$14.5 Million Awarded in Abdominal Compartment Syndrome Case in Massachusetts

The family of a Chelmsford woman who died a day after thyroid surgery at Brockton Hospital was awarded $14.5 million by Middlesex County, Massachusetts jury in a medical malpractice case this week after five hours of deliberation. Under a favorable provision of Massachusetts law, the award included more than $5 million in interest.

compartment syndrome verdictPlaintiff’s decedent was a 30-year-old woman who went to the doctor because of a lump on her thyroid gland. Her surgeons did a biopsy on the benign lump, but in recovery, someone noticed that her abdomen was swollen and her stomach and legs had turned blue. She developed abdominal compartment syndrome from the air that had gotten into her stomach.

The doctors did what they should have done initially. They operated again and released the air. Unfortunately, the surgeons closed the wound immediately without letting all the air escape. She was flown to Boston Medical Center for surgery but died later that day.

I cannot imagine how this case went to trial. Often the doctor’s medical malpractice lawyers defend these cases based on the difficulty of diagnosing abdominal compartments because it often occurs in patients with other causes of circulatory or respiratory failure. So the plaintiff’s medical malpractice claim is usually defended because the doctor did not diagnose abdominal compartment syndrome. After all, the patient’s symptomology was consistent with other problems, and the patient died or suffered a severe injury before the condition was uncovered. In this Boston medical malpractice case, the diagnosis was not the problem. Instead, the doctors’ conduct after they knew of the condition led to medical malpractice.

One more comment about the case: when the woman was in trouble, they transported her by helicopter to another Boston hospital. If I’m getting elective surgery, I’d much rather do it at the hospital, where they will send me if a problem occurs.

Compartmental Syndrome

Compartment syndrome occurs when a fixed compartment, delineated by myofascial layers and/or bone, is subject to increasing pressure, leading to vascular compromise and ischemia. So you see this medical condition  when the pressure in a muscle compartment becomes too high. This results resulting in decreased blood supply to the muscle tissue. This can cause pain, numbness, tingling, and even ischemia, necrosis, and paralysis. 

So this condition is a true medical emergency.  Doctors need to look for this if there are signs and symptoms.  There is no definitive test. Compartment syndrome is a diagnosis of exclusion in many ways.  Treatment typically involves surgical decompression of the affected area.

But trauma doctors and orthopedic doctors are familiar with how to measure compartment pressures and they know what a big deal it is if you have compartmental syndrome.  The most simple way to measure it is with a compartment tester. It is a quick test to administer.  You have information that might make the diagnosis in just a few minutes.

Some people think you need a broken bone to have compartmental syndrome.  You don’t.  When after an accident and there is great pain that is not proportional to what you would expect, that is a sign you need to dig further to look for compartmental syndrome.

Abdominal Compartmental Syndrome

Abdominal compartment syndrome is a lifethreatening medical condition. What happens is that increased pressure in the abdominal cavity leads to organ dysfunction. This increased pressure is caused by an accumulation of fluid, gas, or blood that compresses organs and blood vessels in the abdomen.

Symptoms of abdominal compartment syndrome are sometimes challenging to diagnose, leading to disputes in a malpractice lawsuit as to whether they should have been diagnosed. These symptoms include abdominal distension, abdominal pain, decreased urine output, and hypotension. Treatment includes decompressive laparotomy, which involves making an incision in the abdomen to reduce pressure, and medical management of organ dysfunction.

Abdominal compartmental syndrome (ACS)  is commonly associated with limb trauma.  But it can occur in the abdomen, like it did in the case we are talking about above. ACS has a high mortality rate if it goes undiagnosed and untreated. Prompt recognition and appropriate intervention are required to preserve organ function and prevent death.

Intra-abdominal hypertension is an intra-abdominal pressure greater than 12 mm Hg. Abdominal compartment syndrome is a pressure greater than 20 mm Hg, associated with new organ dysfunction (e.g., kidney failure, respiratory dysfunction, etc.). Intra-abdominal hypertension is graded, I-IV as follows: grade I, 12-15; grade II, 16-20; grade III, 21-25; and grade IV, above 25.

The signs and symptoms of ACS include hypotension, metabolic acidosis,  respiratory decompensation and hypercarbia,  oliguria or anuria,  an unexpected increase in abdominal size, and tenseness of the abdominal wall.

The first line of treatment for ACS is sedation and paralysis to relax the abdominal wall, evacuation of intestinal contents, drainage of ascites or other intra-abdominal or retroperitoneal fluid collections, and optimizing systemic pressure. If the blood pressure is reasonable, you want to offload the excess fluid via diuresis. If these more conservative treatments fail, decompressive laparotomy is necessary.

You can find the State Journal-Register story on this case here.

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