track of the liquid. Turns out all the liquid they had been putting into him since the day before, never came out.  Finally near morning, when he could barely breathe, he called a nurse.  He had gone into heart failure, because basically, the liquid was flooding his heart and lungs.  14 pounds worth of liquid.

 

It set him back so much, it almost killed him.

 

Fortunately, a family member who is a doctor (in another city) stepped in at that point and pushed to have him placed into ICU and observed carefully for 48 hours.  It was touch and go, but he survived, and thankfully, is home now after a week.

 

He wants to forget it all, put it all behind him.  The rest of us feel the hospital was so negligent, we shouldn't just let it be.  It was a horrible situation and they should be made aware of it.

 

 

[Misha]

I don't have any clear cut response, but I wanted to let you know that I will keep your dad in my thoughts and prayers for an issue free recovery and good health. 

 

Hugs to you all, this sounds like a terrible situation to have gone through.

[Anne in CA]

I would make sure that someone higher up knows what happened. It does no one any good for this to be swept under the rug.

[mamiof5]

I am not sure what would I do, but reading this made me sad and gave me goosebumps! They could have killed your dad!!! It's so wrong. Not sure how to go about malpractice with a hospital, but I would feel the same way, he can't just let it go. I am so glad he's OK!!! What a horrible and scary experience :(

[OneStepAtATime]

:grouphug:  :grouphug:  :grouphug:

 

I don't blame him for wanting to put it all behind him (was in a similar situation while dealing with cancer and I just did not have it in me to do anything but move to another health care facility), but I fully understand your feelings.  Yes, the hospital is negligent and next time someone could die.  They absolutely should be held accountable in some way to ensure that whatever system failure occurred has a much smaller chance (hopefully nil) of occurring the next time.  But your dad may very well not be up to dealing with this and his physical and mental health have got to be taken into consideration.  Is there a medical attorney you could consult just to see what your options might be?

[gardenmom5]

what's your goal other than making them aware of it?

and what would the ramifications of pursuing and achieving that be?

Edited March 27, 2016 by gardenmom5

[hornblower]

Here we have hospital ombudsmen whom you can contact about any issues. Maybe call and see if there is something similar?

 

I think I would follow up so the hospital can learn from this mistake and implement a protocol or review training for staff to monitor output. I would type up pretty much what you've written here and just send it in. It doesn't have to be a huge thing requiring an attorney, and your father doesn't have to do anything.

 

 

Sent from my iPad using Tapatalk

[Carrie12345]

I am so sorry this happened! I'd suggest consulting with several lawyers to get a clear picture of your options.  

 

My stepfather's malpractice case is a nightmare.  His lawyer (and the ones before that) are upfront about telling him his case would have been cut and dry in a different state.  Where he is, it isn't enough that he nearly died and required an additional surgery for an undisputed mistake - he has to prove it made him suffer more than his initial health issue.  Which could mean trying to find experts willing to testify against an entity that could damage their careers.  And pay them, without knowing if he'll recoup their fees.  It's been long and stressful.  It wouldn't be in other places.

[bolt.]

I would follow up with the hospital to try and make them more aware of the potential for that unexpected situation to arise. (Much like hornblower) It's important that mistakes get analyzed and changes to procedures are realistically considered: but I'd have no need for attorneys, money, or a sense of 'teaching them a lesson' by 'making them pay'. Litigation would not be my choice (unless the error itself resulted in a monetary cost/loss).

[Truscifi]

Our hospital has an office of quality care that would investigate such a complaint. Perhaps yours has something similar.

[StephanieZ]

My 2c (having been in your shoes, but with a dead dad as a result of the hospital negligence) . . .

 

Note, my experiences shadow my words, and my experiences were brutal and sad. 

 

One, if you can't recover big, big money, don't bother with a law suit. (For me, it'd have to be 300k+++ and/or to support a victim with long term critical needs that can't otherwise be met.) 

 

You can't likely recover significant monetary damages since those are based on pain/suffering as well as lost companionship/earning power, etc. Assuming he has no lasting harm done and the suffering was of short duration, then there is little case. 

 

Any law suit requires a lawyer, which is both $$$ and depressing as hell, as you will be faced with the realization that an old, harmed or old, dead person is worth very little to our court system. It's all about lost earning power. Maybe also lost companionship/love . . . then there is the argument that the old frail decrepit person had little of that left to give. Very depressing. All around. Don't go there, IME.

 

HOWEVER, if I were in your shoes, I'd definitely file board complaints at the various professional boards. I'd get Dad's medical records, make a list of every nurse and doctor and hospital, etc. . . . and file board complaints at the various regulatory boards. Should not take you more than a handful of part days of hassles, and will probably result in much teeth grinding and head banging among those who contributed to his poor care. Honestly, this will likely make them pay more attention than a regular law suit. Professionals have insurance to protect them financially, but their licenses, those are without price. Hit them where it hurts.

