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.