78 year old female is admitted to hospital on 7/14 for acute bronchiolitis due to RSV, sepsis, likely pneumonia and acute asthma exacerbation. EKG in ER demonstrates chronic left bundle branch block. Started on Azithromycin, Ceftriaxone and lovenox for VTE prophylaxis. She was also provided with daily pulmicort, DuoNeb and IV Solu-Medrol for asthma.
On 7/15, the Troponin I was .67 and she was felt to have non-STEMI. Echo showed anterioapical hypokineses with EF of 50 to 54% of Cardiology consulted and recommended left heart cath once respiratory status improved. Lovenox increasd to 110 mg. q12h. She was noted to have transaminitis initially which improved while in the hospital. Troponins also normalized from peak of .67.
On 7/17, Cardiology noted that left heart cath can take place once cleared by pulmonary. On that same date, pulmonary noted that he expected the patient could lay flat and have left heart cath done in the next 24 to 48 hours with continued medical management.
The events that are the subject of the requested review began on 7/18. The following is a timeline of the significant information on that day leading to her death on 7/19.
7/18
0554 CBC: Hgb-12.7 Hct-39.1 WBC- 14.8
0821 Aspirin 81mg given
1123 Examined by Hospitalist and documented as follows:
• Sitting up on side of bed at the time of exam
• Mild bibasilar rales
• No abdominal tenderness
• Doing well- complains of dry cough
1140 Examined by Cardiology ARNP and documented as follows:
• Wheezing present
• Left heart Cath once cleared by pulmonary
• No abdominal tenderness
1200 Nurses note for first time that patient has pain in abdomen
1200 BP-141/79
1206 Lovenox 110mg given subcutaneous in abdomen
1339 Acute Pain in lower left abdomen noted by nurses
1339 Duo Neb nebulizer given by RT
1348 Tylenol 650mg given by nurses
1356 Hospitalist notified by nurses that patient is requesting gas relief
1406 Order for Mylicon Routine q6h PRN Reason stated in order- flatulence
1511 Mylicon 40mg given
1543 Hospitalist notified of patient's pain in left lower quadrant
1602 Hospitalist Order for Morphine Routine q4h PRN- 1 day for severe pain
1621 Nurse assessment- Cramping, bloating, gas, loss of appetite, nausea
• Multiple bruising noted to anterior lower right and left abdomen; purple and blue
• Agitation
• Dyspnea on exertion (had since admission)
• Anxiety/stress precipitating factor to bloating, gas
1621 Morphine 2mg injection given
1629 BP 129/77; P-74; RR-19; on 2L O2
1639 Hospitalist notified regarding patient's pain
1640 Full liquid diet ordered by hospitalist
1715 Examined by pulmonary and she noted as follows:
• Sitting in recliner
• Not in distress
• Cap refill sluggish
• Nontender abdomen
1730 Nurses note that patient was still in pain and that hospitalist was informed. New orders placed. Pt is assisted to bed, pain meds and ice pack iare given, monitored closely for any changes. This note also states that CT tech was called for transport. (Please note: Our chart does not include a copy of the order for the CT abdomen/pelvis. Therefore, we do not know the exact time it was ordered and whether it was stat. Given this nursing note, assumedly it was ordered at or around this time.)
1837 Nurses note that patient is stable and that she was c/o sharp pain in the left lower quadrant of her abdomen.
2015 Morphine 2mg injection given
2015 BP- 98/69
2020 Prednisone 40mg given
2030 Pulmicort nebulizer .5mg given by RT
• DuoNeb nebulizer given by RT; patient vomiting
2100 Patient now on 4L O2 (increased from 2L)
2119 Order for Omnipaque (CT with Contrast)
2121 – 2133 CT Abdomen & Pelvis w/ Contrast completed
2145 Ct Report dictated (Call report recorded in PACS) Radiology interpretation:
"Large left rectus abdominis wall hematoma measuring approximately 11.2 x 15 x 23 cm with hemosiderin fluid level and multiple foci of active hemorrhage/extravasation. Surgical Consultation recommended."
2235 Nurse notes that patient's CT result was read and that the hospitalist and ICU PA were aware. Rapid Response team also on the case. Nurse notes that patient is alert and oriented x4 and vital signs were stable. (Please note that the last recorded bp was 98/69 at 2015.)
