70-year-old Black male
Prior to stroke: seizure (2004), hernia mesh surgery (2000, 2004), PE (2004), memory loss, warfarin, Keppra, enlarged prostate (urgency to go), could still drive, play dominos with friends, went to his dr appts regularly, went to breakfast/dinner with wife, fully independent
After stroke (09-2022): dysphagia, hemiplegia left side, acute kidney failure - UTIs, incontinence, bowel incontinence, incident of sepsis
Background:
• Stroke 09-2022
• Went to rehab facility from 10-17-22 to 12-2-22 for hemiplegia on left side
• Made progress in PT, moving feet, but short-term memory was not good
• Back in the hospital on 12-2-22 after low BP, dehydration
• Saw 3 small strokes
• Lost physical progress made in rehab
• Released to new rehab 12-28-22
New Rehab:
• On rehab floor from 12-28-22 to 4-6-23, but rehab progress plateaued in February
• Transferred to long term nursing care at same facility on 4-6-23
Long term care:
• Maintaining during this time – short-term memory is very poor, needs full assistance
• On daily polyethylene glycol powder for BMs
• Sees his wife and daughter 5-6 times per week
On 6-6-23, patient starts complaining in the afternoon that his stomach is hurting. Shortly after making this complaint, he projectile vomits a large amount of coffee-ground looking substance. He states he feels much better, and the staff give him Zofran. The patient’s wife states she is concerned his bowels could be blocked because of his history with the hernia mesh and asks the staff to ensure he is not blocked.
Later that evening, the patient projectile vomits again, and it was the consistency of coffee grounds. They do an x-ray. The radiologist reports normal bowels, no blockage, no obstruction. The patient is given Zofran and fluids. Bowel sounds are documented first as hyperactive, and then later in the evening as hypoactive.
On 6-7-23 the patient does not vomit and is still on Zofran.
On 6-8-23 during the 7am shift change, the overnight nurse tells the morning shift nurse that the patient is doing poorly.
A CNA sees the patient and is immediately concerned with his health. She asks the morning nurse to look at the patient and the morning nurse tells the CNA to take his pulse ox. The pulse ox machine does not work, so the morning nurse tells the CNA to grab another one. By the time the CNA comes back to the patient’s room, the patient projectile vomited brown substance and was not breathing. The morning nurse comes in, staff attempt life-saving measures, and shortly after he is declared dead.
The patient’s wife did a private autopsy. The findings:
• acute pneumonia
• marked dehydration
• bowel obstruction (ischemic gangrene)
• stage 3 constipation
• complicated by right frontal lobe acute cerebral vascular accident
Bowel elimination documentation from 6-1 to 6-8
6-1
• Overnight: Incontinent, large size, formed/normal
• Day: Continent, small size, formed/normal
6-2
• Overnight: Incontinent, large size, formed/normal
6-3
• Overnight: Incontinent, large size, formed/normal
• Evening: Incontinent, large size, formed/normal
6-4
• Overnight: Incontinent, medium size, formed/normal
• Evening: Incontinent, medium size, formed/normal
6-5
• Day: Incontinent, medium size, formed/normal
• Evening: Incontinent, medium size, formed/normal
6-6
• Overnight: Incontinent, large size, formed/normal
• Evening: Incontinent, small size, constipated/hard
6-7
• Overnight: Incontinent, large size, formed/normal
• Day: Continent, small size, formed/normal
• Evening: Incontinent, large size, formed/normal
6-8
• Overnight: Incontinent, large size, formed/normal
Files:
No questions yet!
Do you believe there might have been medical error?
It appears a bowel obstruction lead to ischemic bowel, sepsis, and death. The patient was it increased risk for bowel obstruction which the wife who visits the patient multiple times per week pointed out to staff on 6.6.23. The most appropriate imaging would have been a CT rather than x-ray.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient was clinically worsening with fluctuating bowel sounds 6/6/23. Unclear if an abdominal exam was performed on 6/7/23. An ishcemic bowel obstruction with suspected aspiration pneumonia and sepsis was not identified early. Serial abdominal exams or a CT scan 6/6 or 6/7 likely would have identified the obstruction earlier allowing earlier interventions with iv antibiotics, bowel rest, and colorectal surgery consultation
What makes you a good expert for this case?
I have worked in the inpatient and outpatient settings as a gastroenterologist in the Texas Medical Center for 10 years.
How often do you encounter cases similar to this one in your practice?
I see a case similar to this one on a monthly basis in our tertiary care level 1 trauma center hospitals.
Do you believe there might have been medical error?
Given the episodes of projectile vomiting, further evaluation should have begun with the first episode. The presence of bowel movements does not rule-out bowel obstruction, nor does bowel sounds. There was not report of an abdominal exam—distention, tenderness.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The bowel obstruction clearly led to this patient’s death.
What makes you a good expert for this case?
I testified in a similar case earlier this year. That case was a post-operative case at a skilled nursing facility.
How often do you encounter cases similar to this one in your practice?
I do not work in LTC facilities at this time. However, I do see patient in my office with similar histories and risk factors for bowel obstruction.
Do you believe there might have been medical error?
