1. Confidential Attorney Work Project: This is a confidential work project prepared in
anticipation of or directly related to litigation; it is owned by Victory Mine, Attorney at
Law.
RE: Henry Smith
DOB: 02/18/1938
Dear Attorney Mine:
I have completed my review of Mr. Smith's medical records regarding his hospitalization
at The Hospital from May 17th – May 27, 2008. I have included my comments and
recommendations at this time for your consideration regarding this case.
HISTORY: Mr. Smith returned home from Duke University Hospital on May 6th after
having surgery (a fusion of L3 and L4). I have no records of his hospital stay at Duke.
On May 17th, around 0500, Mr. Smith was awakened by experiencing extreme SOB
(Shortness of Breath). He denied having any chest pain, heart palpitations or nausea at
this time. He came to The Hospital ER and was diagnosed with hypoxia (low oxygen in
the blood). I could not find the exact oxygen saturation of Mr. Smith on his arrival to the
ER. His admitting physician was Dr. Ross. His primary physician is Dr. Whine at the VA
Hospital. From the ER, he was sent to radiology for a CT scan of the chest. He was
found to have a pulmonary embolus of the left lower lobe and a pulmonary mass of
about 19mm. He was ordered to be sent to ASD (Adult Special Care Department) or
Telemetry.
Mr. Smith has a history of Diabetes Mellitus which he controls with insulin and diet. His
routine home meds were ordered to be given. A neurosurgery consult was ordered.
Being six days post-op spinal fusion, Mr. Smith had full use of his legs when he came
into the ER.
He denied any numbness or tingling in either lower extremely. Dr. Ross ordered
Coumadin 5mg po (by mouth) beginning on 05/18. He also ordered a PT and INR daily.

2. Other appropriate labs were ordered as was an IV of NS (normal saline) with 20 MEQ of
potassium to run at 75cc/hr. See Excerpt 1
LABS: Some of Mr. Smith's lab results were significant;(i.e. the INR range determining
whether to give or hold Coumadin and the Creatinine levels to determine whether
contrast could be used during the MRI and CT scans). His admission potassium was a
little on the low side (3) and his Creatinine was a little on the high side (1.4). His
Troponin was 0 and his Beta natriuretic peptide was 96. Both of these labs rule out
cardiac involvement. Others were WNL (within normal limits).
Emergency Department:
Arrival: time looks to be around 0800
Nursing Assessment: Under the Neurological and Genitourinary Systems, the nurse
marked "no complaint". This makes us believe that all was normal with these two
systems upon his arrival.
Progress Notes: Lovenox was ordered and given. Neurosurgery was consulted per
request of Dr. Ross. At 1400 the nurse charts that "Dr. Toesss to see patient……to
Excerpt 1

3. hold Lovenox until Ok’ed with Neurosurgery". Neurosurgery saw patient and stated that
they felt it was OK to administer Lovenox and Coumadin to maintain an INR of 2-3.
Initial History and Physical: (the patient filled out this part) Under the Neurological
System, the patient marked "no history of problems". The nurse filled out the rest. Under
Physical Assessment, section V Neurological System, the nurse has marked the
extremity strength to be 2-3 for the right and left leg. Under section V Musculoskeletal,
she has marked "other" and written "decreased mobility secondary to recent back
surgery". Under Cardiac System she did not score his pedal pulses. She should have
scored them 0-4, instead she simply initialed that they were present. She also charted
that he had trace pedal edema and was wearing his TED hose. Using the Braden Scale,
under Activity, she has scored him a "3", "walks occasionally". (See Excerpt 2 and 3)
Excerpt 2

4. PHYSICIAN HISTORY AND PHYSICAL REPORT ADMISSION:
Mr. Smith's H & P that was dictated by Dr. Ross states basically the same as mentioned
above. The only abnormalities were:
LUNGS: Decreased breath sounds bilaterally
SKIN: Vesicle or pustule lesion in the area of the patient's chin.
NEUROLOGICAL: Alert and oriented. Motor and Sensory normal. His PLAN was (see
Excerpt 4)
Excerpt 3
Excerpt 4

5. ON THE FLOOR: Mr. Smith's care on the floor was routine. In my professional opinion,
neuro checks were not performed as often as they should have been. They were
documented only at the beginning and end of each shift. Noting that he was post lumbar
fusion and on anticoagulants, his neuro status should have been evaluated more
frequently.
From May 17th-21st, Mr. Smith was basically being treated for his PE, and not much
thought was given to his post op situation. On the 24 hour flow sheet the nurse initialed
that she checked on him every hour. There were no initials on the "turned" column. I am
unable to determine whether Mr. Smith was able to turn himself as needed. Also,
Incentive Spirometry was ordered and it is not checked on the sheet so it appears Mr.
Smith was not encouraged to use it. (See Excerpt 5)
Excerpt 5