2256 Hospitalist APRN notes that she spoke to radiology. Per radiology, another MD was previously contacted with the result. (Please note: It is believed radiology may have been referring to a conversation with the patient's out of town son-in-law who is a physician.)
2300 BP – 102/66; p-85; rr-18; 4L O2
@2300 Hospitalist APRN informs Hospitalist about CT. Hospitalist note (timed at 0630 the following morning) indicates that per nurse and EMR, the patient was hemodynamically stable and not showing signs of hypotension and shock. He instructed Hospitalist APRN to contact surgery.
2321 Routine Consult Order to General Surgery entered
2347 Note by nurses that Morphine not given because BP was too low.
7/19/22
0000 Note from rapid response team (RRT) nurse reflects as follows:
RRT made aware of CT results by charge nurse. Upon assessment, pt complained of LLQ abd pain which radiated to her groin and left back. RRT noted vital signs stable. No complaints of cp, sob or palpitations. RRT made ICU PA aware of situation. New orders received. Primary RN made hospitalist aware of situation for which they placed new lab orders and a surgery consult. ICU PA, RRT and primary RN placed calls to covering surgeon. Primary RN received call back from surgery. Surgeon stated NPO and would see first thing in AM.
A note by the attending hospitalist at 0630 reflects that the general surgeon had recommended to keep the patient NPO. He further noted emergent surgery could not be performed since the patient had multiple comorbidities, morbid obesity with a BMI 54 and advanced age. (Presumably this was input received from the surgeon. However, there are no notes from surgery.)
0000 Nurses note NPO
0019 Order for Protamine by ICU PA
Order for tranexamic acid by ICU PA
0035 Venous blood collected for CBC
0052 ICU PA Consult Note reflects in pertinent part:
Patient complains of weakness and generalized fatigue, but denies having chest pain, shortness of breath, dyspnea on exertion, palpitations or near syncope. Bedside ultrasound reveals a large fluid collection . Lovenox and aspirin discontinued. H&H and T&S pending. Initial call and message attempt was placed to on-call surgeon without success. Nurse contacted surgery- surgery will see in AM.
0110 Nausea and vomiting noted
0049 100 mg IV Protamine given
0117 1000 mg IV Tranexamic acid given
0131 CBC resulted: Hgb-10.2; Hct-32.1; WBC is now 33.1
Nurse notes that ICU PA was made aware of CBC results. He recommended
primary RN to make surgeon aware of CBC results. Primary RN paged surgeon.
RRT made Hospitalist aware of situation and interventions.
0140 Critical Care PA notes that he requested surgery to be consulted with the CBC results.
0236 aPTT- 24.2; Protime 13.0; INR 1.1
0249 Code Blue
0257 Order for Transfusion of unmatched blood
Critical Care PA notes that the staff attempted to contact the surgeon. PA called critical care medicine attending and he was able to provide the cell number of surgeon. Surgeon called and asked for time to review the MR. Surgeon called back and stated surgical intervention was not advisable considering the complexity of the hematoma.
0330 Order for mass transfusion protocol
0425 Pronounced
Cause of Death per death certificate: Cardiac Arrest, hemorrhagic shock, acute blood loss anemia
In reviewing the timeline and case facts, was it appropriate at or around midnight for the on call surgeon to simply recommend the patient to be NPO and that he would see her in the morning? The CT demonstrated a large active bleed. The patient's blood pressure also significantly dropped from the bp that morning. In fact, the nurses just noted that they could not give morphine because bp was too low. The patient's overall condition before the new onset abdominal pain had been improving with plans for a cath in the next 24 hours. Had the surgeon responded to the hospital shortly after midnight and emergently had taken the patient to surgery to address the bleed would she have likely survived?
Would the standard of care for the surgeon change at all had he been contacted at 2145 when the CT results first became available or would it have been appropriate to wait until the next morning? If contacted at 2145-2200 and taken to surgery, does she likely survive.
Finally, does any delay in obtaining the CT play any role in the surgical decision making?
Files:
No questions yet!
Do you believe there might have been medical error?
