On Friday April 6, 2018 at around noon Mr. A. presented to his primary care physician Dr. B. with complaints of lower abdominal pain which had started 6 days earlier as well as decreased appetite, nausea, early satiety, weight loss. Vital signs T 97.9 F, HR 89/min, BP 131/68 mmHg, RR 22/min, pulse ox 95%. Dr. B. noted that the abdomen was distended and tender to palpation in the left lower quadrant and ordered a STAT CT abdomen and pelvis (CTAP) with contrast.
The CTAP was completed on the same say at 3:15 PM, but apparently only reviewed and reported by The radiologist Dr. C. on Monday April 9. The CT revealed a large abscess in mesentery of the left lower abdomen, adjacent to loops of small bowel, measuring 9.9 x 6.4 x 5.1 cm. Within the abscess small collections of gas were noted, along with extravasated oral contrast material from the small bowel. Dr. C. further documented that “Case was discussed with Dr. B. on the morning of April 9.”
On April 9, 2018 Mr. A. presented to the ED with worsening abdominal pain. He was found to be septic (respiration rate 27, heart rate 119, WBC 16.5, bandemia 22%) but not in septic shock (blood pressure 169/82 off pressors). A CT that day at 8:32 AM revealed an extraluminal fluid collection in the left lower quadrant, about 9.3 x 6 cm, adjacent to the mid and distal descending colon, most likely a large diverticular abscess, and a moderate amount of free fluid in the pelvis and inferior abdomen.
Given those findings, Mr. A. was brought emergently to the OR for an exploratory laparotomy, which revealed free pus in the peritoneal cavity, as well as an inflammatory mass. According to the operative report, this intra-abdominal infection was originating by some small bowel pathology, and a small bowel resection was performed. Interestingly enough, pathologic examination of the surgical specimen did not reveal any abnormality of the small bowel, and specifically did not demonstrate any perforation or areas of ischemia.
Mr. A.'s post-operative course was complicated by prolonged endo-tracheal intubation (4 days) as well as temporary non-oliguric acute kidney injury which resolved very quickly: creatinine level raised to 2.1 on post-op day #1 but had already returned to 0.99 by POD #3. The remaining post-operative course was characterized by a slow recovery but no other significant complications.
On POD #16 Mr. A. was discharged to an acute rehab, but then transferred back to the hospital two days later, with abdominal distension, worsening abdominal pain, WBC 20K, and creatinine 1.2. A CTAP with contrast demonstrated interval development of a new abscess cavity. He was treated with the antibiotics Zosyn and Vancomycin and IR drainage. Of note, Vanco serum trough level increased rapidly to 45 µg/mL. At this time Mr. A.’s creatinine levels increased rapidly, and plateaued to 10.41. The progress notes indicated that this episode of acute kidney injury was due to acute tubular necrosis resulting from dehydration, IV contrast, and antibiotics.
Two weeks later, Mr. A. was transferred again to an acute rehab, and required three treatments with hemodialysis, but his kidney function then improved at the point that hemodialysis was no longer required.
Was the primary care physician negligent in not following up on the CT until Monday? Was the radiologist negligent in not reading immediately the CT ordered STAT? Since an intra-abdominal infection was already present on Friday April 6, did Mr. A. suffer any damage from the 2-day delay in diagnosis and treatment?
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Do you believe there might have been medical error?
Yes and Yes to both questions. Patient showed signs of intrabdominal pathology, which was serious enough for the primary physician to order STAT CT scan. STAT tests and imaging should be completed within an couple hours. Which means the test must be done, resulted and the result to be reviewed. There was significant delay in reporting the CT scan. In my opinion, a physician who orders a test is responsible to follow up with the result. Did the PCP notify the radiologist about the stat CT that needs to be reported immediately? Did the PCP call to follow up on the test result before closing the office for the weekend? Did the PCP knew that the image result will not be available until Monday? If PCP knew that the result will not be available until Monday, patient should've been sent to the ED immediately or directly admit the patient to the hospital for immediate evaluation and management. Also, it sounds like the CT scan was done as outpatient, probably in an imaging center. What kind of protocol are in place at that imaging center regarding stat orders? Does the staff notify the physician when they receive a stat test? An imaging center that is performing a STAT test, should take responsibility to report it as soon as possible and not to delay the test for almost three days. The radiologist knows the significance of these findings and even if the radiologist cannot reach the ordering physician, he/she should've notified the patient and advised him to visit ED immediately.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There was significant delay in acting on a test that was thought (appropriately) to be urgent. This patient should've been admitted to the hospital and most likely undergone surgery on Friday the 6th.
What makes you a good expert for this case?
As a board certified intensivist, I manage many patients with intraabdominal infection, sepsis and septic shock on a daily basis.
How often do you encounter cases similar to this one in your practice?
I see and manage multiple patients with sepsis and septic shock on a daily basis and I manage multiple patients with intraabdominal infection on a weekly basis.
Do you believe there might have been medical error?
1 Since the original ordering physicianDr.B ordered the CTAP “STAT” he was implying that results were needed immediately to help make the diagnosis for appropriate treatment ; 2. The radiologist DrC reading a STAT request should have notified the ordering physician on the same day that the CT was done.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Delaying making the diagnosis delayed starting treatment; which then requires more aggressive treatment modalities and allowed the original condition to become worse.
What makes you a good expert for this case?
I have participated for 0ver 10 years on a Risk Assessment panel goes my malpractice carrier. There are exactly the type of cases that we review
How often do you encounter cases similar to this one in your practice?
Decisions to order CTAP occur weekly In my practice ; we have procedures in place to avoid this type of event from happening
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