6. Also the Daily Assessment Data sheet shows that he was evaluated at 0900 and not
again until 1945 (almost 11 hours later). During this time, the strength and range of
motion in his lower extremeties went from a "3" to a "1". This should have been
addressed immediately.(See excerpt 6)
NURSES NOTES: At 0900 the nurse wrote that Mr. Smith had movement and
sensation in lower extremeties. At 1830, she charted that the patient complained of
back and leg pain, bilateral leg numbness and weakness. She charted that the MD was
there and aware and new orders were written; one for a STAT MRI, (regarding the
decreased feeling and mobility in his legs) but that she was unable to send him stat
because of his claustraphobia. She got an order for Ativan and gave the medication
which she states did not help him any. (See excerpt 7). She should not have delayed in
sending him for his MRI just because of his claustraphobia. It was ordered STAT and
Excerpt 6

7. she should have sent him STAT regardless of his anxiety. At 1945 a different nurse
charted that Mr. Smith became incontinent of urine. This is obviously another sign that
there was a problem with his neurological status. (Excerpt7)
Excerpt 7

8. At 2020 the same nurse who discovered he was incontinent of urine charted that Mr.
Smith complained of pain, was medicated with 2 mg of Dilaudid, and at 2120 was
transferred for his MRI. She stated it was completed at 2330 with and without IV
contrast. The X Ray of the spine was also completed.
On 5/22/2008, she charted that he was being prepared for emergency surgery at 0100
and left the floor at 0116 for surgery. (See excerpt 8)
Excerpt 8

9. The following consultation report does not make any medical sense. (See Excerpt 9)
(Excerpt 9)

10. .
Mr. Smith arrived in the surgical room at 0204 and left the OR room at 0402. His
procedure was: Lumbar Laminectomy/ Foraminotomy/Decompression and Exploration
of Lumbar Wound with Hematoma Evacuation. The procedure started at 0227 and
completed at 0351. He had two JP (Jackson-Pratt) drains inserted after the hematoma
was evacated. These were later connected to wall suction. (See Excerpt 10)
Recap: Stat MRI was ordered at 1830 and was not completed until 2330. Mr. Smith
went to surgery (for evacuation of the hematoma found on MRI) at 0227. The MRI was
ordered STAT and the order was not carried out STAT. Stat orders are to be completed
within one hour.
Excerpt 9 continued
This is the first mention of
hematoma. The nurse already
charted that he was incontinent of
urine and had decreased movement
and sensation in his lower
extremities. DF

11. (Continued next page)
Excerpt 10

12. The anticoagulants were discontinued, Fresh Frozen Plasma, Packed Red Cells, and
Vitamin K were all given in hopes to reverse the anticoagulants. Mr Smith was sent to
surgery again later in the afternoon for placement of a Greenfield Filter in his Inferior
Vena Cava. Dr Kudo performed this surgey without incident. As you can see from the
rest of the chart, the hospital staff and doctors try to downplay the fact that if the MRI
Excerpt 10 continued

13. had been done STAT, the hematoma would have been evacuated earlier leading to a
better prognosis for Mr. Smith.
My legal nurse consultant summary:
1) Neuro checks should have been performed on Mr. Smith every hour. Although he
was several days post-op his spinal surgery, the fact that he was on anticoagulants for
the pulmonary embolius should have alerted the nurses and physicians of the possibility
of bleeding in the lumbar surgical site. The physicians should have ordered neuro
checks every hour and although they did not order this, the nurses should have known
to perform them every hour. Anytime someone is on anticoagulants for a PE, there is a
chance of bleeding elsewhere in the body.
If neuro checks had been done more frequently, the nurses would have noticed the
decrease in the strength and feelings in Mr. Smith’s legs. This would have alerted them
sooner to the possibility of a hematoma. A different nurse discovering his urinary
incontinence was the first symptom the nurses noticed that there was a problem.
2) When the physician finally ordered the stat MRI, the nurse should not have delayed
sending him. A patient saying they are claustrophobic is no excuse for a delay
expecially when symptoms of a problem have been ongoing. The MRI was ordered at
1830 and Mr. Smith was not sent until 2120. Stat orders are to be completed within 1
hour. It was nearly 5 hours later that the MRI was completed. Surgery to evacuate the
hematoma found on the MRI was started at 0227, nearly 8 hours after the MRI was
ordered
3) By the time the physicians all communicated, surgery to evacute the hematoma
(found on the MRI) was started at 0227, nearly 8 hours after the MRI was ordered.
In my e-discovery, the literature states, “The results are most favorable if
decompression is accomplished early….and evacuation of the hematoma is performed
within 6 hours of symptom onset.”

14. (I did not reference this article but can retreive the information if necessary)
Had neuro checks been performed more frequently, the onset on his symptoms would
have been noted before 1830 giving Mr. Smith a much better prognosis. This delay
caused the hematoma to enlarge thus increasing pressure on the caudia equina and
creating the neuro deficits in the lower extremeties.
The chain of events in this case lead to Mr. Smith’s poor outcome. His nurse was
neglegent. His phyisicians failed to follow up on their MRI order, and did not have
adequate control of his coagulation. I recommend that you pursue the nurse, attending
and consulting physicians and associates, and the hospital. The OR staff seemed to be
on top of their duties therefore I see no neglegence on their behalf.
Thank you for allowing me to participate in this very nteresting case. Please to not
hesitate to contact me if I can be of further assistance. I look forward with eagerness to
work with you again in the near future.
Very Truly Yours,
Debbie Fernando, RN, BS, CLNC, MHA/GER
Certified Legal Nurse Consultant