 

Now, if you feel sympathetic and might not want to "punish them" with board complaints, then you *could* contact the hospital and let them know your concerns and that you'd like a sit down meeting with the doctors involved, the nursing staff involved, and whatever administrators are interested, and you'd like them to present you with a review of your loved one's care, identifying their errors, and letting you know what they are doing to make sure this never happens to another patient. In my ideal world, that would be the end of things.

 

Honestly, in the case of my dad, if the hospital staff had been forthcoming after his care-caused accident and consequent death, my brother and I would not have sued. We begged them for explanation of what happened. All we wanted was to understand and to know they would take better care next time . . . Dad was dead, and we weren't in it for money. But, they clammed up completely as soon as the accident occurred (as it was obviously negligent), not being willing to share any information with us about how/what had happened. We *had* to sue to get a lawyer to pay experts to read and interpret the thousands of pages of medical records to even idenittfy the actual people who failed their duties. (In Dad's case, it turned out that a day nurse failed to "re order" a restraint order and then the night nurse also failed to find that omission on her required daily review of renewals of standing orders . . . AND a PT AND the paired OT both also failed to properly secure Dad before leaving him . . . AND some unknown staff failed to lock the wheels on his bed . . . The *least* culpable people, IMHO, were his actual nurse at the time of the accident (because Dad had been moved from ICU to a recovery/medical floor just the night before, so he was new to her wing, and she had many other patients, so she had no way to know he -- a recent survivor of a massive stroke who was on blood thinners -- was as fragile as he was and that when the PT & OT left him alone in a chair -- that was his first time out of bed in 10 days and he was unsafe to be alone for any time, let alone while seated adjacent to a wheeled bed with unlocked wheels . . . And, his actual doctor(s), who had appropriately *ordered* continuous 24/7 restraint, but because of laws, those orders MUST be renewed daily (cannot be "standing" orders without renewal). SO, all this is to say that unfortunately, it is hard to know WHO is at fault in the complex environment of a hospital adverse event. If the hospital has some system through which to complain, I'd start there. If I wasn't confident that they were taking the problems very seriously, I'd get medical records and start filing complaints -- the more the merrier, and I'd let the boards figure out who actually screwed up. So, anyway, that's my 2c. 

 

(And, yes, we did win a significant financial settlement. It was enough to notice, but not life changing. The money wasn't worth the agony of the process. BUT, knowing the truth of what happened and knowing that those whose sloppiness killed Dad were to some small degree called to the carpet, well, that made it worth it.)

 

I'm so very sorry this happened to your dad. 

 

I have lots of medical professional friends and family. I love and trust them . . . BUT, I am incredibly paranoid and controlling about anyone in the hospital. I've seen lots of errors, and Dad's death was 100% preventable . . . I ask loads of questions, and I never leave them alone in the hospital, ever. 

 

 

Edited March 28, 2016 by StephanieZ

[goldberry]

 

 

Now, if you feel sympathetic and might not want to "punish them" with board complaints, then you *could* contact the hospital and let them know your concerns and that you'd like a sit down meeting with the doctors involved, the nursing staff involved, and whatever administrators are interested, and you'd like them to present you with a review of your loved one's care, identifying their errors, and letting you know what they are doing to make sure this never happens to another patient. In my ideal world, that would be the end of things.

 

. 

 

That would be my first step.  I would see how it went at that stage before deciding if/how to pursue further.  Several years ago my dad suffered some significant negligence but recovered.  He did not want to pursue it at all, and basically ordered all of us not to as well.

 

(Stephanie and OP both,  :grouphug: )

[VeteranMom]

Did the hospital and doctor own up to what they did?  Was their an acknowledgement of their mess up?  That would mean a lot for me.  

My Mom was made very sick when I was a kid.  A doctor was treating her for a condition with the wrong medication due to a lab result that was mis-interpreted.  How did the doctor handle it?  He called her to explain and immediately got her on the correct medication.  He owned up to what had happened and my Mom could have sued, but didn't.

 

 

[Halftime Hope]

<snip>

 

I have lots of medical professional friends and family. I love and trust them . . . BUT, I am incredibly paranoid and controlling about anyone in the hospital. I've seen lots of errors, and Dad's death was 100% preventable . . . I ask loads of questions, and I never leave them alone in the hospital, ever.  <snip>

 

This exactly.  My rule is to never, ever, ever, leave a person who is critically ill alone in the hospital, if there is any way to avoid it.

