Our client, a 42 year old kindergarten teacher, was experiencing intra-abdominal pain for which she sought treatment with her family doctor. Our client’s family doctor diagnosed her with gallbladder stones and referred her to Defendant, Dr. Ledesma, for treatment. Defendant Dr. Ledesma performed a laparoscopic cholecystectomy at Defendant, Northeastern Hospital.
Our client’s post-operative course was immediately characterized by significant abdominal pain greater than would have been expected from a laparoscopic cholecystectomy, whereas minimal pain and discharge within 24 hours is normally expected after such a procedure.
Our client remained hospitalized for 4 days after surgery. Throughout the entire four days after surgery, our client complained of and was treated with pain control medication for persistent abdominal pain, nausea, vomiting, difficulty with bowel movements and temperature elevations.
In addition, our client was noted to have a markedly elevated WBC (white blood count) of 16,600 with 20% bands. This blood work indicated a high likelihood of significant infection, it was alleged. Despite this clinical picture, no further diagnostic studies were done.
Dr. Ledesma wrote instructions on an order sheet to discharge the patient “if an enema provides good results.” An enema was administered, but only fluid was returned. After being notified of this fact, Dr. Ledesma ordered more Demerol for pain, as well as an oral laxative.
Despite the fact that no discharge order was given our client was discharged from the hospital by the nursing staff.
Fifteen days later our client was readmitted to Defendant, Northeastern Hospital, with fever, chills and abdominal pain. She was found to have a bile leak, the source of which was not entirely clear. An infectious process that had begun during the hospitalization had eventuated into a massive intra-abdominal infection.
Our client went on to suffer further infectious complications, including an obstruction of her right kidney which required placement of a nephrostomy tube. She also suffered bacterial tubo-ovarian abscesses requiring a total abdominal hysterectomy and bilateral salpingo-oophorectomy, which were performed at the Hospital of the University of Pennsylvania.
According to plaintiff’s expert, Dr. Anthony Coletta, our client’s post-operative clinical picture was clearly one consistent with a potential complication of laparoscopic cholecystectomy that warranted further evaluation, including additional blood work (serial CBC’s and liver function tests) and an abdominal CT scan to rule out intra-abdominal complications.
Our client’s persistent pain, low grade fever, markedly increased white blood count, lack of bowel function, and nausea and vomiting were all warning signs of complications, such as a post-operative bile leak, bowel injury or intra-abdominal infection. Despite this picture, no appropriate diagnostic studies were performed to rule out why she was having these unusual symptoms.
Further, Dr. Ledesma prematurely ordered the discharge our client without appropriately investigating why she was having the symptoms she was.
As a result, the bile leak and evolving infectious process went unrecognized, causing a diffuse peritonitis which, in turn, required two major laparotomies and the loss of her female reproductive organs.
Result: $4,003,200, consisting of $4 million in non-economic damages and $3,200 in lost wages.
Attorney: Anthony J. Baratta of Baratta, Russell & Baratta