In this new series, we will present malpractice quandaries and give you, the reader, the chance to voice your verdict.
A 30-year-old female with a history of hypertension and gastric bypass surgery was transported to a busy urban ED by ambulance for acute onset of abdominal pain an hour prior to arrival. The pain was severe, radiated to her back, and was associated with multiple episodes of non-bloody emesis. She had no fever, chest pain, trouble breathing, change in bowel movements or other complaints.
The triage nurse documented an obese woman screaming in pain and holding an emesis bag. Vital signs were temperature 98.4, blood pressure 108/54, pulse 115, respirations 24, and pulse ox 100% on room air. Pertinent physical exam findings noted by the physician included active vomiting with diffuse abdominal tenderness and no rebound or guarding. Labs including CBC, metabolic panel, UA, pregnancy test were ordered and the patient received ondansetron 8 mg IV and hydromorphone 2 mg IV. Thirty minutes later, the patient was still in severe pain so she was given a second dose of hydromorphone 2 mg IV after which she appeared more comfortable.
About 90 minutes later, the labs were returned showing a WBC of 16 with a left shift and 18% bands. Metabolic panel was normal except for bicarbonate of 17, and UA/UCG were both negative. A CT scan with IV and oral contrast was then ordered and was performed two hours later. Results were called to the physician 40 minutes after the exam had been completed and showed a high-grade bowel obstruction with possible internal hernia and no free air. By this time the patient had been in the emergency department five hours. Her blood pressure had dropped to 94/43 and she remained tachycardic with a pulse of 123. A surgical consult was called and an NG tube and fluid bolus of 2 liters normal saline were ordered. The surgical consult noted that the patient’s blood pressure had dropped to 82/36 and that she had a rigid abdomen. Recommendations included a Foley catheter, pressors, IV fluids, pre-op antibiotics, and emergency surgery once the patient was stabilized. After two more hours, the patient had not improved and she was taken to surgery hypotensive – 8 hours after her arrival. She died in the OR prior to the first incision.
An autopsy showed that the cause of death was small intestinal necrosis due to strangulation from an internal hernia. This hernia was thought to be due to the patient’s prior gastric bypass surgery.
The patient’s family sued and the case went to trial. The plaintiff’s emergency medicine expert criticized the delays in the patient’s care as leading to her death – including failure to order imaging on arrival for a patient presenting by ambulance with severe pain and multiple risk factors for bowel obstruction, failing to order immediate IV fluids, failing to call the surgeon on the patient’s arrival, and allowing a sick patient to wait 2 hours for a CT scan after it was finally ordered. The defense emergency medicine expert argued that the patient’s presentation, including the initial vital signs and presentation by ambulance for severe abdominal pain, was actually quite common and most often due to non-serious causes of abdominal pain. The expert also noted that delays in care were quite typical for patients with abdominal pain being seen in a busy urban emergency department. In addition, the defense surgical expert argued that even with perfect care, this patient would have died from her severe internal hernia complicated by ischemic bowel.
Did the physician’s care represent “reasonable practice” or did inappropriate delays cause the patient’s death? Comment below.
21 Comments
Unbelievable statements from an “expert ” criticizing this care.
Are we now responsible for immediate diagnoses?
Sad outcome, not malpractice.
Totally agree with Robert. Sad outcome, not malpractice.
We see undifferentiated abdominal pains, chest pains, headaches, etc… If patient arrived with a note on their foreheads saying “Acute Bowel Ischemia” “Pulmonary Embolism” “Shunt malfunction” etc., then we wouldn’t need doctors. Even lawyers could treat patients!
Sounds entirely reasonable and appropriate to me. We are taught that bariatric surgery patients should always get IV and oral contrast and this takes at least 2 hours. Does not sounds like plain films would have shown anything and physician’s documented exam does not suggest acute abdomen. Calling the surgeon on arrival for every patient complaining of severe abdominal pain is laughable. Perhaps the only thing that should have been done differently was faster administration of IV fluids.
I would want to know what is the typical wait time from ordering to completion for CT scans in order to know if it was inappropriate. If that is the customary time for that ED, then it is a system process problem to be handled by the facility director or such, and not the “blame” of that ED physician in this particular case. Regarding the allegations of not being timely by trying medications first and not getting surgical consult right away, we all know that is hyperbole and neither of these things are routinely done. Certainly if there is presentation of an acute abdomen on presentation, then a surgical consult is done promptly, but it would not sound to be such the case on the initial presentation for this patient. Especially in the current atmosphere of trying to reduce/ “think hard about” ordering CT scans, it would not be appropriate to scan every abdominal pain patient right away (about 15-20% of our patients).
