Four year old girl taken to pediatric emergency department on three consecutive days for abdominal pain, nausea, and vomiting in September 2018. On the third day she was diagnosed with a perforated appendix with multiple abscesses.
A quick summary of the first two presentations follows:
9/26/18: Patient’s parents report fever of two days followed by one night and day of vomiting. Abdominal examination is documented to be normal. No labs or imaging were ordered but Zofran was ordered and the patient discharged – the diagnosis was gastrititis. The patient was seen by a resident and attending.
9/27/18: Patient’s parents reported that their daughter had been diagnosed with a stomach virus, pain with urination, continued abdominal pain and vomiting. The abdominal examination charted indicates no signs of surgical abdomen. The physician ordered an abdominal series, 3 views, with the radiology impression being ‘Fecal stasis. Mildly prominent small bowel loops. No free air. No active disease. CRP was elevated at 4.1. WBC – 13.20. No ultrasound or CT abdomen was ordered. Patient discharged – diagnosis gastroenteritis and constipation.
Ultimately, the patient was admitted through the emergency department on 9/28/18 for a ruptured appendix resulting in four surgeries during a two month long admission.
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Do you believe there might have been medical error?
First visit, probably no deviation from standard of care - would need to review records Second visit, most likely deviation from standard of care. It was a "bounceback" visit that should raise some red flags and encourage a more thorough workup. There are some simple scoring tools to assess likelihood of appendicitis that are well known. Again, would need to review labs and vital signs to assess further. Fairly classic missed appendicitis diagnosed as gastroenteritis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Obviously the appendicitis led to the perforation. Delay in diagnosis is the main reason for a perforated appendix.
What makes you a good expert for this case?
I am a straight shooter. I will let you know the strengths and weaknesses of your case based on the medical records and literature. Reports are detailed with citations from the medical literature to back opinions.
How often do you encounter cases similar to this one in your practice?
pediatric abdominal pain is seen every week in my emergency department.
Do you believe there might have been medical error?
On the 2nd visit, an abdominal U/S should have been done. It is an easy, painless test without radiation exposure. Any child that returns to the ED with abdominal pain needs to have an appendicitis ruled out. Plus there was elevated inflammatory markers (WBC and CRP) on the 2nd visit which are non-specific but signs of trouble in a returning patient. As a good surgeon taught me, “Never bet against the appendix” especially in children.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the appendicitis was picked up sooner, it was most likely not ruptured with the mildly elevated inflammatory markers. When the appendix is ruptured, the WBC count is typically >20,000. Without rupture, no abdominal abscesses typically.
What makes you a good expert for this case?
26 years of experience with 24 yrs in the pediatric ED. Also, I am an editor and writer for evidence based medicine.
How often do you encounter cases similar to this one in your practice?
Very common, unfortunately. Appendicitis is a difficult diagnosis especially in pediatrics but the ability to perform a quick ultrasound helps.
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