Conservative treatment of rectus sheath hematoma includes rest; analgesics; hematoma compression; ice packs; treatment of predisposing conditions; and if necessary, more aggressive therapies of intravenous fluid resuscitation, reversal of anticoagulation, and transfusion We get this kind of call all the time. the bleeding usually stops because of the rectus sheeth, and normally there is not a lot of blood loss from this area
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
lots of co morbid conditions. 0131 hct is stable. died relatively quickly. Fortunately, the majority of cases of rectus sheath hematoma can be successfully managed nonoperatively. Multiple case series have demonstrated that around 80% of patients may be managed with no invasive intervention, including rest, ice, compression, and analgesia. In patients with coagulopathy, cessation of anticoagulation therapy or, if needed, reversal of the coagulopathy is sufficient to allow the bleeding to tamponade within the sheath. In patients with significant anemia or hemodynamic instability, transfusion of blood products is indicated. If, despite these measures, the patient has persistent evidence of bleeding, the most appropriate initial intervention is angioembolization, which has been reported to control ongoing hemorrhage in virtually 100% of cases successfully. It is rare for rectus sheath hematoma to require surgical intervention. In fact, laparotomy in many cases would pose a bigger risk of bleeding to the patient than is necessary, especially in patients with coagulopathy
What makes you a good expert for this case?
This would be an easy case for me to defend based on the treatment for this condition as stated above.
How often do you encounter cases similar to this one in your practice?
5/6 times per year. This is a frequent consult as many of our patients are on anti coagulation.
Do you believe there might have been medical error?
Based on the information available to me, there was a significant delay in diagnosis and recognition in hemorrhagic shock. The patient initially had documented signs on exam based on the 07/16 1621 note describing significant abdominal wall bruising. This, with the fact that the patient was on full dose anticoagulation, should have warranted at least a repeat hemoglobin at that time. At 2015 on that same day, the patient had a significant hemodynamic change bordering hypotension (in this case, it would count as hypotension given her known baseline was 140 earlier in the admission. In my opinion, this was the time to move the patient to a step down unit or an ICU and expedite a STAT CT with IV contrast with hemorrhagic shock as the leading diagnosis until proven otherwise. Additionally, consideration of packed red blood cells could have been given at this time as well. I would need the actual medical chart to appreciate at what time the CT was ordered and to see if there was any consideration of hemorrhagic shock as a diagnosis prior to this. Once the CT results became available, 2 consults should have been made - Interventional radiology (IR) given active extravasation was seen on CT and the surgical consult which was placed. I am not aware of the system in place at this specific hospital, but this is a crucial point in time as if the hospital did not have IR available, focus should have been on resuscitation and transfer to another facility. Given the patient was not evaluated by the surgical team during an active bleed, it is not appropriate to wait until the following morning to evaluate such a patient. Even if the patient was not deemed a surgical candidate, often times surgical teams are called upon to assist with resuscitation and help coordinate other services such as IR or movement into an ICU. Again, without knowing which type of hospital system this case is from, this may be a limitation of the system but in this situation the consultant should at least evaluate the patient and make a decision best for patient care knowing their system limitations.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above, there is a significant delay in diagnosis of hemorrhagic shock, significant delay in time to resuscitation with blood products, lack of involvement of key consultants such as IR who was not even called according to the above records and the surgical team who deferred to the next morning for evaluation. Typically for hemorrhagic shock, patients are resuscitated with red blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio - this was not done in this case. There was delay in cessation of full dose anticoagulation after the CT results became available. No one team is at fault, but there appears to be multiple key moments for opportunity for improvement in care.
What makes you a good expert for this case?
I am a trauma surgeon with vast experience in recognition and management of hemorrhagic shock. This includes when surgical management is warranted as well as when surgery is not warranted but non-operative treatments such as resuscitation or coordination of other services are required. This is part of my daily clinical duties and there is strong evidence in the literature that no physicians are better than our specialty in this regard.
How often do you encounter cases similar to this one in your practice?
Hemorrhagic shock management is nearly a daily consultation to my service in my practice.
Do you believe there might have been medical error?
There are several concerns about this case. First, the surgeon should have seen the patient when called. Rectus sheath hematomas can be difficult to treat surgically given the difficulty of find the bleeding source within the muscle fibers and hematoma present. It certainly would have warranted a discussion between the interventional radiologist and the surgeon given the complexities of the case, especially when the blood pressure was too low to give opioid medication. Secondly, it was not stated (but perhaps it occurred) that an order was written to stop the lovenox. Protamine does not work as well to reverse lovenonx as it is for unfractionated heparin. Therefore, measuring anti Xa levels in all patients receiving therapeutic lovenonx would be indicated to make sure that the dosing was not too high (it goes without saying the 110 mg Q12 H is a huge does particularly in the elderly where kidney function may be compromised). Transexamic acid can be effective as a massive hemorrhage treatment, but should not be given more than 3 hours after the start of the bleed as there is data that it worsens bleeding (CT done 2121 to 2133 and TXA given at 0117) The surgeon is the person in the hospital most acquaint with bleed management. Even if it was determined that the patient should have gone to IR rather than the OR, some documentation should have been done to communicate that line of thinking to the others caring for the patient.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The lack of checking anti Xa in this patient and the delay in surgical input and resuscitation direction by the surgeon very likely contributed to the bad outcome. It does not say specifically that the lovenox was discontinued, but likely occurred due to the doing of protamine.