There are lot of things missings in this case. Before judging the Emergency Physician used correct judgement in assessing the patient and giving appropriate treatment.
In this case I would like to find out the type of gastric bypass was done and how frequent the patient had this problem.
Patient that is screaming with pain, with normal vital signs, it is reasonable to give pain medications and reevaluate the patient.
What is missing here is the status of bowl sounds and lactic acid.
The delay in processing this patient to come to final Dx is not unreasonable,
Unfortunately in our culture of hysterical and over dramatic patients who abuse EMS this case was easily overlooked. Gastric Bypass patients frequently have psychological issues as well. That makes it very difficult. I agree the delays are not atypical for most busy urban ED’s. That has to do with the large number of routine work ups we do for “those who can get care no where else”, or those who “deserve convenient care when they want it”…as long as we are the outpatient work up center for all the lazy primary care providers who send everything they don’t want to sort to us, this is going to happen. Why is anyone surprised. Maybe Radiology and the hospital are more responsible as they don’t give us the tests as fast as we order them. I dream of a world where I get a CT as fast as I get a pain score. What is THEIR role to support us if we are there to order tests immediately when the patient arrives. What if we could get a urine analysis in the first hour of a patients arrival? What if all test we ordered were resulted in less than 2 hours from when ordered? Did this ED physician have any of this under his control? This follows the mentality of lets CT everyone. What happened to choose wisely? Honestly, I see 5-8 patients every shift with complex histories and abdominal pain. 5 hrs from arrival to ct and clear diagnosis isn’t out of the normal. I had an 18 yr old female patient with 8 hr work up for appendicitis. Spoke no English, but I knew exam was suspicious but not classic and history was not great. Basic labs and urine and hcg all normal. US ordered, non diagnostic for appendix and small cyst, so CT ordered, was diagnostic acute appendicitis. I’m glad I didn’t discharge her with US as the end my patients work up . Given our all of the issues that surround this case in question I’d say it was typical and that the tests and linear progress of work up seems logical albeit less timely than retrospective analysis would indicate. I am a bit confused though by the surgeon and his lack of immediate transfer to OR if he thought the patient was that ill.
It is interesting that oral contrast was used. That likely accounted for much of the 2 hours it took to do the CT. Unfortunately there are still radiologists who insist on this despite evidence that it is rarely useful.
This should clearly be a defense verdict. If it was, the plaintiff’s whore should be fined for an incorrect
hindsight bias opinion and dragging one of his colleagues through the malpractice mud. If there was a plaintiff verdict, it should be appealed . I have won this type of case before as an expert.
This is a very easy case to second-guess (especially with the relative hypotension in a pt with baseline hypertension) but putting myself in that department — or that patient in mine — I can easily see the case unfolding just this way with the same awful outcome. I agree with the surgeon – few ways to see this going right.
Not optimal, but reasonable. I know that plain film x-rays rarely change management, but in this case might have been able to provide a more rapid diagnosis of the bowel obstruction. Also, the literature shows that oral contrast is not needed for Emergency Department patients, and a non-contrast CT could have been obtained more quickly.
Step by step managment for this case is right. But i think that an abdominal xary and upright cxr make that Ep a quicker diagnosis. I agree with that surgeon about prognosis. Busy ED is not a reason for delay in managment for the court , unfortunatly .
Sad to hear.
1). Imaging should have been ordered on pt arrival. IV contrast only should have been sufficient. We all know these results take time to return, so order early,
2). The surgeon should have been notified of pt’s presence immediately after leaving the room by the ED doctor, no excuse. They want to be called EARLY not late.
3). This a case where a serum lactate could have given advanced warning as to how serious the underlying cause of illness was. I usually despise their use because of so many false positives, but it would have been quite helpful here in avoiding her demise.
3). Fluids, fluids, fluids. Not enough to induce CHF, but get and keep them going! No excuse there either.
4). PAIN CONTROL! If this woman was screaming or writhing in pain, for God’s sake, medicate her! If she is obese she will need more than a normal sized person. Just saying.
Sorry, but this was really a big mess.
Unless she had a peritoneal abdomen on initial exam it would not be usual practice to call a surgeon immediately where I work.
