Death by Catheterization?

: Sudden, unexpected deaths of older

adults are often not questioned
Burgess, Ann Wolbert DNSc, RN, CS, FAAN
Two days before her death, 90-year-old Agnes Wiggins stared at her daughter (her only child), seemed
uneasy, shuffled her feet and, finally, said she needed to see a doctor. This was especially alarming
because Ms. Wiggins had been noncommunicative for more than two years. Because she had
progressive dementia and required total care, she lived in a nursing home. Immediately after she spoke,
her physical and mental status deteriorated. The daughter was told the next day that blood work and a
urine analysis had been ordered, but the tests were never performed. At 9:44 that evening, the daughter
was notified that her mother was in respiratory distress and had been transferred to the hospital
Ms. Wiggins was found unresponsive in her room. She had no palpable pulses, and her respirations
were poor. She coded, and an ambulance was called. At the ED, she was found to be in ventricular
tachycardia. Cardioversion was performed, and she was intubated and placed on a ventilator. Although
her pulse returned, there was no evidence of neurologic survival. According to the ED nurse's notes,
when he inserted a Foley catheter, he noticed hematomas and lacerations on Ms. Wiggins's genitalia;
the hematomas appeared on the external genitalia. In addition, on the medial aspects of the labia
minora, approximately 1 cm above the urethral opening, there was a stellate tear approximately 3 cm in
length across the widest part.

There was also a small (1-to-1.5-cm) tear in the posterior vagina at the introitus. A milky white
discharge was found. There was no explanation for a long red contusion on Ms. Wiggins's left forearm
and ecchymosis from a healing skin tear on her right arm; the bruise wasn't over a bony prominence, as
in accidental bruising; this suggested that it was caused by someone else, perhaps intentionally. The
color of the bruise indicated that it was 24 to 48 hours old.

The admitting ED diagnosis: an episode of ventricular tachycardia and genital trauma of unknown
etiology.
Ms. Wiggins was taken off life support, and she died 12 hours after admission to the ED. Her autopsy
report indicated the following: marked, generalized arteriosclerosis (involving 25% of the coronary
arteries), multiple pulmonary emboli, lacerations and contusions of patulous labia majora and labia
minora from attempted catheterization, and cholecystolithiasis. No obvious brain pathology was found.
No internal pelvic examination was reported, despite the trauma to the region.
The medical examiner determined that the cause of death was multiple pulmonary emboli associated
with arteriosclerotic disease and that the manner of death was natural-another surprising finding,
considering the pelvic trauma. What caused the tears? Was sexual abuse a factor? Unfortunately, that
possibility was never explored by the medical examiner. In forensic investigations, the cause of death is
the disease or injury that precipitated the chain of events leading to death. The manner of death
characterizes the cause itself; the cause can be natural, accidental, homicidal, suicidal, or undetermined.
Natural deaths are those caused solely by disease and doesn't involve trauma; the other manners of
death all involve trauma. 1 Unfortunately, the deaths of older adults rarely make it onto the forensics
pathologist's radar screen, even if they're sudden and unexpected.
In many cases, autopsy can determine the manner of death with a high degree of certainty. When there
is trauma, however, there may be questions, such as whether the injury was a direct cause of the death
and, if so, whether it was a result of an intentional or unintentional act. In equivocal medical situations
like this, the ultimate decision may be left up to a jury
Ms. Wiggins's daughter, alarmed about her mother's sudden death and the circumstances surrounding it,
brought a civil suit against the nursing home for negligent care
THE TRIAL
Was Ms. Wiggins's genital injury caused intentionally, as during sexual assault, or unintentionally, as a
result of a traumatic catheterization? Because the medical examiner had collected no evidence that
could have indicated a sexual assault had occurred, no criminal charges were considered. Instead, the
civil suit maintained that the nursing home had been negligent in its care of Ms. Wiggins. The suit
claimed that genital trauma set into motion a lethal chain of events whereby multiple pulmonary emboli
were released, causing the death of Ms. Wiggins. Defense counsel argued the injury was not the fault of
the nursing home. Since there were no plaintiff witnesses to testify to the care provided in the nursing
home, the plaintiff's attorney needed to prove that what evidence was available pointed to negligence at
the nursing home.

Unfortunately, there was no photographic evidence to show the jury. The medical examiner hadn't
taken photographs, and although the ED nurse had taken Polaroid photos, the defense argued
successfully that because they were of poor quality they should be kept out.