He should have been transferred to ER because of the coffee ground emesis. Zofran masked some of his symptoms. Did staff call a physician of just use standing orders?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The delay in diagnosis caused his death
What makes you a good expert for this case?
As a generalist, I need to know when a patient needs to see a specialist. He did, urgently.
How often do you encounter cases similar to this one in your practice?
early in my career, often. lately not much.
Do you believe there might have been medical error?
coffee ground emesis is c/w gi bleed and alone warranted ER evaluation--warfarin raises the risk of GI bleeding and if a bleed occurs patients decline rapidly Projectile vomiting may be red flag of obstruction and warranted consideration of ER eval depending on how the patient was tolerating po.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
if hypotensive from gi bleed then direct relationship established if ER eval for gi bleed led to successful resuscitation/stabilization then workup likely would have revealed the pathology found at autopsy
What makes you a good expert for this case?
Years of experience in management of elderly chronically ill patients as well as med mal expert witness experience.
How often do you encounter cases similar to this one in your practice?
do not go to nursing home or exteded care facilities
Do you believe there might have been medical error?
Patient has a history of a surgically repaired hernia. Complains of abdominal pain and projectile vomiting. A small bowel obstruction is the leading diagnosis. Needed to have emergent CT scan of the abdomen. This was not done. Giving zofran was inappropriate-you needed to find out the cause of the abdominal pain and projectile vomiting,not treat a symptom. Obviously a failure to timely diagnosis a small bowel obstruction,leading to his untimely and preventable death.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The failure to timely consider a small bowel obstruction in a man who underwent prior abdominal surgery and now presents with abdominal pain and projectile vomiting caused the bowel to become gangrenous which subsequently led to his premature death.
What makes you a good expert for this case?
I have dealt with way too many cases in which a failure to timely diagnose a patient's alarming symptoms has led to injury and even death. i have reviewed over 50 cases,many of which involve a failure to timely recognize,diagnose and treat a condition which ultimately led to the death of the patient.
How often do you encounter cases similar to this one in your practice?
Occasionally we see patients who present with abdominal pain and vomiting, and promptly take them to the Emergency Room for urgent evaluation to rule out bowel obstruction.
Do you believe there might have been medical error?
After 2 episodes of projectile vomiting, the patient, who could not provide a good history because of likely dementia, should have been evaluated by a physician in the nursing home or should have been sent to the emergency department (with approval of family) for an evaluation. Without additional information, e.g. vital signs, results of laboratory tests, oral intake of fluids and food, etc, it is difficult to comment further,.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the bowel obstruction was diagnosed after 2nd episode of projectile vomiting, he could have been treated medically, probably in a hospital setting, forestalling his death. He may not have been a surgical candidate given his multiple morbidities and poor functional/cognitive status. Regardless, because of his multiple morbidities and poor functional/cognitive status, his life expectancy was likely limited.
What makes you a good expert for this case?
I am an internationally recognized expert in geriatric medicine and have worked effectively with both defense and plaintiff attorneys.
How often do you encounter cases similar to this one in your practice?
My clinical practice is currently hospital-based, serving as the attending physician to about 10-14 acutely ill persons aged 65 years or older, most of whom have multiple chronic conditions and many of whom have significant functional and cognitive deficits.
Do you believe there might have been medical error?
This patient had multiple medical problems including communication issues (e.g. poor memory) that may have contributed to inaccurately communicating his ongoing issues. On 6/6 an abdominal film was done for abdominal pain and vomiting and was unremarkable. While this alone does not exclude many possible causes including bowel ischemia, there were insufficient indications for more definitive studies such as CT with contrast. The patient continued to have BMs which would have been reassuring to staff. In classic bowel ischemia, the pain is out of proportion to the other clinical findings and did not appear to be present in this case. Because of the patient's prior (and possible new) CVA, he likely developed aspiration pneumonia from vomiting and was unable to protect his airways. This was the most likely immediate cause of death. The new CVA seems unrelated unless due to hypotension. The bowel obstruction most likely was incomplete and or was not severe until soon before he died.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I do not believe there was causation because there was no medical error to have prevented this outcome as explained above. In addition, I doubt the aspiration pneumonia (the immediate cause of death in mu opinion) was preventable given the CNS issues described. Lastly, in a perfect world, this patient would have been a very high risk for bowel resection and more likely than not would have either not survived or had a very poor postoperative outcome.
What makes you a good expert for this case?
I have been a clinician since 1982 - 15+ years’ critical care training / experience followed by 23 years as a hospitalist. Experience practicing in both large AMCs and mid-size community hospitals caring for patients with and without housestaff. Extensive research background in medical errors, patient safety and addressing a variety of solutions to prevent errors/harm. Over 20 years of medical legal consulting experience for both plaintiffs and defendants. Currently I am an Associate Professor of Medicine at Harvard Medical School.
How often do you encounter cases similar to this one in your practice?
Bowel ischemia and aspiration pneumonia are common illnesses that hospitalists may care for though more often the former is seen by surgeons and the latter when it results in respiratory failure needing ventilatory support require ICU/critical care rather than medical floor/hospitalist care.
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