76 y/o male patient presents to a freestanding ED at 0932 with complaints of 2 days of bloody diarrhea and 1 day of dizziness. Initial vitals reflect bp of 126/63 and temp of 36.2 c. Patient is alert and oriented. Initial blood draw at 0934 shows H&H at 8.0/23.7. The BUN and creatinine are elevated and the venous lactate is critically low at 3.2. Occult blood stool test is positive. EKG shows incomplete left BBB.
At 1000 the standing BP is noted to be 104/47,
ED MD calls hospitalist at another hospital in the system for admission at 1045. The hospitalist accepts admission and the admitting orders include medical telemetry, routine consultation with GI, Hgb q6 x 3 and Protonix 80mg IV B/D. Patient requires COVID negative test prior to transfer (it is negative). In the meantime, 1000ml NS bolus given at 1116.
At 1244 Patient is noted to have some SOB with mild exertion. 2 L NC given. At 1300 the vitals reflect BP at 136/70, HR- 92, RR-15 and 100% O2 sat. EMS arrives and transports patient to second facility at 1324. The BP at 1332 is 110/83. (Note: patient had hx of hypertension). Patient arrives at second hospital at 1345.
No repeat Hgb drawn at arrival. Patient is also not placed on telemetry. At 1604, a rounding nurse enters an order for Hgb to be taken in AM for each day of admission. The note is electronically signed at 1650 by a GI MD. However, it is not clear if rounding nurse signed for MD or if she was communicating with GI MD when she entered the orders. There is no consultation note either. The rounding nurse also entered an order for a CT scan of the abdomen/pelvis on an ASAP basis. The order is not cosigned by the GI DOC. (Note: the rounding nurse is an RN, not APRN.) The GI rounding nurse does not order a stat Hgb (last one was at 0934), repeat labs or blood products. Additionally, she does not order an EKG or recognize that the patient is not on telemetry as initially ordered. Finally, the vitals at this time showed a bp of 104/68.
Patient seen by hospitalist at 1830. He orders 1 unit of blood to be given routine. He also orders 1000ml NS. No Hgb done at that time. No EKG ordered. Patient is not on telemetry. Patient is noted to be alert and oriented.
At 2027, patient's bp is 105/54 and HR is 112. His RR is 20. The blood draw for Hgb is completed at 2038. The Hgb/Hct are 6.8/20. It does not appear that any additional fluids had been given since the initial bolus at the first hospital.
At 2130, the hospitalist is informed by the nursing staff that the patient is anxious. He issues an order for Ativan.
The unit of blood is ready at 2158 but not given immediately. The Ativan is given at 2203.
At 2248, the GI MD enters electronic orders to obtain consent for EGD for the next morning. He also issues standard order to hold any blood thinners. It appears these orders were entered remotely. Additionally, the asap CT scan ordered by the GI rounding nurse at 1604 had not yet been performed at that time.
At 2320, the patient's bp is recorded to be 96/57. His temperature is 36.1 c. He is also noted to be very agitated and complaining of not being able to breathe. Rapid response is called. The blood transfusion is started at that time.
However, he further deteriorated and code blue is initiated at 0011. Code sheets show Vfib initially. Despite resuscitative measures, patient dies at 0027. Death Cert completed by hospitalist reflects GI bleeding, acute blood loss anemia and hypovolemic shock. No autopsy performed.
In reviewing the facts, I am interested in a review of the case to address the following questions:
1. Was the death preventable had their been earlier blood administration or if patient was being monitored with telemetry?
2. Does the GI MD have any responsibility either individually or through his rounding nurse to order blood in a more timely manner?
3. Does the GI MD, individually or through his rounding nurse, have a responsibility to ensure that the patient is placed on telemetry and/or have another EKG completed?
3. Assuming the patient was only seen by the GI rounding nurse, was there a responsibility for the GI MD to see the patient himself that same evening? If so, in what timeframe?
4. Can a GI MD delegate responsibility to issue orders on his behalf to a registered nurse without communication regarding the patient?
5. Did GI team meet the standard of care.
Files:
No questions yet!
Do you believe there might have been medical error?
I believe the error lies in 2 areas (a) hospital transfer and possible failure to insure the patient was fully stabilized and monitored. The acuity may not have been conveyed or received and (b) the on call/in hospital team may have some responsibility for lack of timely monitoring and management. This would be the patient’s HOSPITALbased team (MD and RN in house), not the consulting GI
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Hypotension could have been caught earlier with monitoring and more attention
What makes you a good expert for this case?
Inpatient and outpatient mgmt of GI bleeds. Greater than 20 years experience; large hospitals who receive these transfers
How often do you encounter cases similar to this one in your practice?
Regularly see these patients, with bleeds in larger hospital centers
Do you believe there might have been medical error?
There was a lack of continuity of care from the initial hospital to the next, and the patient didn't receive timely workup or temporizing of his obvious GI bleed.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Earlier transfusion and more aggressive rehydration would have likely prevented the deterioration of this patient. He needed a bleeding scan or CT angiogram, presuming there was continued hematochezia (rectal bleeding).
What makes you a good expert for this case?
26 years of FT GI practice; we routinely see cases such as this daily at our hospital. I've performed over 25,000 endoscopic procedures; see c.v.
How often do you encounter cases similar to this one in your practice?
Literally very single week in the hospital.
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