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This month we look at a case involving several health care professionals and several practice sites including a hospital, rehab, stroke clinic, and primary care physician’s office. It’s a reminder that while it’s important to act in the moment to treat an emergency situation, it is equally important to reexamine what was prescribed once the emergency situation has abated and determine whether such medication is still necessary.
Facts of the Case
The patient, Ms W, was 48 years old at the end of February when she arrived in the emergency department of her local hospital with a severe headache. She already had a complex medical history as a result of being involved in a car accident 3 years before. The car accident had caused the patient significant pain which was treated with orthopedic and chiropractic care, and a variety of medications. Ms W’s medications included duloxetine, cyclobenzaprine, sulindac, pregabalin, and warfarin (for atrial fibrillation).
At the hospital, a CT scan revealed a ruptured left intracranial aneurysm with hemorrhage, which was successfully treated surgically. While at the hospital, Ms W was started on divalproex sodium 250mg 3 times a day, which was prescribed for seizure prophylaxis and to treat agitation secondary to delirium. (Ms W’s other medications were continued.) Baseline liver function tests, including AST (aspartate aminotransferase), ALT (alanine transaminase) and bilirubin, conducted on March 23rd were within normal range.
On March 27th, Ms W was transferred to a rehab facility where divalproex sodium was continued at a dose of 250mg daily. Her other medications, including duloxetine, were continued. No liver function tests were performed while Ms W was at the rehab facility.
On April 13th, Ms W was discharged from the rehab facility on multiple medications including duloxetine, divalproex sodium, trazodone, propranolol, and warfarin. She was instructed to follow up with her primary care physician on April 20th, and the hospital’s stroke clinic on April 30th. She was not advised to have liver function tests, or that there might be risks from the combination of divalproex sodium and duloxetine.
At her appointment with her primary care physician, Dr P, he performed prothrombin time (PT) and INR tests to check blood clotting but failed to order any liver function tests. Ms W’s INR was 1.5. Ten days later, on April 30, Ms W had her appointment with a nurse practitioner (NP) at the stroke clinic. At this appointment, Ms W’s INR reading was at 5.0. The NP adjusted the patient’s warfarin dose. No liver function tests were ordered or conducted.
Ms W began to feel ill the next day. As the week progressed, she began to suffer from confusion, lethargy, fatigue, nausea, and weakness. She called her primary care physician on May 8th, and he told her to immediately go to the emergency department. At the hospital, her blood test results were markedly abnormal. Her bilirubin was 4.9, AST was 2772, ALT was 2556 and blood ammonia 71. A CT scan revealed a spontaneous portosystemic shunt.
Ms. W was diagnosed with hepatic failure secondary to medications, most likely divalproex sodium and possibly duloxetine. She was discharged a week later, and seen weekly by her primary care physician, but she continued to deteriorate. By May 30th, she was admitted to the hospital again where a liver biopsy revealed sub-massive hepatocellular necrosis, consistent with drug-induced etiology. Her liver failure was severe and life-threatening, and she required a liver transplant. Six months later, she was readmitted to the hospital for acute liver transplant rejection which was treated medically.
Patient Sues
After she recovered, Ms W contacted a plaintiff’s attorney and filed a medical malpractice lawsuit against the hospital, the rehab facility, the nurse practitioner in the stroke clinic, and Ms W’s primary care physician. Ms W’s attorney hired 2 medical experts to go over the records and assess Ms W’s medical treatment.
Both experts found fault with the clinicians’ treatment. The first expert found that Ms W’s care had fallen below the acceptable standard in monitoring liver function in a patient on medications that have the potential for liver toxicity, such as divalproex sodium and duloxetine. Liver function tests should have been obtained at the rehab facility, opined the expert, plus the patient should have been advised to have liver function monitoring after hospital discharge. The expert faulted the primary care physician for failing to order liver function tests when he saw the patient after she was released from the hospital on April 20.