 

During my FIL's care, on several (three or four? I've forgotten....) separate occasions, hospital mistakes very nearly killed him, as in bleeding profusely from an intestinal bleed while waiting for the Plavix they gave him, which he hadn't been on at home, to leave his bloodstream.  Three units of blood before he was stable.

 

About a year before his death, his PC physician finally--after those three mistakes--wrote some kind of order that went to the hospitalists in her group saying that any time they changed a med, they had to call me and discuss it with me prior to writing the order.  (Can you imagine!) I'd talk the individual docs through the confounding factors for his body, and then they'd have a better idea what could be done and what couldn't.  Every time we went to the hospital, I'd take two pages with an executive summary of his health issues, what meds he was on, and the danger areas, but that wouldn't be enough to get their attention, because it would be at the front of the chart where no one would look at it.  Sigh.

[G5052]

I'd definitely report it. How far is up to you.

 

But a lawsuit? Nope. Not me. You're talking years and years before resolution, and probably only a fraction in the end for you. It's not something I'd want to spend my time on.

[J-rap]

what's your goal other than making them aware of it?

and what would the ramifications of pursuing and achieving that be?

 

Good questions.  I would want to find out 1) What was the missing link?  Was it the nurse on shift?  The doctor overseeing the case?  They should be made aware of their mistake (and held accountable) so that it never happens again.   2)  Shouldn't this obviously be part of their routine protocol?  If it isn't, it needs to be.  

 

Very obvious steps were missed.  I don't want it to happen again to someone else.  If a doctor or nurse isn't being responsible, they should't be there.  Lives are dependent on them!

[J-rap]

Here we have hospital ombudsmen whom you can contact about any issues. Maybe call and see if there is something similar?

 

I think I would follow up so the hospital can learn from this mistake and implement a protocol or review training for staff to monitor output. I would type up pretty much what you've written here and just send it in. It doesn't have to be a huge thing requiring an attorney, and your father doesn't have to do anything.

 

 

Sent from my iPad using Tapatalk

 

Yes, something like this sounds good.  We'd rather not involve an attorney, and do not want my father to have to do anything.  

[J-rap]

I am so sorry this happened! I'd suggest consulting with several lawyers to get a clear picture of your options.  

 

My stepfather's malpractice case is a nightmare.  His lawyer (and the ones before that) are upfront about telling him his case would have been cut and dry in a different state.  Where he is, it isn't enough that he nearly died and required an additional surgery for an undisputed mistake - he has to prove it made him suffer more than his initial health issue.  Which could mean trying to find experts willing to testify against an entity that could damage their careers.  And pay them, without knowing if he'll recoup their fees.  It's been long and stressful.  It wouldn't be in other places.

 

Sorry for your stepfather.  Certainly, my father did suffer more because of their mistake.  In most cases, an attorney would be the obvious answer.  We just don't want to have to involve my father, which is tricky.

[J-rap]

Our hospital has an office of quality care that would investigate such a complaint. Perhaps yours has something similar.

 

Good point.  That should probably be the first thing we do.

[Suzanne115]

I would definitely at least let the hospital administrators know what happened. I would not file a lawsuit.  My dad died as a result of negligence on the part of a nursing home.  It was a clear cut case of negligence.  My brother sued the nursing home.  The trial and pre-trial preparation were emotionally extremely hard.  My brother lost the lawsuit.  We went through all of the agony for nothing.   I hope your father continues to do well and I am sorry for what you all went through.

 

Suzanne

[Katy]

I second the hospital ombudsman as a place to start.  Then, depending on how you feel, you can contact the medical boards of the doctor in charge of him and/or an attorney.

 

IME with an extremely dehydrated patient it is typical to track fluids in & out.  If the doctor didn't order that or if the nursing staff neglected to do it, or if it was ordered and the doctor didn't note the problem to treat it, someone should be reprimanded EVEN IF YOUR DAD IS UNINTERESTED IN PURSUING ANYTHING FURTHER.

[J-rap]

My 2c (having been in your shoes, but with a dead dad as a result of the hospital negligence) . . .

 

Note, my experiences shadow my words, and my experiences were brutal and sad. 

 

One, if you can't recover big, big money, don't bother with a law suit. (For me, it'd have to be 300k+++ and/or to support a victim with long term critical needs that can't otherwise be met.) 

 

You can't likely recover significant monetary damages since those are based on pain/suffering as well as lost companionship/earning power, etc. Assuming he has no lasting harm done and the suffering was of short duration, then there is little case. 

