November 12, 2020, 79 year old female presents to Hospital complaining of black stools and abdominal pain. Her initial hemoglobin level was 7, and she was admitted for a blood transfusion and further evaluation. After a blood transfusion, patient underwent a gastroenterology workup including an upper endoscopy, which found a duodenal ulcer with pigmented material but no active bleeding at the time. The gastroenterologist recommended returning the patient to the ward for ongoing care and IV Protonix. At 1552 that afternoon, the patient’s hemoglobin level was 8.1.
The evening of November 12 and overnight, the patient continued to have bloody stools. She became tachycardic, and pale. At 0014, on November 13, the nurse on duty assessed patient’s vital signs, which were normal except for sinus tachycardia, with a heart rate of 120. At 0430 on November 13, the nurse on duty charted: “Called placed to physician, On-call, HCH Hospitalist, MD, Questions concerns, and/or orders, pt looks pale. VSS. Awaiting labs. Has passed two bloody stools.” Although timed at 0430, the note was not entered into the chart until 0627. Also at 0627, the same nurse charted a second “Call placed to physician,” with an identical note to the prior one.
At 0655, the same nurse charted, Called placed to physician, On-call, HCH Hospitalist, MD, Change in patient condition, Questions, concerns, and/or orders, Hgb 5.1 this am.”
At 0700, the patient was noted by the oncoming morning shift nurse to have a heart rate of only 50; diminished breath sounds and agonal breathing; weak pulses; skin that was dusky, cool, and clammy; and no movement or response to being shaken. An “event note” she entered later that morning states: “During shift change at bedside, patient observed to be unresponsive to painful stimuli, agonal breathing, bradycardic with heart rate 47 bpm and oxygen saturation in 70s, immediately started on 5 liters oxygen, rapid response, charge nurse and respiratory team notified immediately." The hospitalist was notified via phone about patient’s condition and family called to come to hospital. A second blood transfusion was started at 0800, but patient was pronounced dead at 0840.
Her death certificate lists her causes of death as “hypotensive shock,” “severe blood loss,” and “acute GI bleed.”
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Do you believe there might have been medical error?
See below Was the pt appropriately in the ICU post EGD? Was there a plan for follow up hemoglobin? Is it true that no one tried to reach the physician until four hours after there was a change in vital signs and ongoing rectal bleeding? Was the GI ever reached? Does the hospital have IR or surgical back up? It’s hard to believe the patient simply died, because nobody could be reached.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Was the pt appropriately in the ICU post EGD? Was there a plan for follow up hemoglobin? Is it true that no one tried to reach the physician until four hours after there was a change in vital signs and ongoing rectal bleeding? Was the GI ever reached? Does the hospital have IR or surgical back up? It’s hard to believe the patient simply died, because nobody could be reached.
What makes you a good expert for this case?
17 years of practice in endoscopy including interventional training
How often do you encounter cases similar to this one in your practice?
Never had a hospitalized patient exsanguinate under my watch but it (rarely) happens
Do you believe there might have been medical error?
79 y/o patient with DM, signs and symptoms of overt gastrointestinal bleeding, and upper endoscopy revealing duodenal ulcer with pigmented lesion not treated endoscopically. The described lesion suggests Forrest Class 2C flat pigmented spot (10% rebleeding rate; 3% mortality) or Forrest Class 2B adherent clot (22% rebleeding rate; 7%mortality). After the upper endoscopy there were continued signs and symptoms of active acute upper gi bleeding as suggested by the blood stool and tachycardia. Nursing care appears to be limited to charting without evidence of direct communication with physician or escalation to nursing or hospital leadership. Severe acute decompensation appears to have occurred by nursing shift change at 0700. The rapid response was initiated after a point at which resuscitation efforts were unlikely to save the patient.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Failure/delay to recognize active acute gastrointestinal bleeding and patient decompensating. Failure/delay to escalate care or concerns. CT angiogram could have been ordered to look for active bleeding and interventional radiology consulted for consideration of embolization.
What makes you a good expert for this case?
I have been a practicing gastroenterologist treating GI bleeding in level 4 trauma hospitals in the Texas Medical Center for ten years.
How often do you encounter cases similar to this one in your practice?
I encounter cases similar to this one weekly.
Do you believe there might have been medical error?
It's difficult to answer this question without knowing what exactly is meant by "error". Error in charting? Error in assessment? Error in not respond to a nurse call? If we lump all of these potential possibilities and place them under the umbrella term of "error", then I would actually bump the score up to 9, bordering on 10, depending on what action was taken or not taken by the physician who was being contacted.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Hours after the procedure it is reported that the patient was having bloody stools. Note the word "bloody" rather than black or melenic. If a patient with an upper GI source of bleeding (e.g. a duodenal lesion, ulcer or otherwise), is having bloody stools, i.e. hematochezia, that is a sign of a major/brisk bleed. This constitutes an emergency. Moreover, it is evident that the indeed lost a substantial amount of blood (3 units) within less than 24 hours, as discerned by the hemoglobin change and what seems to be hypotensive shock and probably consequent myocardial infarction. In cases like this, either a second look endoscopy is needed, greater efforts are needed to correct any coagulopathy (if present), and/or interventional radiology needs to be consulted for consideration of angiography and embolization of the bleeding vessel. Unless perhaps in a patient with severe comorbidities, a patient presenting with an upper GI bleed, e.g. from a duodenal ulcer, should not die like this.
What makes you a good expert for this case?
I'm the director of endoscopy at my institution. I have published on the subject matter of GI bleeding. I am accustomed to multidisciplinary management, as is sometimes needed in cases like this. I am a pedigreed, solid, and impartial expert. I routinely manage upper GI bleeding. I am able to pick apart the case to find the devils in the details, as needed.
How often do you encounter cases similar to this one in your practice?
Depending on what is meant by "similar to this one", at least once a month.
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