The Expert: Dr. Jeffrey Schwab, a surgeon based in Georgia, testifies for the defense as to the defendant general surgeon’s treatment of the patient.
During a 2015 Georgia medical malpractice case, Dr. Jeffrey Schwab, a Georgia general surgeon testifies for the defense as to the plaintiff’s claim that medical negligence following a patient’s hiatal hernia operation led to her demise. In this case the patient had bleeding post-operatively with the development of a hematoma that the surgeon had to decide how to treat.
The expert begins by explaining that post-operative bleeding is not unusual and is a problem that happens to even the best surgeons. He describes that this hemorrhage is not always from a single identifiable blood vessel, but often from a diffusely oozing raw surface of tiny capillaries that can be deceptively persistent. In this case, the treating surgeon recognized that there was significant bleeding occurring post-operatively and transfused the patient on two occasions. At the same time, he obtained serial CT scans that demonstrated that the bleeding was no longer occurring, but a large, stable, and eventually resolving hematoma was present adjacent to the diaphragm.
The expert testified that there was no need to drain this hematoma early on. The wound was closed, the clot was resolving, and there was no evidence of infection. It was appropriate to allow the body to reabsorb the hematoma on its own. Schwab explains that placing an external drain at this point would be a “two-way street” by creating an inward pathway for infection within a sterile blood clot. Thus, the standard of care does not demand drainage of a sterile hematoma like this, and it was appropriate to initially observe this complication rather than unnecessarily take the risks associated with draining it.
In addition to the risks involved in draining a sterile hematoma, Schwab testifies that, when a blood clot initially collects, it has the consistency of “Jello.” Trying to drain this early on through a tubing can be as effective as trying to suck up Jello through a small tube. It is therefore more appropriate to wait until the body’s immune system has liquefied the blood clot prior to attempting to drain it. By delaying the drainage, the now-liquefied clot can be more easily and effectively aspirated and fully evacuated.
Finally, Schwab addresses whether the patient’s initial discharge from the hospital was appropriate and within the standard of care. He affirms that it was. The patient returned a few days later complaining of leg swelling and shortness of breath. This was eventually felt to be related to pressure that the fluid collection was putting on the diaphragm, making it more difficult for the patient to breathe. She also had recently developed a fever, which gave the surgeon cause to worry that the fluid collection was becoming infected and leading to a subphrenic abscess pressing on and irritating the diaphragm. Because of these two new findings, the surgeon decided it was time to risk the drainage that needed to be done.
This drain was placed by a radiologist, which complied with the standard of care; as a result, the radiologist could determine when that drain should be removed. He did just that, determining the day prior to the second discharge that the subphrenic abscess was completely drained. He therefore removed the drain he had placed. Schwab testifies that the general surgeon could not be held responsible for this decision since he played no part in making it.
The jury agreed, returning a verdict for the defense.
Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.
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