A 34-year-old male went to urgent care around 10 am, complaining of right upper quadrant pain that had started at 4 that morning and was worse with movement. He denied any nausea, vomiting, or diarrhea. Initial vitals were BP 131/84, pulse 67, respiratory rate 18, O2 saturation 98% on room air, temperature 97.2.
On examination, his abdomen was soft, with mild tenderness in the right middle quadrant, and no rebound, guarding, masses, or distention. An EKG was normal. A CBC showed that the patient's white blood cell count was 12.1, his AST was 38, and GGT was 72.
An ultrasound of the right upper quadrant was normal, except that the pancreas was not visualized secondary to overlying bowel gas. A CT abdomen without contrast was read as showing no acute pathology, but the report did describe a "mildly dilated, air-filled appendix with several appendicoliths," with "no periappendiceal inflammatory change." Clinical correlation was advised.
The patient was treated with IV fluids and 30 mg of Toradol. His pain did not improve, so he was given 4 mg of IV morphine at 11:23. He was discharged home in "improved" condition around 1:30 pm, with instructions to return "immediately if worse in any way."
Four days later, the patient did return, complaining of no improvement in his right upper quadrant pain, new left upper quadrant pain for the past 2 days, and being unable to keep anything down. He was found to have perforated appendicitis and peritonitis with septic shock.
He was taken for an exploratory laparotomy, emergency appendectomy, and abdominal washout shortly after arrival. Operative findings were described as "A necrotic, perforated appendix with a large amount of purulent fluid throughout the abdomen with marked peritonitis." He spent some time on a ventilator and on pressors, but was eventually weaned off both and moved to the floor. He had later problems with wound dehiscence and infection, requiring a wound VAC for over 3 months, but he did finally make a pretty good recovery.
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Do you believe there might have been medical error?
To begin with, a few pieces of clinical information which I discuss below are necessary to answer the question with more certainty. This is a difficult case as the CT findings are equivocal but not normal. A dilated appendix with several appendicoliths could represent early appendicitis, even without periappendiceal inflammatory changes, in the setting of right sided abdominal pain and a mild leukocytosis. This is certainly not a classic case of appendicitis. Did the emergency physician discuss the case with the surgeon on call or ask for a consultation? Additionally, was close followup arranged or even recommended? The standard "return if worse in any way" is not sufficient; a followup should be arranged, or the patient should be instructed to return to the ED for recheck. The patient did not present until 4 days later with perforated appendix. Standard of care in my shop would be to discuss the case with the surgeon and ask them to evaluate the patient in the ED, and even if discharged home, a 24 hour followup examination, which could have demonstrated more convincing signs of appendicitis on exam or repeat labs (increasing leukocytosis). If the above measures were completed by the physician in the ED, then it is my opinion they did their job appropriately.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Similar to my above discussion, it is reasonable to suspect the patient's symptoms and equivocal CT findings were indeed the early stages of appendicitis. So if the emergency physician did not involve the surgeon and/or arrange close outpatient followup, that action led to the delayed diagnosis of appendicitis and the severe complications which would have been avoided if the patient had had an appendectomy earlier in his clinical course.
What makes you a good expert for this case?
I am a practicing emergency physician in 2 high volume/high acuity emergency departments with over 24 years of ED and urgent care practice experience. Evaluation and diagnosis of appendicitis in the ED is something I have extensive experience with and am comfortable commenting on the care in such cases. In addition, I recently began work as an expert witness this year and have been retained on several cases, While I have not yet testified as an expert in deposition or trial, I have extensive experiencing testifying as a percipient witness throughout my career and am comfortable in that environment. I will be deposed on one of the cases I am working on shortly, and the others have involved oral and written reports. In preparation for my work as an expert witness, I completed a medical expert witness training course through SEAK in February 2022.
How often do you encounter cases similar to this one in your practice?