Sorry but I disagree on each point. Unless you have peritonitis no surgeon would even talk with me let alone come to the ED. Even if you do have perotinitis you’ll still probably run them through the scanner on their way to the OR. This patient did not have perotonitis so calling a surgeon right away is just not needed. If you work in such a place where a surgeon would come down to see a patient immediately with “severe” abdominal pain then I would both love and hate to work there- love it because they would wisk away the serious patients quickly, hate it because it would slow down my dispos of the dozens of “severe” abdominal pain that I see each week that have nothing. If radiology insists on oral contrast then what can you do? There were probably more serious patients waiting for the CT scanner than someone with a soft abdomen. Serum lactate is only elevated once there is severe disease and portends a nearly 100% mortality once it is elevated. Could a serum lactate have changed things if it was elevated- maybe but serum lactates on everyone is a waste of time and money and the surgeon’s response still would have been “what does the CT scan show”. And finally she got medicated a lot more aggressively than most with 2mg dilaudid x2 with the second dose coming 30 minutes after the first- that’s nearly heroic pain control in an urban ED (and a little overly aggressive for my taste- I would have done 1+1 but that’s just me). This was appropriate care given system limitations with a bad disease- some patients are just too sick to be saved.
Reasonable care. Addition of lactate may have given earlier indication of impending dead gut but that may have been normally initially anyway. Patients do not always present with rigid abdomens initially and obese patients are difficult to declare as rigid. Most of the patients we see yelling in pain wind up not having severe pathology and thus necessitate a work-up prior to calling specialists. 4 mg of dilaudid is in no way ignoring pain. Our surgeons usually want PO contrast, especially in people with complicated surgical histories. Literature may be changing that practice but it is not across the board and no expert should say it is. Question of how aware ED doc was of lowering BP but how many of us have been running through a busy shift and not being notified of VS changes? Fluid could have been given but that was not the definitive care needed. Not sure about delay in going to surgery. Why wait in ER two hours to be “stabilized” when pt needs OR now? Overall reasonable care though unfortunate outcome.
Unfortunately not an uncommon scenario (busy ED & complaint of abd pain) which should have some bearing on a verdict. There are early indicators of sepsis (fluids should have been administered earlier) and an obstruction series could have helped (would have given some objective evidence to have the surgeon involved earlier). I don’t agree with the comments above that a surgeon should have been called immediately & what does a patient arriving by ambulance have to do with her management (clearly the plaintiff’s expert trying to misdirect/inflame the jury). Don’t understand why the delay by the surgeon in going to the OR either. No way to tell if the death was preventable and care was not unreasonable but my gut says that if not a defense verdict then the hospital, surgeon & EP probably all had to settle or split the damages.
Why wait for labs to come back before ordering a CT in a case like this? How would they change management? A patient with gastric bypass history and a presentation described above is at high risk for bowel obstruction. Also, why oral contrast? According to the most recent guidelines from the radiologists, oral contrast is not required to diagnose bowel obstruction or most of other serious acute abdominal conditions. A case like this warrants early surgical involvement. A more reasonable course of action would be to order CT with iv contrast only right after evaluating the patient and giving heads up to the surgeon. Personally, I would get obstructive series while resuscitating/waiting for more definitive test to get done to be able to make a stronger case to the surgeon hoping that he/she might be convinced to be more aggressive and take the patient to OR based on the clinical picture and obvious signs of obstruction on plain x-rays without waiting for CT to get done. I patient with the given previous surgical history and the given clinical presentation requires aggressive management. Hard to make a case here that the care was reasonable.
Good care was provided. Standard of care, as well. You cannot CT everyone with 10/10 abdominal pain. She was given a god work up that moved forward in a step by step approach. Sad outcome. Sad the ED doc is being sued. Nothing done in this case is anything I would do differently. I do this 10 times per day, on shift.
I had to read all the comments to see if I felt as though I could add anything of value, and even though I can’t, well, here I am anyway. This sounds like appropriate care. I probably would have done a screening plain film KUB initially, since I find that- for myself- I’m better at seeing dilation/free air on a plain xray v a CT scan. Our radiologists and we agree that virtually all pts undergoing abd/pelvic CT need oral con only if 1., BMI <20, hx of IBD, hx of prior abd surgery, so this pt would have received PO contrast in my dept. I definitely agree that it would be functionally impossible (and inappropriate) to call surgeon empirically on every "severe" abd pain pt or to expect that the surgeon would do anything (in this modern age) to a pt without an antecedent CT scan. I will say that it speaks to Mark Plaster's (and others, I suspect) effort to change the notion of "standard of care" to "reasonable care". There are many ways to get from "here" to "there", and this ED physician chose a perfectly defendable to get to a diagnosis A bad outcome is not prima facie evidence of bad decision making.