 

Any law suit requires a lawyer, which is both $$$ and depressing as hell, as you will be faced with the realization that an old, harmed or old, dead person is worth very little to our court system. It's all about lost earning power. Maybe also lost companionship/love . . . then there is the argument that the old frail decrepit person had little of that left to give. Very depressing. All around. Don't go there, IME.

 

HOWEVER, if I were in your shoes, I'd definitely file board complaints at the various professional boards. I'd get Dad's medical records, make a list of every nurse and doctor and hospital, etc. . . . and file board complaints at the various regulatory boards. Should not take you more than a handful of part days of hassles, and will probably result in much teeth grinding and head banging among those who contributed to his poor care. Honestly, this will likely make them pay more attention than a regular law suit. Professionals have insurance to protect them financially, but their licenses, those are without price. Hit them where it hurts.

 

Now, if you feel sympathetic and might not want to "punish them" with board complaints, then you *could* contact the hospital and let them know your concerns and that you'd like a sit down meeting with the doctors involved, the nursing staff involved, and whatever administrators are interested, and you'd like them to present you with a review of your loved one's care, identifying their errors, and letting you know what they are doing to make sure this never happens to another patient. In my ideal world, that would be the end of things.

 

Honestly, in the case of my dad, if the hospital staff had been forthcoming after his care-caused accident and consequent death, my brother and I would not have sued. We begged them for explanation of what happened. All we wanted was to understand and to know they would take better care next time . . . Dad was dead, and we weren't in it for money. But, they clammed up completely as soon as the accident occurred (as it was obviously negligent), not being willing to share any information with us about how/what had happened. We *had* to sue to get a lawyer to pay experts to read and interpret the thousands of pages of medical records to even idenittfy the actual people who failed their duties. (In Dad's case, it turned out that a day nurse failed to "re order" a restraint order and then the night nurse also failed to find that omission on her required daily review of renewals of standing orders . . . AND a PT AND the paired OT both also failed to properly secure Dad before leaving him . . . AND some unknown staff failed to lock the wheels on his bed . . . The *least* culpable people, IMHO, were his actual nurse at the time of the accident (because Dad had been moved from ICU to a recovery/medical floor just the night before, so he was new to her wing, and she had many other patients, so she had no way to know he -- a recent survivor of a massive stroke who was on blood thinners -- was as fragile as he was and that when the PT & OT left him alone in a chair -- that was his first time out of bed in 10 days and he was unsafe to be alone for any time, let alone while seated adjacent to a wheeled bed with unlocked wheels . . . And, his actual doctor(s), who had appropriately *ordered* continuous 24/7 restraint, but because of laws, those orders MUST be renewed daily (cannot be "standing" orders without renewal). SO, all this is to say that unfortunately, it is hard to know WHO is at fault in the complex environment of a hospital adverse event. If the hospital has some system through which to complain, I'd start there. If I wasn't confident that they were taking the problems very seriously, I'd get medical records and start filing complaints -- the more the merrier, and I'd let the boards figure out who actually screwed up. So, anyway, that's my 2c. 

 

(And, yes, we did win a significant financial settlement. It was enough to notice, but not life changing. The money wasn't worth the agony of the process. BUT, knowing the truth of what happened and knowing that those whose sloppiness killed Dad were to some small degree called to the carpet, well, that made it worth it.)

 

I'm so very sorry this happened to your dad. 

 

I have lots of medical professional friends and family. I love and trust them . . . BUT, I am incredibly paranoid and controlling about anyone in the hospital. I've seen lots of errors, and Dad's death was 100% preventable . . . I ask loads of questions, and I never leave them alone in the hospital, ever. 

 

I am so, so sorry for what happened to your father.  Thank you for taking the time to write all of that.  How extraordinarily painful.  You bring up some great points.  Sometimes it does seem like just a whole string of things (in this case, passing responsibility from one person to another to another) and crucial information being lost along the way.  Completely preventable.  It does change the way I will personally deal with medical situations in the future.  

[J-rap]

Did the hospital and doctor own up to what they did?  Was their an acknowledgement of their mess up?  That would mean a lot for me.  

My Mom was made very sick when I was a kid.  A doctor was treating her for a condition with the wrong medication due to a lab result that was mis-interpreted.  How did the doctor handle it?  He called her to explain and immediately got her on the correct medication.  He owned up to what had happened and my Mom could have sued, but didn't.

 

My brother, who is a doctor in another city entirely, was the one who rushed up there and insisted on having my father put in ICU after the event mentioned, so that he would get the 24-hour care on all vitals that was required. The new doctor in ICU was great.  I don't think anyone apologized for what happened though, and owned up to it.

[VeteranMom]

My brother, who is a doctor in another city entirely, was the one who rushed up there and insisted on having my father put in ICU after the event mentioned, so that he would get the 24-hour care on all vitals that was required. The new doctor in ICU was great.  I don't think anyone apologized for what happened though, and owned up to it.

