A 79-year-old female patient was admitted on 7/13/2021 with severe abdominal pain, diarrhea, and bloody stool. She gave a history of similar symptoms over the past several months, worsening over the past week. A colonoscopy had been done as an outpatient on 7/2, which had showed moderately severe diverticulitis with multiple non-bleeding diverticula in the sigmoid. In the ER, an initial CT showed sigmoid diverticulitis with no perforation or abscess, as well as marked mural thickening and luminal narrowing in the inflamed segment, and mild wall thickening in the ascending colon. She was admitted with a diagnosis of ischemic colitis and started on broad spectrum antibiotics. An infectious disease consult was requested "as patient had C. diff antigen positive but toxin negative." The morning of 7/20, a routine CT abdomen with oral contrast was ordered for "abdominal pain." The CT was completed around 1 pm and read as showing a small bowel obstruction with a transition point in the left midabdomen and minimal contrast beyond that point. It also again showed the marked wall thickening of the sigmoid, as well as "mild upstream distension of the large bowel," fluid filled, which was thought to possibly represent partial, low-grade obstruction. There was mild free fluid, but "no evidence of perforation," according to the radiology report. Later that same evening, the patient became increasingly weak and tachypneic, with abdominal distension, cold mottled extremities, and decreased bowel sounds. The patient was described as febrile and pale-appearing, and it was noted that her last bowel movement had been 2 days earlier. A rapid response was called around 8 pm and the patient was intubated and upgraded to the ICU. A surgical consult was requested, but it appears that the surgeon did not see the patient that night. A note by the attending PA at 3:53 the following morning (7/21) states that the surgeon had reviewed the CT images from the previous day and "states small-bowel obstruction is likely partial. He states can place NG tube if patient develops nausea or vomiting."
At about 1 pm on 7/22, a different surgeon saw the patient and decided to proceed with sigmoidectomy and colostomy -- apparently for worsening colitis, not for any suspicion of perforation. The patient was taken emergently to the OR, where she was found to have a perforated colon and 1.4 liters of stool in her abdomen. She underwent an open sigmoid colectomy with colostomy and an en bloc small bowel resection with primary anastomosis. The patient continued to decline after the surgery, requiring hemodialysis and pressors. Because of her overall poor prognosis, the family eventually decided on hospice, and the patient passed away 8/5/21. Causes of death were listed on the death certificate as sepsis and bowel perforation.
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Q: Was there additional imaging the night of her decompensation. What anabiotic’s was she treated with. Did she ever have a duplex to support a diagnosis of ischemic colitis. Were there any other risk factors for ischemic colitis?
A: —
Do you believe there might have been medical error?
Her hospital course is very protracted and I wonder if the general surgeon should have been consulted earlier. Typically if diverticulitis is managed medically the patients will recover quickly. It sounds like she had smoldering disease that needed surgical intervention much sooner. In addition, from reading the short description, it sounds as if a delay in diagnosis was made regarding the perforation. The patient likely perforated nearly 24 hours before being taken to the operating room. It would be important to know if there was any peritonitis the evening she was transferred to the intensive care unit and if any abdominal pain film, x-rays were obtained at that time. Was there any free air under the diaphragm for a chest x-ray would also be helpful information.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient’s diverticulitis progressed to perforation. It’s difficult to know whether her perforation was caused by her medical care because it does not state what kind of antibiotics she was on as part of her care. It would also be important to know if she was on any steroids.
What makes you a good expert for this case?
I am a complex gastrointestinal surgeon, board-certified in general surgery and in complex surgical oncology. I have published any papers on failure to rescue and surgical quality. I am currently an assistant professor on the tenure track at The Ohio State University.
How often do you encounter cases similar to this one in your practice?
We often manage colitis as part of the complex care for a patient population. As a tertiary referral center, our patients are the sickest of the sick.
Do you believe there might have been medical error?
Physical exam findings were not documented in the written scenario which is critically important to the management of this patient. If there was peritonitis present on exam, regardless of CT findings, then the patient needed an operation. If there was no bedside evaluation by the surgeon for more than 12 hours after being called, that is very concerning. The patient was decompensating with a known potential septic source in the abdomen, but there was a failure to rescue. Additionally, the CT shows what is a very likely a large bowel obstruction and that is managed surgically in an urgent or emergent fashion
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This patient had very clear evidence of worsening sepsis and a known very likely source in the abdomen based on the CT report. She needed urgent evaluation by surgery and exploratory laparotomy for source control if there was any hope of survival
What makes you a good expert for this case?
I am board certified in general surgery and surgical critical care. I work at a very busy verified level one trauma center and I have an academic appointment at the local medical school I have 17 years of experience post fellowship. I am the medical director of the acute care surgery section at our hospital
How often do you encounter cases similar to this one in your practice?
I see and manage patients with sepsis related to surgical diagnoses similar to this patient on a weekly basis. I manage both their operative and critical care needs.
Do you believe there might have been medical error?
