A 70 y/o male underwent appendectomy 0n 7/2/2020.
Pathology revealed moderately differentiated adenocarcinoma of vermiform appendix, with the tumor invading through the serosa into the mesoappendix. There was no evidence of metastatic disease.
The patient remained in the hospital and 8 days later, the surgeon elected to perform a laparoscopic right hemicolectomy.
On the early morning hours of post op day 1, the patient began c/o of dyspnea.
The internist ordered a chest x-ray.
No VQ scan was ordered.
The patient had been on DVT prophylaxis for 8 days while in hospital (Lovenox) but there is no record of nursing checks of calves. (Presumably since pneumatic compression devices in place.).
On the evening of post op day 1 (12 hours after CXR), the patient suffered a massive PE which resulted in his death.
Files:
Q: how many days later did the patient die?
A: appendectomy 7/2. Hemicolectomy 7/10. Death-9:00pm 7/11
Q: what were the vital signs, oxygen saturation and CXR results?
A: O2 sats on 2l normal. CXR 10:48am on 7/11-subsegmental atelectatic changes at lung bases. 7/11 tachycardic 118-130
Q: How do we know the cause of death was PE? Was there a CTA or autopsy?
A: autopsy left deep vein thrombosis from popliteal vein and venous plexus of the calf muscle
Q: Complain of dyspnea on Post-op Day 1 is very common. Was the patient hypoxic? What was his SO2 and how much O2 did her require? What was his HR? What was his BP?
A: pt not hypoxic on 2L per NC. HR 118-130. BP elevated but consistent
Q: The title of this case is "Massive DVT". Was there LE Doppler done? If so, when?
A: Found on autopsy. No studies performed date of death except CXR.
Q: What was the dose of Lovenox and what was patient's weight?
A: Lovenox 0.4 q24H; H-72" W 241
Q: What did the CXR show?
A: CXR 10:48am on 7/11-subsegmental atelectatic changes at lung bases.
Q: Did autopsy also showed PE or only DVT?
A: —
Do you believe there might have been medical error?
The initial surgery was appropriate since the potential pre-surgical diagnosis was appendicitis. The second surgery was appropriate after the pathology was determined. Further colonic evaluation and resection of disease free margins necessary. The placement of DVT protection with Lovenox is appropriate. The only question is the dosing schedule and administered dose. The suddenness of the Massive Pulmonary Embolus that caused the death is unfortunate but it emanated from any source between the calf propagating all the way thru the inferior vena cava into the right ventricle and thence into the lungs. Did the patient have a preexisting and unknown coagulopathy such as Factor V Leiden or Prothrombin mutation ? We don't know. Bed ridden status for 8 days is certainly a cause for concern post-operatively but appropriate regimen for prevention was in place. Post op ambulatory status would also might have been appropriate provided no other reasons existed for the patient to remain recumbent. Checking for potential DVT on a daily evaluation would be an appropriate measure in spite of the other therapies in place. The potential for medical malpractice remains limited based on the questions posed above.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Bed ridden status for 8 days is certainly a cause for concern post-operatively but appropriate regimen for prevention was in place. Post op ambulatory status would also might have been appropriate provided no other reasons existed for the patient to remain recumbent. Checking for potential DVT on a daily evaluation would be an appropriate measure in spite of the other therapies in place.
What makes you a good expert for this case?
Hematology/Oncology Subspecialty and Internal Medicine experience.
How often do you encounter cases similar to this one in your practice?
Not uncommon but not frequent to see such unfortunate events
Do you believe there might have been medical error?
This is an interesting case and probably is incomplete in the data that I have reviewed. It sounds like staging was done with CT scan of chest abdomen and pelvis and no distance spread was found after the discovery of the cancer of the appendix. We do not know the cell type as to whether this was colonic type or mucinous or neuro endocrine but it sounds like garden-variety colonic type. In the absence of tissue staging, it was appropriate for the surgeon to schedule a staging laparotomy and anticipated right hemicolectomy with lymph nodes to be obtained planning at least 12 lymph nodes to be submitted to pathology. The patient was on preventative anticoagulation but it is unknown if he had any type of underlying coagulation defect other than cancer which predispose has one too thromboembolic phenomena. The big question in my mind as weather at the first sign of dyspnea the patient should’ve had a CT angiogram of the chest and initiated on much more aggressive anticoagulation. The laparotomy was necessary to complete staging and to decide if there was peritoneal spread even with the absence of metastatic spread to the chest abdomen pelvis on CT scan. Lymph node status was essential to determine if the patient required postoperative chemotherapy. The error was not obtaining a CT angiogram at the first evidence of deterioration in respiratory status
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Early intervention could have averted this patient’s demise after quick identification of a pulmonary embolus of severe nature
What makes you a good expert for this case?
I see these cases all of the time and have expertise in G.I. malignancy where I trained at Georgetown university medical center and see Venus thromboembolic phenomena occuring all the time in the context of cancer
How often do you encounter cases similar to this one in your practice?
Four or five times a year but quick intervention usually averts patients demise
Do you believe there might have been medical error?