I'd elevate the matter then.  I'm sure the ICU doctor knew what had happened and that there was a screw-up, but he's not going to throw another doctor under the bus.  Everyone who came in contact with your Dad is responsible for what happened and at the very least the details of what happened need to be investigated and taken very seriously.  At his age, fluid overload is so dangerous and someone should have caught what was happening at some point.  I'm upset for you. There are so many signs that could have been caught and one wonders why he wasn't being monitored for signs of fluid overload.  I worked in hospitals for many years as a nurse.  This is nursing 101.       

[LMV]

Admittedly there are many nuances and details you aren't sharing in your post. To be fair, I'm not suggesting you are attempting to be deceitful, rather that you may not really understand. Having said that, I can imagine that those missing details and nuances may be quite important in terms of how poorly (or perhaps well) this was truly handled by any involved physicians and nurses.

 

If we break your initial post down a bit. 

 

"My other-wise healthy, 88-year-old father came down with e-coli pneumonia.  He was extremely dehydrated and had very low blood oxygen.  He was taken by ambulance to the local hospital late morning, where they immediately put him on oxygen, antibiotics, and an IV for the dehydration."

 

For what it is worth, gram negative pneumonias are not common community acquired pneumonia pathogens. Sure we see them but more commonly in debilitated patients, nursing home residents (or patients with recent prior admissions, or in ventilator associated infections. The rest of this statement makes me strongly suspect that your father was likely septic. Goal directed therapy for sepsis involves volume resuscitation with crystalloids. Generally we start with 30mL/kg (so at least a few liters in a 70kg adult) and go from there based on clinical response. If you add in another liter or two to correct for the dehydration your father probably should have received at least 3L of fluid in the ED/early hours of his admission. 

 

"Within just a few hours, he felt so much better.  At least at first. They kept him on an IV for dehydration throughout the day and then all night.  But they never weighed him or kept careful track of the liquid."

 

Ok, if this is the case then this is a poor idea (although technically assessing volume status with weights and or I/O does not fit into the CMS sepsis bundle but I digress) but I wonder if perhaps they were aware of how much fluid they were giving (on some level they must have been because some physician wrote an order for that fluid) and the nurses actually were recording I/O and perhaps even using bed weights and the physicians involved felt that they needed to give more fluid because they had other evidence of poor perfusion (i.e. elevated lactate, creatinine, borderline or even low BP etc). 

 

"Turns out all the liquid they had been putting into him since the day before, never came out.  Finally near morning, when he could barely breathe, he called a nurse.  He had gone into heart failure, because basically, the liquid was flooding his heart and lungs.  14 pounds worth of liquid."

 

A few thoughts--in a patient with fully functional kidneys and normal cardiac function (which I admit may be a poor assumption for most octogenarians) fluid will not accumulate. So when you have a mismatch of fluid in and fluid out then either you started out with a volume deficit, which it sounds like your father did, or the body is struggling to maintain homeostasis due to some degree of organ compromise, or both. What the scenario was, what else was going on, and the rationale for the continued volume will be the critical pieces of whether or not any of this was inappropriate care. I will say that in someone who is septic receiving 5-6L over the initial 24 hour period is not outside of reasonable. Some patients may actually require more aggressive volume resuscitation than that. I'm not saying what was done in your dad's case is automatically right (or wrong) but a weight gain of 6L like your dad had from ED admission to hospital day #2 doesn't automatically raise any red flags.

 

As far as going into heart failure, this won't happen if your father has normal systolic and diastolic function.  I suppose it is possible that he did prior to admission and the cardiac dysfunction was just part of the end organ damage from sepsis. I suspect it is more likely that your father had some degree of chronic CHF prior to admission. Perhaps he wasn't aware of this and or didn't make the physicians caring for him aware of this so they could be more judicious with volume. Or perhaps they realized he had a subnormal EF and felt that they would provide volume to prevent further damage to his organs and deal with some degree of pulmonary edema as they went along. It sounds like ultimately that is what happened. You don't mention that he required intubation/mechanical ventilation so I'm guessing that once he was out of sepsis they were able to diurese  him and he did reasonably well. 

 

"It set him back so much, it almost killed him. Fortunately, a family member who is a doctor (in another city) stepped in at that point and pushed to have him placed into ICU and observed carefully for 48 hours.  It was touch and go, but he survived, and thankfully, is home now after a week. He wants to forget it all, put it all behind him.  The rest of us feel the hospital was so negligent, we shouldn't just let it be.  It was a horrible situation and they should be made aware of it."