Diverticulitis is a common problem and while most cases can be managed with antibiotic therapy, patients are certainly at risk of disease progression with complications such as bowel perforation. My concern regarding an error is related to the clinical deterioration - the patient had worsening abdominal pain, tachypnea and mottled extremities. They were then intubated. Absent another clear etiology for this clinical change, as a surgeon I would think of an intra-abdominal source of the sepsis. That means examining the patient and most likely proceeding to the OR. The error was in not evaluating the patient in person & treating the earlier CT scan
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is impossible to know when the perforation occurred, however it is likely that an earlier operation may have prevented such significant intra-abdominal contamination and the subsequent profound inflammatory response that led to the patient’s death. Earlier in person evaluation may have prompted earlier operation
What makes you a good expert for this case?
I am an acute care surgeon who practices trauma surgery, emergency general surgery and surgical critical care. I have taken care of similar such patients, particularly in the ICU on a near weekly basis.
How often do you encounter cases similar to this one in your practice?
I take care of patients with complicated diverticulitis on a near weekly basis. I have managed people with a similar course in the ICU nearly every time I round in the unit (every month)
Do you believe there might have been medical error?
The CT was completed around 1 pm and read as showing a small bowel obstruction with a transition point in the left mid abdomen and minimal contrast beyond that point. It also again showed the marked wall thickening of the sigmoid, as well as "mild upstream distension of the large bowel," fluid filled, which was thought to possibly represent partial, low-grade obstruction. There was mild free fluid, but "no evidence of perforation," according to the radiology report Here is the breach in the standard of care. Base on this alone, a reasonable surgeon would have proceeded to the OR. Was the CT contrast ?oral may have been missed
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Failure to timely operate. Sounds like there was enough clinical signs and symptom as well as diagnostic imaging to proceed to the OR. sounds the delay was more than 12 hours.
What makes you a good expert for this case?
Decades of reviews for both the plaintiff and defense. The ability to explain complex medical problems to the court and jury. Extremely thorough in reviews
How often do you encounter cases similar to this one in your practice?
In his new position, Dr. C. is leading the way for improved surgical care for those who have served our great country. Dr. C. has joined the surgical team at the Hunter Holmes McGuire Veterans Administration Medical Center in Richmond, Virginia. Furthermore, Dr. C will join the faculty as a full-time colon and rectal surgeon to help teach, train, and educate the young physicians who comprise the backbone of the VA organization. Dr. C was the first Board certified colon and rectal surgeon for the southern crescent area in Atlanta, Georgia. Many of his patients traveled long distances to receive his high quality care, due to his unique ability to put patients and family at ease during difficult and often stressful times. Dr. C is an innovator, pioneer, and pacesetter of emerging, developing, and innovative colorectal techniques. He is active in teaching, educating, and collaborating with physicians both domestically and internationally, in which his passion is advocating for advances in colorectal diagnosis and treatment, promoting quality access, and maintaining affordability in the current healthcare debate. In addition to his clinical work, Dr. C has advanced his leadership skills by earning an MBA degree. Because of his current life-style change, Dr. C is passionate about educating and teaching, in addition to, promoting nutrition as a mainstay for a healthy way of living. In fact, Dr. Cohen is a two-time Ironman triathlon finisher and is still very active. Dr. C has partnered with medical industry for the past 25 years to educate, teach, and promote innovative technology that adds value for patients, physicians, and the institution. Furthermore, as a leader in the field of colon and rectal surgery, Dr. C prides himself on keeping abreast about evidence-based medicine, and is a consultant for many medical-legal and peer-review cases that require his particular skills for a fair and just assessment.
Do you believe there might have been medical error?
It appears that the patient had not improved, or even worsened since her admission on 7/13. The CT scan from 7/20 at 1 PM showed bowel obstruction with a transition point and persistent Sigmoid colon inflammation. There is a clear indication to proceed to surgery at this time. Instead, a surgical consult was called at 8 PM. Had the patient been examined personally by the surgeon at this time, He/she should have taken the patient to the operating room immediately. Instead, a CT review in the middle of the night was performed and the order to place an NG tube if the patient got nauseous or vomited. This is an inappropriate conclusion based on the fact she had a bowel obstruction. I'd have to review the chart, but it appears the patient was not seen by surgery again until 1 PM on 7/22 and then taken to the OR. The fatal outcome was all but assured by this time. It is my impression there was a clear indication for surgery at 1 PM on 7/20. There was a 48 hour delay in getting this patient to the OR. During that delay the patient perforated her colon precipitating irreversible sepsis and death.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There was a 48 hour delay in getting this patient to the OR. During that delay the patient perforated her colon precipitating irreversible sepsis and death. Had the patient been taken to the OR at the first clear indicated time, the colon was not perforated yet. The delay resulted in the perforation that resulted in the death of the patient.
What makes you a good expert for this case?
Extensive experience in colonic, small bowel and abdominal surgery
How often do you encounter cases similar to this one in your practice?
75 to 100 times a year. However, as of 2019 I limited my practice to breast surgery and since then have not performed colonic surgery. Prior to that colon, small bowel and abdominal surgery was frequent.
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