Although there is not enough information to make a clear judgement form the case, the patient's history of cancer and recent surgery, the lack of other history to explain a sudden dyspnea exacerbation and presentation with short of breath put PE very high in the differential diagnosis list. The fact that the patient was receiving Lovenox is not a sufficient reason to rule out this diagnosis. If the patient was tachycardic, hypotensive, hypoxemic, had acute dyspnea onset and/ or the chest XT was normal , the case for PE would be even stronger.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Based on the above justification, prompt PE/DVT diagnosis would have resulted in anticoagulation and/or IVC filter placement, depending on the postoperative bleeding risk. Any of those interventions could have prevented death if the death occurred form a recurrent PE. If the initial PE resulted in death, one would expect a very rapid patient deterioration (which is not clear from the summary) and appropriate actions such as ICU admission, fluid resuscitation, interventional radiology/cardiothoracic surgery consultations
What makes you a good expert for this case?
I am surgical intensivist and, therefore, I see cases such as these frequently. Furthermore, I work as a surgical intensivist in an orthopedic hospital, where the incidence of DVT/PE is very high. I have also presented in two Grand Rounds at an NYU hospital on the topic, "Venous Thromboembolism in the hospital setting" and "Advances in VTE".
How often do you encounter cases similar to this one in your practice?
As described above, I frequently encounter similar cases.
Do you believe there might have been medical error?
The patient was already on 2 modalities of DVT prophylaxis. She was on injections q 8 hourly, most likely heparin and second pneumatic compression device.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient had failed 2 modalities of DVT prophylaxis. there is no 100% protection. if there is a massive DVT, the nurse should have at least checked the pulse, if she could check the calves with the pneumatic compression device. Massive DVT will cause a feeble pulse to undetectable pulse. if there is no documentation, she did not check it. that's a deviation of SOC with nursing. if she checks it and documented there was a pulse, this is questionable and can go either way. hope this helps.
What makes you a good expert for this case?
I have done several cases of defense and plaintiff work in MA, NH, NY, and FL.
How often do you encounter cases similar to this one in your practice?
at least 4 of them. over the past 6 years.
Do you believe there might have been medical error?
Thank you for answering all my questions. From the information provided, it appears that patient was hemodynamically stable (normal/elevated BP and O2 saturation). Feeling of dyspnea post-op day 1 is very common, as most patients have some level of atelectasis after surgery, as reported on the CXR as well. The Tachycardia may need to be investigated further if it was new or present post-op. Tachycardia could be viewed as symptoms of post-op pain (in combination with elevated BP). On on the hind side, now can be related to the PE. Therefore, based no this data, I don't feel there are enough clinical warning signs for the physician to pursue further testing for evaluation of PE. However, there is no report of lower extremity edema or pain (unclear if it is not mentioned here, or not examined by the team). If patient had lower extremity edema or pain, then a doppler would've been indicated. For that reason, I mark this as "Very unlikely" instead of "Definitely No"
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Patient with obesity (BMI 32), in patient with over one week of hospitalization, and malignancy is at high risk for developing DVT/PE. This condition was not related to medical error or injury.
What makes you a good expert for this case?
As a board certified Internal Medicine and critical care physician, I work at cardiovascular ICU. I take care of many patients with large pulmonary embolism and extensive DVT on a regular basis which require advanced treatments such as thrombectomy or thrombolysis treatments. and mange these patients. As Intensivist, may role is to diagnose, treat and on sometimes revive these type of patients.
How often do you encounter cases similar to this one in your practice?
I see several patients every week which are admitted for extensive DVT, PE or arterial occlusion. We provide advanced treatments such as thrombectomy, thrombolysis, bypass procedures and so on for these patients.
Do you believe there might have been medical error?
I am an niternist and a hematologist. Appendiceal cancers cause increased clotting as does postoperative immobilization. It is worthwhile to review what prophylaxis was done or not done before and after surgery.. Lovenox is usually held before surgery- was it put back after surgery and was it actually administered and at what time?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes, the patient died, and that is the worst possible outcome. His baseline prognosis from appendiceal cancer should also be assessed.
What makes you a good expert for this case?
The Hematologist/Oncologist who wrote this review had been Associate Professor of Medicine while a full-time attending at the University Hospital of a Medical School until 2009. Prior to 2004 had been an Associate Clinical Professor of Medicine. He is currently in private practice. He is first author of over thirty academic articles, chapters and several books. Over the past two decades he held the positions of Interim Chief of Hematology and Oncologyat a Medical School, Director of the Cancer Center at a teaching community hospital; Chief of Hematology and Oncology and Chief of Service at a large municipal Medical Center and concurrently Director of the Cancer Center of several hospital in a network; and Co-Director of Oncology at an affiliated University Hospital and Medical Center. He developed and ran two clinical research programs as well as a community advocacy group, a consulting group, and a non-profit educational institution. In addition to Internal Medicine and Oncology, the reviewer is Board Certified in Quality Assurance and Utilization Review and holds an MBA. He was listed several times as the best in his specialty by the Castle Connolly Guide to Americas top Doctors.
How often do you encounter cases similar to this one in your practice?
Perioperative DVT is common and I see about one every other week.
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