Sorry to disagree with all the above who say the care was appropriate but it wasn’t here’s why:
EMS CARE. They note “severe” abominable pain, acute onset ( embolus, rupture, obstruction, dissection, infection) all come to mind instantly , radiating into her back, multiple episodes of vomiting and the gave her an emesis bag (indicating continuing vomiting or nausea [ can’t take orals]
TRIAGE CARE: grossly abnormal vital signs, RR. 24, HR 115, meeting initial considerations for S.I.R.S. criteria which automatically triggers the need for I.V. Fluids to see if sepsis or septic shock is present or pending . All that is needed is two of the criteria and elevated temperature is not one of them
Her temperature was normal but with a respiratory rate of 24. She could be abnormally normal from mouth breathing. A rectal temp would have been better especially since we don’t know how cold it was or if this patient had received ice chips or cold drinks before calling EMS.
ED CARE
Treating Nurse
should repeat such obviously abnormal vital signs to see which way they are trending and report these to treating doc
MD CARE
THE WORKUP
The labs and test ordering were almost but not completely ok. Although there is a lot of controversy about ordering an obstruction series as being useless but it is incontrovertible that if free air or a severe bowel obstruction is seen on the OBS, then the treatment, consultations, and orders on the patient will change radically. From the routine ct. scan of abdomen/pelvis. Yes I know surgery will still want a CT scan. All the things ordered two hours plus later after waiting for the ct. with oral contrast and it read by radiology, in a patient with nausea requiring 8 mg of IV Zofran could be ordered and in the patient hours earlier before labs come back showing severe sepsis already present.
Physical exam often does not provide a diagnosis or great indicator for treatment. But vomiting with continuing nausea by itself would indicate a need for IV fluids just to help the patient feel better.
BUSY URBAN ED.
So what! Most are, if it’s too busy for the amount of staff present, get more, or set up protocols for common situations like this where the nursing staff can initiate standing agreed upon flow orders starting IV fluids etc. This is a system problem.
SORRY FOLKS. If you gamble sometimes you lose
WHAT WAS THE REASON FOR NOT STARTING IV FLUIDS?
The main issues in the care of this patient is recognition, at triage, of a potentially fatal disease and early notification of the on call surgeon. Any patient who has had gastric bypass surgery who presents with severe abdominal pain radiating to the back with vomiting and diffuse abdominal tenderness has a mesenteric volvulus until proven otherwise. The patient will only develop signs of peritonism (rebound/guarding) once the bowel is infarcted or perforated. By then it is too late, in many cases, to save the patient. This is why the mortality rate from mesenteric ischaemia is still so high (>50%). A properly trained surgeon or an experienced staff specialist in Emergency Care would be expected to recognise such a pattern of presentation. The only person who can rescue a patient with a mesenteric volvulus is the surgeon.
Lactate levels are often not elevated early in the course of a volvulus and should NOT be used as a discriminating test. Because the arterial inflow AND mesenteric venous return from the bowel are occluded with a mesenteric volvulus, the lactate level may be only marginally elevated until the patient develops secondary hypotension and organ failure.
This condition represents a time critical illness just like AMI, Stroke/CVA or multi trauma. A Faculty Triage with notification of the Consultant Surgeon/Surgical team at time zero should happen just as in any of these other conditions. There are mandated time lines for PCA/stent in AMI, interventional radiology/stent in CVA and ATLS resuscitation of multi trauma patients which have resulted in improved morbidity and mortality. For example, the American Heart Association/American Stroke Association Guidelines mandate a door to physician time of <10 minutes, door to stroke/cardiology team <15 minutes, door to CT scan <25 minutes and door to CT interpretation of <45 minutes. This is standard of care. I disagree with the argument that a busy urban hospital cannot apply the same principle to a the assessment of /intervention in a surgical abdomen.
The recognition/treatment of a patient having a stroke or AMI relies on patterns of symptoms and signs, degree of suspicion in a high risk patient and appropriate triage, escalation of care and specialist referral. The same applies to patients who present with an acute abdomen. I believe the surgeon should be given the opportunity to salvage such a patient at triage, NOT 5 hours later. I acknowledge that it is easy in retrospect to be critical of patient care, but patient care will only improve if faculty triage, treatment algorithms and standard of care protocols are in place for patients who present with acute abdomens.