Plaintiff witnesses.
The daughter testified that three days before her mother's death, she had reported changes in her
mother's condition to the nursing staff. (According to nursing notes, the daughter complained that Ms.
Wiggins appeared glassy eyed, listless, in a fog, staring, and refusing to be fed.) The daughter
recounted seeing her mother's injuries in the ED. She described dark areas around the vagina, clotted
blood, and two very visible tears. The top tear was large and Y shaped, and the skin beneath it was red
and puffy. The second smaller tear was near the rectum. The physician told her the injuries were not
more than 48 hours old because they were not infected.

Police testimony included observations that the victim's vaginal area appeared very red and there was
bloody fluid on the pads underneath her in the ED, as well as descriptions of the bruising.

The ED nurse testified from his notes that upon arrival Ms. Wiggins was comatose and unresponsive to
painful stimuli. There was continued bleeding in the vaginal area, and the labia were swollen, and
bruising was present. Results of laboratory testing were as follows: a vaginal smear indicated moderate
numbers of red blood cells, white blood cells, and epithelial cells, and elevated bacterial levels (4+); no
yeast or Trichomonas was seen. No chlamydiae or gonococci were isolated. The nurse testified that he
catheterized the patient easily, that it had not been a difficult insertion. He said that the adult absorbent
undergarment she'd had on at admission had been on for more than two hours, given that feces were
hardened and caked onto her skin.
The defense hypothesized that because Ms. Wiggins was postmenopausal, she'd had nonestrogenized
vaginal tissue that was fragile and susceptible to accidental bruising, as in an attempted catheterization
or rough perineal care. Yet according to her records, Ms. Wiggins was using hormone replacement
therapy, and the vaginal tissue would therefore have had some degree of estrogenization.
Defense witnesses.
The medical examiner testified that the cause of death was preexisting disease and added that the
vaginal trauma was from a botched catheterization-one of many he had seen in his career.

The nursing home LPN testified that she had tried to catheterize Ms. Wiggins and that although she'd
meant to record it, she'd been busy and had forgotten. But this was a different story from that offered
during her deposition, prior to the trial.

At deposition, no evidence was ever presented that a catheterization had been performed at the nursing
home. The director of nursing said that she didn't think anyone had performed a catheterization. No
catheterization kits had been checked out of the supply closet. The LPN said that she'd been unable to
perform a catheterization because another resident had died that evening and her responsibilities on that
case took much of her time. The assistant who would have helped her with the catheterization said she
hadn't been contacted about doing so. The LPN had asked that a hat be used to collect urine during the
day shift. The day shift did not perform a catheterization because Ms. Wiggins was up and dressed.
THE JURY'S DECISION
The jury came back with a verdict for the defense, deciding that the nursing home was not liable for
Ms. Wiggins's death. It rejected the idea that a traumatic injury was caused by a deliberate act, relying
heavily on the testimony of the medical examiner, who claimed to have seen numerous botched
catheterizations.

The jury rejected the police officer's testimony of bloody fluid on the sheets and believed defense
testimony that the fluids could be from sloppy wiping of the patient with povidone iodine (Betadine)
for the catheterization (believing that the orange fluid was mistaken for red blood). It rejected the
argument that genital trauma played a role in the death. And the jury believed the LPN, despite the fact
she changed her story about the catheterization three different times (never did it, tried to do it, did it
but didn't chart it).

A surprising discovery.
It was not until later, when the plaintiff's attorney talked with the jury foreman, that further insight into
the jury's decision was gained. The foreman told the attorney that the jury had wanted to award some
money to the daughter but felt that the wrong agency had been sued. The jury believed that the injury
was caused by a badly performed catheterization-one performed by the hospital's ED nurse and not by
the nursing home LPN. The ED nurse seemed hyperactive to the jury, with a rapid-fire speech pattern
and a tendency to answer a question before the attorney had completed it. They believed that the nurse
would bring this kinetic style into the workplace, that he would act quickly and be rough, sloppy, and
careless with patients. Because of this, they believed that he had bruised and cut Ms. Wiggins. The
foreperson also said that everyone on the jury agreed that the hospital had a less-than-perfect
reputation.

FORENSIC LESSONS
Nurses need a basic understanding of forensic nursing-in terms of collecting evidence, taking forensic
photographs, and testifying. There are protocols for the collection of evidence and for photographing
patient injuries. Every ED and ICU should have a camera available with measurement and color scales.
If called on to testify at a trial, nurses need to be prepared by the attorney. An attorney can teach them
how they should appear on the stand and what to expect on cross-examination.