If an older patient undergoes general anesthesia, cardiac complications are possible. One urologist forgot that, to his regret.
 

Dr. Y, age 57, is an experienced general urologist who practices at a university hospital in the Northeast. In his clinical setting, the family physician—often one from the university’s own clinic—retains control of the patient even if he’s admitted by a specialist. This arrangement is ostensibly to ensure that the patient receives comprehensive care. Dr. Y, while conceding the validity of this holistic approach, resented having FP residents writing orders on his patients, orders that sometimes interfered with his care.
 
The patient in this case was a 74-year-old woman who presented originally with recurrent bladder infections, and occasional hematuria. Dr. Y performed cystoscopy, which revealed several bladder polyps that he fulgurated with a hot loop. Histology showed precancerous changes, and Dr. Y arranged for follow-up in his office. At that visit, the patient complained that her hematuria had returned, and Dr. Y, after an informed-consent discussion, scheduled her for repeat cystoscopy and excision biopsy of her presumed lesions. She underwent cystoscopy as before, but no polyps were found.
 
In the recovery room, the woman reported chest pressure and difficulty breathing. The FP resident ordered an ECG, which showed some ST segment depression. He summoned the cardiology resident, who had just been to a seminar where it was emphasized that MIs could occur in older women with minimal ECG changes. Sensitized to the issue, he quickly recognized the possibility of an infarct, and ordered Retavase, a powerful thrombolytic agent, on the basis of ST depression in the anterior leads.
 
“This is awesome stuff,” he told Dr. Y as the nurse made the infusion. “It can completely reverse an infarct in evolution as you watch the screen.” Just as he had predicted, the ST segments came back up and the patient’s chest pressure subsided. It seemed that disaster had been averted, and the patient was transferred to the ICU. But three hours later she developed hemiplegia. A stat CT scan revealed a massive hemorrhagic infarct over the left hemisphere. As her condition deteriorated, the patient was intubated and placed on life support, but declared brain-dead two days later.
 
Shocked at the woman’s death and angry at Dr. Y, the family consulted a plaintiff lawyer who had the chart reviewed by a cardiologist. He determined the patient was maltreated and had not been warned of the potential complications of surgery. A malpractice suit followed shortly thereafter.
 
The defendant pleads ignorance
 
At deposition, the patient’s son testified that his mother had no cardiac problems before the cystoscopy, implying that somehow Dr. Y had induced the crisis, and that his mother had not understood there was a risk of cardiac complications under general anesthesia. The plaintiff expert testified that, on the basis of the son’s testimony, Dr. Y had not obtained adequate informed consent, and should be held liable for the complications—both the MI and the devastating hemorrhagic stroke caused by the thrombolytic drug. He added that depressed ST segments were an inadequate indication for such a drug, and did not meet the American College of Cardiology guidelines for its use.
 
Dr. Y stated that he was unfamiliar with the modern treatment of infarcts, but that the cystoscopy had gone smoothly. He pointed to the distant relation between putting a cystoscope in the bladder and the blocking off of a coronary artery, but the lawyer grilled him about “autonomic stress reaction” and other concepts unfamiliar to him.
 
After attempts to settle failed, the case proceeded to trial. Dr. Y related his version of “what he always told the patients,” and in such a commonsense and understandable way, that he was quite persuasive with the jury. The plaintiff lawyer belligerently challenged him about “clot-buster” treatment, but Dr. Y replied calmly, “I am a urologist. I don’t know about cardiology treatments. I rely on my cardiologist to know these things.”
 
The jury ruled against the cardiologist, with an award of $1.6 million. They exonerated Dr. Y, deciding that he had obtained adequate informed consent, even though he had not mentioned the possibility of intracranial hemorrhage from thrombolytic drugs. Dr. Y returned to his practice with a new respect for the informed-consent process.
 
Legal background
 
The doctrine of informed consent requires a doctor to explain all the treatment options and their benefits, risks, and probable outcomes. A flood of lawsuits in the 1960s based on “failure to obtain informed consent” led to the passage of new requirements in al-most every state legislature. Nowadays, informed-consent lawsuits occur rarely, and then usually in conjunction with a suit for a bad outcome, as in this case.
 
Guidelines issued by medical groups are often used by plaintiff lawyers to show that a defendant doctor failed to meet the standard of care. This is so even though the professional bodies state explicitly that guidelines are recommendations, not binding standards of care. In this case, the plaintiff lawyer was able to convince the jury that the cardiologist should not have given Retavase because her ECG did not show the ST segment elevation specified by the ACC guidelines. The fact that she then had a massive stroke as a complication of the therapy gave the plaintiff’s case a tremendous sympathy appeal.
 
Protecting yourself
 
When an informed consent case is filed today, it is usually because the patient suffered a serious complication or death, typically from a complication not listed or mentioned by the physician. To lessen your vulnerability to such suits, use general, encompassing language, such as “the risk of a serious complication, or even death, is x%.” Also hand out patient material. Defense lawyers can introduce patient handouts as evidence and even give jurors copies, walking them through the material using a projector. Finally, get patients to sign informed-consent forms that are often provided by hospitals or medical societies.