What makes you a good expert for this case?
I have 14 years of experience in trauma and acute care surgery at a busy verified level one trauma center and I am director of the acute care surgery section or our department of surgery.
How often do you encounter cases similar to this one in your practice?
We see rectus sheath hematomas several time per year. Most of them can be managed non-operatively, or with interventional radiology. In the case of hemorrhagic shock as in this case, urgent surgical intervention may be the only way to stop the bleeding
Do you believe there might have been medical error?
A rectus sheath hematoma with active bleeding in an unstable patient requires some kind of intervention. Surgey, however, is not the best intervention - interventional radiology for embolization of the epigastric artery is the best approach. Operating on a recuts sheath hematoma is a good way to lose a great deal of blood and it is an operation with significant morbidity. Surgical intervention is a last resort. However, I do think it is within the surgeon’s scope of responsibility to recognize the severity of the patient’s course and either come evaluate the patient and/or recommend interventional radiology to evaluate the patient. An actively bleeding patient needs resuscitation with balanced blood products. I agree with the administration of TXA I cannot tell from the report if the patient was on some form of anticoagulation (Coumadin, xarelto, etc) or anti platelet therapy in which case reversal with Kcentra or platelets would be appropriate. The major question here is whether the surgeon recommended, on the basis of active extravasation on a contrast CT, that the patient be evaluated by IR. I would not expect the ICU team to appropriately consult the IR team - surgeons deal with bleeding and hemorrhagic shock, and saying it can wait till morning is not appropriate
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient required more aggressive intervention than she received. She clearly decompensated more quickly than expected, but an evaluation by IR and embolization MAY have stopped the bleeding before she coded.
What makes you a good expert for this case?
I am a surgeon practicing trauma, acute care surgery and surgical critical care. I treat patients with with hemorrhagic shock on a near daily basis. I treat patients with rectus sheath hematomas on a monthly basis. I would welcome the opportunity to chat more about this case
How often do you encounter cases similar to this one in your practice?
Please see my above answer. At least once a month I treat rectus sheath hematomas
Do you believe there might have been medical error?
With an enlarging rectus hematoma could have considered interventional radiology or surgery. Clearly she continued to bleeding.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
With an enlarging rectus hematoma could have considered interventional radiology or surgery. Clearly she continued to bleeding.
What makes you a good expert for this case?
I am board certified in general surgery, but practice surgical oncology.
How often do you encounter cases similar to this one in your practice?
This would be very rare for me to see. A general surgery expert witness who does ACS call would be best.
Do you believe there might have been medical error?
There appears to be a significant delay in the reversal of anticoagulation for this patient (administration of protamine after the CT scan was several hours )In addition, the surgeon should not delay seeing a patient who is in in hemorrhagic shock—this should not be delayed an evaluation. This patient who is very tenuous and has very little physiologic reserve should’ve been taken care of aggressively at the first signs of stage three shock. These patients cannot stand to take a hit and deserve aggressive management and definitive therapy at the earliest diagnosis. This shows a clear pattern of failure to rescue
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Intramuscular hematomas are known complications of anticoagulation. These incidences are difficult to predict. However, once diagnosed should be managed aggressively, especially in patients with low physiologic reserve to prevent sequelae that cannot be recovered
What makes you a good expert for this case?
Hemorrhagic shock is something taken care of, and managed by many general surgeons. I serve at a tertiary referral center that takes care of many patients with hemorrhagic shock from multiple etiologies, including tumors and benign processes. The medical management of these and surgical management should be in a multidisciplinary fashion, which I am often included in.
How often do you encounter cases similar to this one in your practice?
As a complex surgical oncologist and board-certified general surgeon, we often take care of both medical and surgical bleeding. These events should be managed in a multidisciplinary fashion and an expeditious manner to avoid severity, morbidity, and mortality.
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