I evaluate patients with suspected appendicitis very frequently, nearly every shift I work. I have seen unusual presentations of appendicitis on many occasions. As I often say, patients don't read the book on appendicitis so the classic presentation is not always the case, requiring high index of suspicion to diagnose those unusual cases.
Do you believe there might have been medical error?
Right-middle abdominal tenderness, elevated WBC and the CT findings should ideally have triggered a surgical consult. However, it is likely that the surgical service would also have recommended discharge. The discharge instructions are not very specific to the case. It would be important to know what was discussed with the patient in addition to what was written. However, it seems that the patient did not follow the instructions and did not return "immediately" once he "worsened" - with an earlier presentation to the hospital on the second visit, his case would have likely had a better course.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Had the patient followed the (admittedly poor) return instructions, he likely wouldn't have experienced this complicated and life-threatening course. It is unlikely that even with a surgical consultation this patient would have received different care on the first visit (e.g. admission for observation or surgery would have been unlikely).
What makes you a good expert for this case?
I see patients similar to this patient on his first visit quiet frequently. I can speak to the role of surgical consultation and the importance of a thorough discussion of the follow-up care/return precautions.
How often do you encounter cases similar to this one in your practice?
I would estimate that I see a case similar to this patient on his first visit about once or twice per month.
Do you believe there might have been medical error?
Patient presented with symptoms of likely early appendicitis. His CT did not show definitely appendicitis. His labs don't support appendicitis either. If the patient is able to eat and drink then he needed good return precautions to return to worsening pain, vomiting, fevers, etc. It took 4 days for the patient to return.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I dont think there was an error. I think that with good return precautions (I would like to see them) the patient would have come back sooner. Morphine can mask pain but not for 4 days. I believe the patient would have been having worsening symptoms over those 4 days but did not go to the ER for them.
What makes you a good expert for this case?
I work in the ER and see patients with similar presentations all the time.
How often do you encounter cases similar to this one in your practice?
I encounter several patients presenting to the ER with abdominal pain. Based on history, labs and possibly imaging the decision is made if the patient is stable to go home. Usually a patient who is not vomiting, with labs that look good and patient can eat/drink then they usually go home with good return precautions.
Do you believe there might have been medical error?
This practitioner was obviously very concerned about an intra-abdominal process going on with this patient. This is evidenced by a lab work up and a RUQ US and then a CT scan. The clinical examination (history and physical) was not textbook for appendicitis but in a man with right sided abdominal pain and tenderness, the differential diagnostic list is short. I suspect this doctor/practitioner had appendicitis on his/her list of possibilities. The CT was clearly suspicious for an early appendicitis and c/w the brief clinical history of pain (several hours). The standard of care at the time of the CT result required one of several options: 1. Observation in the ED or UC and serial examinations. 2. Admission and consultation with a surgeon who would likely observe and do serial exams. 3. Very tight and strict discharge instructions with firm guidelines about when to return (ie. Return if worse or if not better in 12 hours). Given the early clinical presentation and early CT findings, there was time to address his complaint fully and comfortably over the next 12-18 hours without bringing perforation into the picture. This patient did get worse after discharge (as one would expect) and it seems he was told to return but did not for 4 days. That said, the practitioner dropped the ball by not recognizing appendicitis when the patient was under his or her care and I feel there was a deviation in the standard of care based on the summary presented.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Similar reasoning. An unperforated appendix requires surgery and a brief hospital stay. Complications of a simple appendectomy exist but pale in comparison to the surgery required for a perforated appendix. Specifically, there is a longer hospital stay, more medication/antibiotics and morbidity down the road (ie bowel obstruction).
What makes you a good expert for this case?
I have been practicing general EM for over 25 years in both academic and community settings. This is a bread and butter type problem, encountered regularly. I am well versed in being an expert witness. I connect with people very well and speak plainly about medical issues so all can understand.
How often do you encounter cases similar to this one in your practice?
Regularly. 1-2 times monthly. More frequently in our ED where I may be involved peripherally.
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