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 tachypneic 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.
Pediatric Trauma Surgeon or Pediatric Surgical Intensivist Preferred
Files:
No questions yet!
Do you believe there might have been medical error?
A lot would depend on when the patient was examined by the pediatric trauma surgeon and decision making process. Assessing a 3 year old is difficult and additional studies including laboratory and radiology should help in making the correct diagnosis. Maybe the child needed an intervention on the 6/12 evening rather than 6/13AM. No reasonable inference can be made with the data provided above which is too brief.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The child likely became septic because of small bowel content contaminating the abdomen. However, the placement of responsibility will depend on a detailed evaluation of medical records including vital signs, lab values, the work up that was initiated to evaluate symptom and so on. Would not cast blame without thorough review of records.
What makes you a good expert for this case?
I have been a level 1 pediatric trauma director. It is important to have processes in place to protect the injured child at a recognized trauma center. If there are deficiencies I may find them. I am an ATLS instructor and teach trauma course. I deal with pediatric trauma day in and day out.
How often do you encounter cases similar to this one in your practice?
A lot. We are in a busy pediatric trauma center.
Do you believe there might have been medical error?
CT did not include oral contrast - breach of SOC Failing to do this miss’ed bowel injury
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Delay in surgery led to sepsis and death Had the CT been done with oral contrast the bowel injury would have been detected. Missing this resulted in sepsis This led to an irreversible situation and death
What makes you a good expert for this case?
I’m a pediatric trauma surgeon I’m experienced in court I’ve never lost a case in which I’ve provided expert testimony
How often do you encounter cases similar to this one in your practice?
Every day I’m head of pediatric surgery at our county trauma facility- we admit several cases daily - all sorts of trauma
Do you believe there might have been medical error?
The synopsis of the case is vague. Probably done on purpose. The initial work-up appears to be appropriate. Many children have free fluid that is unexplained after trauma. The patient was clinically watched and found to have clinical signs consistent with the ability to try p.o. When this failed, there was a change in care to go to the operating room. There is a nice gap between the initiation of liquids and the patient complaining of pain and receiving morphine. It is hard to tell which time during the evening that this actually happened. There is good data that show that even a delay in operating on small bowel injury is from blunt trauma does not increase mortality as long as the operation is done when the clinical course suggest not tolerating conservative measures. The remainder of the operation/postoperative course is to vaguely to make any other opinions without seeing the entire chart.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Essentially the same question. I do not know the details of the operation and how the abdominal wall has extensive bleeding and how this resulted in sepsis. My guess is that the description of abdominal wall bleeding was actually mesenteric bleeding. But again need to review the entire chart
What makes you a good expert for this case?
I am a pediatric surgeon who has practiced at a level 1 pediatric trauma center for 20 years. There is never a simple answer with any of these cases. Dissecting the entire chart and looking at what is objective data from the chart as opposed to subjective data interpreting after the fact is of what keep to determine whether or not this Harwell come could have been avoided or is part of the underlying rate of mortality for blunt abdominal trauma
How often do you encounter cases similar to this one in your practice?
Yes, we receive many trauma victims who arrived with similar mechanisms of injury. The outside evaluation can commonly mask the ability to ascertain exact diagnoses.
Do you believe there might have been medical error?
1) The patient underwent CT evaluation of abdomen - small amount of free fluid may be seen but there was no free air suggestive of a hollow viscus injury - these injuries are delayed in presentation so not surprising that the this was diagnosed later 2) The patient reportedly had a benign abdominal exam the following day - no peritoneal signs noted so no hard indication for operative intervention
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Unclear that final outcome was from initial management - would need more information from the chart to better delineate the cause
What makes you a good expert for this case?
I am a practicing pediatric surgeon with over 20 years experience.
How often do you encounter cases similar to this one in your practice?
Previously, I had been the chief of pediatric surgery and had been involved with 2 LEVEL 1 Pediatric trauma hospitals so I have had significant exposure to these scenarios
Want to open a case or submit response?
Comments are accepted only from Pediatric Surgery experts.