From the Research
In a medical malpractice case involving this complex obstetric case with delayed diagnosis of bowel injury, the following 30 questions would be appropriate for written discovery requests, prioritizing the most recent and highest quality study available, which in this case is 1.
Questions for Written Discovery Requests
- Please describe your educational background, training, and experience in managing high-risk pregnancies and performing cesarean sections in patients with multiple prior cesarean deliveries.
- What was your assessment of this patient's risk factors prior to surgery, including obesity, prior lap band, multiple gestation, and history of two previous cesarean sections?
- Please describe in detail the surgical technique you employed during the cesarean section, including your approach to the abdomen given the patient's surgical history.
- What precautions did you take during surgery to identify and avoid injury to the bowel, particularly given the patient's history of abdominal surgery?
- Describe your inspection of the abdominal cavity prior to closure, including any assessment for potential bowel injury.
- What specific steps did you take to ensure proper closure of the abdomen, and what suture materials were used?
- Please provide your complete operative notes, including any complications or difficulties encountered during the procedure.
- When did you first become aware of the patient's post-operative complaints of severe abdominal pain, and what was your assessment of these complaints?
- What differential diagnoses did you consider when the patient developed fever, tachypnea, and elevated lactic acid on postoperative day 1?
- Why wasn't a surgical consult obtained when the patient required a rapid response and ICU transfer on postoperative day 1?
- Please explain your interpretation of the first CT scan showing pneumoperitoneum and dilated bowel.
- What was your rationale for not considering bowel injury as a potential diagnosis despite free air under the diaphragm?
- What criteria were used to determine the patient was stable for transfer from ICU to the floor on POD #2 despite ongoing symptoms?
- What was your response to the patient's continued complaints of severe pain and absence of bowel function on POD #3?
- Please explain your interpretation of the second CT scan findings and why these findings did not prompt surgical intervention.
- What is your standard protocol for evaluating postoperative pain that is described as inconsistent with typical post-cesarean section pain?
- What is your understanding of the standard of care for evaluating free air under the diaphragm in a post-surgical patient?
- What consultations did you request during the patient's deteriorating course, and when were they requested?
- What laboratory studies did you order to evaluate the patient's condition, and how did you interpret these results?
- What specific orders did you write regarding pain management, vital sign monitoring, and assessment of bowel function?
- What information did you communicate to the patient about her postoperative condition and potential complications?
- What information was provided during handoffs between you and other physicians regarding this patient's care?
- Please describe all communications you had with nursing staff regarding the patient's complaints and condition.
- What is your understanding of the significance of absent bowel function for three days following abdominal surgery?
- What is your understanding of the significance of pneumoperitoneum on CT scan in a patient three days post-cesarean section?
- What factors contributed to your decision not to return the patient to the operating room despite progressive symptoms and concerning imaging findings?
- What is your understanding of the relationship between delayed diagnosis of bowel injury and patient outcomes?
- What hospital policies or protocols exist regarding evaluation of postoperative complications following cesarean delivery?
- What documentation did you provide regarding your decision-making process throughout the patient's hospital course?
- What changes, if any, have you made to your practice following this case to prevent similar complications or delays in diagnosis?
Rationale for Questions
The questions are designed to assess the defendant's knowledge, judgment, and actions in managing the patient's care, particularly in relation to the diagnosis and treatment of the bowel injury. The questions also seek to understand the defendant's understanding of the standard of care for postoperative complications following cesarean delivery and their adherence to hospital policies and protocols. The most recent study, 1, provides guidance on the management of HELLP syndrome, which is relevant to this case.