6/11/21, 3 y/o involved in MVA. Transported to 1st hospital and intubated for precautions and then transported to a pediatric hospital arriving 10:30pm. CT abdomen/Pelvis with IV contrast shows small amount of fluid in perihepatic region and right paracolic gutter. Pt placed NPO. Transferred to PICU and extubated. 2am 6/12, pt vomiting. 4am, lower abdominal pain and morphine given. Abdomen soft and non-tender. Evening of 6/12 began to advance diet with fluids and pt began c/o lower abdominal and flank pain. Morphine given. Surgery elected. pre-op Ceftriaxone and Metronidazole. Surgery start 8:27am on 6/13/21. Found perforation X2 small intestine and extensive bleeding of lower abdominal wall. Post-op pt became increasingly tachycardic and tachypnic and code blue called 12:55 on 6/14/21. ECMO started. 6/20 ECMO stopped. 6/30/21 worsening respiratory and hemodynamic status. Intubated with aspiration despite NG tube in place. Pt dies 7/1/21.
Based upon limited info, should additional studies have been undertaken upon admission?
Does it appear that surgery should have begun sooner?
Would earlier intervention have prevented septic shock and ultimate death.
Files:
Q: Were antibiotics continued after initial exploratory abdominal surgery?
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Q: Were patient's labs suggestive of coagulopathy?
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Q: What was the indication for ECMO?
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Q: Leading up to intubation on 6/30/21, was patient being fed by mouth, and was speech therapy working with patient?
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Q: What was the timeline of the worsening hemodynamic and respiratory status that led to the 6/30/21 intubation?
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Q: Subsq xrays-repeat CT/CXR/KUB?Child made NPO again?Trauma notified timely-child's arrival/acute changes?New labs performed?(e.g.CBC diff, lactate, CMP, inflammatory markers) Primary Service trauma or PICU? What's communication process of pt status change?
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Do you believe there might have been medical error?
Based on the limited information given, there is not enough detail to raise suspicion of any serious medical error. It would be helpful to know if any additional imaging was obtained after admission in terms of deciding when to go to the operation room, though the CT abdomen and pelvis with contrast is the ideal initial study for an MVA patient with abdominal pain, so there was no additional imaging that would have been more helpful on admission. If the patient was hemodynamically and otherwise clinically stable preoperatively, there was no clear indication to take the patient for exploratory surgery sooner. There is not enough information to determine why the patient died from septic shock, but there is nothing in the description to support a medical error or decision led to that outcome.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is difficult to determine what type of clinically significant medical error, if any, would have occurred based on the information given. Unless there was something egregious that was not described, there is no causation to be had.
What makes you a good expert for this case?
I am an experienced, board certified pediatric intensivist who has taken care of pediatric trauma patients at various points over the past decade, including as a pediatric critical care hospitalist and during fellowship training, both at busy urban level 1 pediatric trauma centers, and most recently a few years at an urban level 2 pediatric trauma center.
How often do you encounter cases similar to this one in your practice?
I left my position at the level 2 trauma center in July 2022, so I no longer see pediatric trauma patients.
Do you believe there might have been medical error?
I believe there are multiple potential areas of care that require in depth examination in the medical record. There may have been a missed injury/delay in diagnosis of that injury. There is a tremendous amount of detail that is left out of this vignette to be certain. I have many detailed questions that would only be answered by an in depth review of the medical record or with deposition or at trial (if it came to that). It would be inappropriate with such a small amount of general information provided given to declare definitive medical error(s). Small bowel injuries in a toddler can be missed on initial workup due to their small size and variations in CT scan techniques in facilities that do not routinely care for children. Observation over time with detailed qualified reassessments via abdominal exams and investigations likely will reveal acute/subtle changes that need urgent interventions. This is often the reason why these children are admitted to Pediatric intensive care units (PICUs) with qualified team members. Clear and timely communication with all involved in the care of the traumatically injured child or critically ill child is vital to survival of the child with life threatening injury and illness. Medicating with morphine without provided documentation of the abdominal exam or notification of the surgical team may have contributed to a delay in diagnosis. There may have been extenuating circumstances as well such as a mass casualty event from this same crash that contributed to a delay as well. The large gap in the vignette to ECMO is troublesome and leaves a large deficit of information. With regard to the latter part of the vignette, aspiration during intubation can occur with an empty stomach as the gastric acid is still being produced. An NG tube does not prevent aspiration. That being said, there may have been other relevant events that contributed to this situation. There is no provided information regarding the intervening events to provide a fair assessment of the care of this poor child in the vignette with a devastating outcome. I would also want to know if a severe anoxic brain injury contributed to the death of this child. Were there intervening exams that provided clues to the underlying status of the organ(s) that failed leading to the child's death? Such detail and a timeline would help identify specific areas of concern for any medical errors that may have or may not have occurred. Did the parents elect to separate the child from technologic support or were they advised to do so because there was no possibility of survival.?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There may have been a missed injury/delay in diagnosis of that injury. There may have been intraoperative misadventures, or ones in the ICU surrounding any of the airway managements, or communication between services. There may have been misadventures in the PICU during any or the interventions that occurred. I have seen so much over the years that I have been in training and practice that could explain what happened to this child. There may not have been communication to appropriate providers with appropriate skill or training to identify concerning changes. There are a multitude of concerns I have about this child's care based on information provided. There is a tremendous amount of detail that has been noticeably left out. There is not good flow of this child's "story" during the time in the medical care and large gaps with huge escalations of therapy without reasonable provided explanation. It does not make medical sense based on what limited information is provided. all of this being said-there may have been excellent care and communication and this child inexplicably died. It does happen. It is an extremely rare event. But one cannot declare anything in either direction without a great deal more information and investigation provided.
What makes you a good expert for this case?
I have over 20 years (post-fellowship training) of experience caring for children just like this child in Pediatric Trauma Centers, both Level I and Level II, in addition to 3 years of PICU fellowship training and even more years on prior to that in residency training in a busy PICU that cared for children with traumatic injuries.
How often do you encounter cases similar to this one in your practice?
Frequently during the warmer months Spring through Fall, when children are outside playing and in the winter months around the Holidays when families are traveling via motor vehicles over long distances.
Do you believe there might have been medical error?
Pt underwent Pan CT appropriately. Feeds were started 24 hr later, so it wasn't rushed. Feeds would have caused peritonitis, but no evidence of free air in abdomen before that. So, there is seems no evidence of medical error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Pt death seems unrelated to the initial event of abdomen perforation as the pt was successfully weaned from ECMO. Although it is unclear how the post ECMO course turned out to be, will need more info on that.
What makes you a good expert for this case?
I had a similar case and took care of a pt with abdominal perforation. I have also published a research on abdominal compartment syndrome which is the cause of death in most cases after abdominal perforation.
How often do you encounter cases similar to this one in your practice?
I have a seen a lot of abdominal perforation patients in similar age group, but traumatic as well as non-traumatic.
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