 

I'm sure this was all very stressful and difficult for you and I really am sorry about that.  If this was my family member, I would respect their wishes regarding complaints and further action. As far as the hospital needing to be aware, I would guess they probably are. Most hospitals track ICU transfers, rapid responses etc. If they are using sepsis as their coding diagnosis then they will definitely be reporting their performance against the sepsis bundle scoring for CMS so that will be looked at.  Just for a point of reference, the mortality rate for sepsis is somewhere between 25-50% depending on study so your dad may be generally appreciative that he did make a full recovery and walked out of the hospital. In answer to your WWYD, I guess I would just thank all involved that my family member was alive. We buried a child due to sepsis and she had amazing physicians, textbook care, but sometimes bad outcomes happen in spite of all of this.

 

My other-wise healthy, 88-year-old father came down with e-coli pneumonia.  He was extremely dehydrated and had very low blood oxygen.  He was taken by ambulance to the local hospital late morning, where they immediately put him on oxygen, antibiotics, and an IV for the dehydration.  Within just a few hours, he felt so much better.  At least at first.

 

They kept him on an IV for dehydration throughout the day and then all night.  But they never weighed him or kept careful track of the liquid. Turns out all the liquid they had been putting into him since the day before, never came out.  Finally near morning, when he could barely breathe, he called a nurse.  He had gone into heart failure, because basically, the liquid was flooding his heart and lungs.  14 pounds worth of liquid.

 

It set him back so much, it almost killed him.

 

Fortunately, a family member who is a doctor (in another city) stepped in at that point and pushed to have him placed into ICU and observed carefully for 48 hours.  It was touch and go, but he survived, and thankfully, is home now after a week.

 

He wants to forget it all, put it all behind him.  The rest of us feel the hospital was so negligent, we shouldn't just let it be.  It was a horrible situation and they should be made aware of it.

 

Edited March 28, 2016 by LMV

[Supertechmom]

I'm sorry your dad was so sick.   As a med surg nurse, fluid overload can be tricky. One shift they are fine, the next they are definitely not.  having pneumonia complicated it. Pneumonia and fluid overload beginning signs are very similar. Fast pulse,rapid breathing, bad lung sounds, messy labs....one would have to be very aware of minute changes in vitals and the patient in the first stages.  Sounds like your dad was on the floor 24-48 hours??  He  could have had 4-5 different nurses in that time frame.  I'm not trying to excuse it but if he had different nurses from admission and on each new shift, then they may have all felt his lungs sounds were related to the pneumonia. Doesn't mean they were bad or neglectful.  Honestly at his age, he probably had some heart condition that was unnoticed because it had crept up gradually on him  and that compounded the fluid issue.  I don't know how many patients come to the hospital "other wise healthy" and leave it with heart issues.   One tends not to know your heart function is not great until your body is sick and can't be sick and cover up poor heart issues.    Really, other wise healthy just means the person has not found an issue that bothers them enough to get it checked out and they still go about their business despite it. Especially the elderly, they tend to pass everything off as getting older. 

 

Without having been there, I suspect he was moved to ICU as a professional courtesy to another doctor. Fluid overload is easily treated on the floor everyday.  Monitoring it doesn't require ICU level monitoring. So either he had a lot more going on that was way more worrisome than pneumonia and fluid overload such as worsening sepsis or a heart issue or kidney failure that needed ICU interventions. Typically, we would have given him a ton of iV Lasix and monitored his urine and lung sounds and labs. 

 

I would call the nurse manager of the floor.   I would tell her your concerns and just let her know that you feel they missed some very important signs of fluid overload and that it worsened your father's condition and forced an ICU visit.  In my experience with both good and bad hospitals, the nurse manager will pull the chart and review everything.  They will talk with the nurses and find out what happened.  They may not tell you all the details or say they were at fault, but they will figure out what happened and reeducate where necessary or make changes where needed.  Nurse managers will also move it up the chain as well.  I would start there and express your concerns with the manager.   But do know that neglect is based on what would a prudent nurse do?  In other words, if you gave the case to 50 nurses and they all say they would have done x, y, and z, then the action taken will have been found to be prudent.  It may have still been wrong in which case massive reeducation would be undertaken so the next time the 50 nurses would say I would have done a in addition to x,y ,z

[J-rap]

Admittedly there are many nuances and details you aren't sharing in your post. To be fair, I'm not suggesting you are attempting to be deceitful, rather that you may not really understand. Having said that, I can imagine that those missing details and nuances may be quite important in terms of how poorly (or perhaps well) this was truly handled by any involved physicians and nurses.

 

If we break your initial post down a bit. 

 

"My other-wise healthy, 88-year-old father came down with e-coli pneumonia.  He was extremely dehydrated and had very low blood oxygen.  He was taken by ambulance to the local hospital late morning, where they immediately put him on oxygen, antibiotics, and an IV for the dehydration."

 

For what it is worth, gram negative pneumonias are not common community acquired pneumonia pathogens. Sure we see them but more commonly in debilitated patients, nursing home residents (or patients with recent prior admissions, or in ventilator associated infections. The rest of this statement makes me strongly suspect that your father was likely septic. Goal directed therapy for sepsis involves volume resuscitation with crystalloids. Generally we start with 30mL/kg (so at least a few liters in a 70kg adult) and go from there based on clinical response. If you add in another liter or two to correct for the dehydration your father probably should have received at least 3L of fluid in the ED/early hours of his admission. 

 

"Within just a few hours, he felt so much better.  At least at first. They kept him on an IV for dehydration throughout the day and then all night.  But they never weighed him or kept careful track of the liquid."

 

Ok, if this is the case then this is a poor idea (although technically assessing volume status with weights and or I/O does not fit into the CMS sepsis bundle but I digress) but I wonder if perhaps they were aware of how much fluid they were giving (on some level they must have been because some physician wrote an order for that fluid) and the nurses actually were recording I/O and perhaps even using bed weights and the physicians involved felt that they needed to give more fluid because they had other evidence of poor perfusion (i.e. elevated lactate, creatinine, borderline or even low BP etc). 

 

"Turns out all the liquid they had been putting into him since the day before, never came out.  Finally near morning, when he could barely breathe, he called a nurse.  He had gone into heart failure, because basically, the liquid was flooding his heart and lungs.  14 pounds worth of liquid."

 

A few thoughts--in a patient with fully functional kidneys and normal cardiac function (which I admit may be a poor assumption for most octogenarians) fluid will not accumulate. So when you have a mismatch of fluid in and fluid out then either you started out with a volume deficit, which it sounds like your father did, or the body is struggling to maintain homeostasis due to some degree of organ compromise, or both. What the scenario was, what else was going on, and the rationale for the continued volume will be the critical pieces of whether or not any of this was inappropriate care. I will say that in someone who is septic receiving 5-6L over the initial 24 hour period is not outside of reasonable. Some patients may actually require more aggressive volume resuscitation than that. I'm not saying what was done in your dad's case is automatically right (or wrong) but a weight gain of 6L like your dad had from ED admission to hospital day #2 doesn't automatically raise any red flags.

 

As far as going into heart failure, this won't happen if your father has normal systolic and diastolic function.  I suppose it is possible that he did prior to admission and the cardiac dysfunction was just part of the end organ damage from sepsis. I suspect it is more likely that your father had some degree of chronic CHF prior to admission. Perhaps he wasn't aware of this and or didn't make the physicians caring for him aware of this so they could be more judicious with volume. Or perhaps they realized he had a subnormal EF and felt that they would provide volume to prevent further damage to his organs and deal with some degree of pulmonary edema as they went along. It sounds like ultimately that is what happened. You don't mention that he required intubation/mechanical ventilation so I'm guessing that once he was out of sepsis they were able to diurese  him and he did reasonably well. 

 

"It set him back so much, it almost killed him. Fortunately, a family member who is a doctor (in another city) stepped in at that point and pushed to have him placed into ICU and observed carefully for 48 hours.  It was touch and go, but he survived, and thankfully, is home now after a week. He wants to forget it all, put it all behind him.  The rest of us feel the hospital was so negligent, we shouldn't just let it be.  It was a horrible situation and they should be made aware of it."

 

I'm sure this was all very stressful and difficult for you and I really am sorry about that.  If this was my family member, I would respect their wishes regarding complaints and further action. As far as the hospital needing to be aware, I would guess they probably are. Most hospitals track ICU transfers, rapid responses etc. If they are using sepsis as their coding diagnosis then they will definitely be reporting their performance against the sepsis bundle scoring for CMS so that will be looked at.  Just for a point of reference, the mortality rate for sepsis is somewhere between 25-50% depending on study so your dad may be generally appreciative that he did make a full recovery and walked out of the hospital. In answer to your WWYD, I guess I would just thank all involved that my family member was alive. We buried a child due to sepsis and she had amazing physicians, textbook care, but sometimes bad outcomes happen in spite of all of this.

Thank you for taking the time to respond.  

 

First and foremost, I want to say how very, very sorry I am about your child.  I can't imagine anything more difficult.

 

Yes, I do believe it had become septic.  It happened very quickly.  He had, in fact, just been visiting us across the country, where we did a lot of sightseeing, boating, etc.  I know it was a rarer form of pneumonia and they believe he could have caught it on the airplane returning home.  This is a man who is otherwise healthy (still cross-country skies in the winter, keeps up his own home and garden, etc), and they believe that it is because of his good health that he was able to leave and is doing well now at home.  

 

Believe me, he is very, very appreciate of the outcome and is so happy to just be home.  

 

However, it seemed that he was on is way to recovery quite quickly before the incident I referred to happened.  Also, they were aware of the amount of liquid they were giving him, but not weighing him or observing output.  (There were no bed scales on his bed.)  

 

Admittedly, I do not understand all of this very well since I'm not in the medical profession, but my brother is a doctor (at a different hospital), which has been very helpful to us in understanding what happened.

 

I'm sure the staff was aware of what they were putting into him, and I know the fluids were necessary.  But shouldn't the hospital staff always be aware as to whether the fluid they are putting into him is either helping him or, well, leaving him?  But I believe I understand what you're saying -- that the fluid might be necessary simply to replace what was lost.

 

What I didn't mention at first is that it wasn't the staff that discovered the problem, it was my father.  Sometime in the middle of the night he called the nurse to tell her that breathing was very difficult.  He was still receiving oxygen at that point.  (He was on oxygen for about 72 hours, due to very low blood oxygen upon arrival at the ER.  They feel the pneumonia had reduced pulmonary function.  By the time he entered the ER, he could barely move his arms and legs.)

 

Anyway, you gave very good information and I appreciate it.  I guess we are taking our time dealing with it partly because we want to have a good understanding of what happened. 

[EmseB]

Tangent: That is interesting. I knew someone who was treated for sepsis with wide open IVs and the nurses were constantly very interested in his output. Why wouldn't this be standard? Seems like it would be necessary to know what was happening to all that fluid?

 

Ok, if this is the case then this is a poor idea (although technically assessing volume status with weights and or I/O does not fit into the CMS sepsis bundle but I digress)

[LMV]

Tangent: That is interesting. I knew someone who was treated for sepsis with wide open IVs and the nurses were constantly very interested in his output. Why wouldn't this be standard? Seems like it would be necessary to know what was happening to all that fluid?

 

 

Oh yeah one of the things that does work in sepsis (with the caveat of the high mortality rate I mentioned above) is volume support with fluids.  I also think that most prudent physicians will be concerned about urine output (perhaps even more because making urine is a good prognostic sign than because they want the I/O to be balanced because honestly, in the first 12-24 hours with severe sepsis that really isn't the biggest goal. What I was referring to was more the CMS Sepsis Bundle requirement where in order to meet the core measures you need to do at least two of the following four:

1.)Measure CVP (which requires putting in a high CVL---which may be necessary for inotropic support anyway and if that is the case then I think trending CVPs can be very helpful as another objective measure but please don't ask me to sign a consent so my husband or child can get a CVL just so you can measure CVP if they don't have some other indication.  In that case, I feel that the risk of the CVL likely outweighs the potential benefit and I'm not in favor.  I practice similarly when it isn't my family member and I'm just a lowly EM physician.  Having said that, I do put in a fair number of CVLs in the ED because often patients will need inotropic or vasopressor support or because I'm not confident they won't and I opt to be a bit proactive in case I'm in the middle of a major trauma (and thus not in a good position to place a CVL) when we actually get to that point.  Sometimes I'll also do it because the admitting physician requests it because they think they will probably be going that way and they don't want to be putting a line in emergently. I can respect both of those scenarios (and I would probably sign the consent in that case for a family member) but just putting a line in so our hospital doesn't get dinged by CMS is hard to justify. [Of course when the hospital gets dinged then they get paid less or don't get paid at all so yeah...]

2.)Measure Central Venous O2 (CVO2) (which requires placing a Pulmonary Atery Catheter i.e. a Swann---now I do sometimes place these in our ED and sometimes they can be helpful but often not and multiple studies have pretty much showed this as well).

3.)Bedside Echocardiogram (Now this has the advantage of being pretty safe---it often isn't as helpful and getting your cardiologists out of bed in the middle of the night to read this may or may not be fair--it also may or may not require that you have more than one cardiologist on over night if you have a large enough STEMI/unstable NSTEMI population. Our hospital is facing this scenario right now because we do have a high volume cath lab and expecting our interventional guy/gal to read these middle of the night STAT echos is not always realistic if they're doing back to back PTCA/stents.)

4.)Passive Leg Raise/Fluid Challenge  

[EmseB]

Thank you for explaining all this. Now that I think on it, it makes sense they were looking for organ function rather than balance.

 

Either way it was all very scary and I have a lot of sympathy for the OP.