January 25th 2023, 78-year-old gentleman with previous medical history of bilat inguinal hernia and previous SBO goes to ER for LLQ abd pain who was found to have a small bowel obstruction.
Official CT READ: “Moderate dilated small bowel loops in the mid abdominal region, which demonstrate thickening of the wall, mesenteric fat stranding and fecalization. There is change of caliber in the mid abdominal region. The findings compatible with enteritis with high-grade mid small bowel obstruction. Recommend surgical consultation.”
General surgery was consulted, and they treated conservatively with an NG tube and fluids. During his hospitalization, PC would have episodes of confusion and would remove his NG tube and IV during admission. Also, found to have increasing renal dysfunction and a declining hemoglobin.
Night of admission Surgeon notes: “I personally troubleshoot the NG which was not working and educated the patient and staff on proper sump management. The NG tube should be kept to continuous low wall suction for the remaining of the time.”
January 26, conservative treatment continues.
Night of Jan 26, RN found PC had pulled out NG tube again. They contacted surgeon and was told “OK TO LEAVE OUT” and he will re-assess when he rounds again.
January 27 1245hrs Hospitalist shows concern for hemoglobin drop (14.2 to 9.6, in 2 days) req GI to see for possible GI bleed.
January 27 1730hrs GI notes no NG tube and RN staff informed them the NG was OK to keep out per Surgery. They recommend small bowel follow through (never done), KUB, IVF and to monitor for signs of GI bleed.
KUB READ: Dilated small bowel loops with delayed small bowel transit. Findings on prior CT abdomen pelvis 01/25/2023 suggest small-bowel obstruction. Please refer to the prior CT.
January 27 2000hrs Surgeon rounds and notes: “Unfortunately last night, patient became dilirius and pulled out his NG tube and PIVs. He still is quite distended and he has not had any return of bowel function.Plan for: 1. A water soluble small bowel through, which is both diagnostic and therapeutic. 2. We recommend the patient ambulate at least three time a day, four times around the unit. 3. Correct electrolytes derangement”
No evidence the NG tube was ever replaced.
At approximately 9:00 a.m. on January 28th, PC was found down on the floor in his room by a nurse tech.He was surrounded by copious amounts of blood and coffee ground emesis surrounding him on the floor. A code was initiated and he was resuscitated and brought to the ICU. He passed later in the day.
Looking for a general surgeon who could speak on SBO/GI management and if this particular plan of care was appropriate. Our concern is about the NG tube coming out and a lack of urgency in concern to a possible intervention.
We appreciate your time and opinions in advance.
Files:
Q: When the patient removed the NGT was any blood found?
A: —
Q: Was the patient on any GI prophylaxis (pepcid, protonix, etc?
A: —
Q: Was the patient on any type of blood thinner at the time of admission?
A: —
Do you believe there might have been medical error?
This patients aspirated from a full stomach. the NG tube should have been replaced
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
With vomitus around the patients mouth, most likely cause of death is aspiration
What makes you a good expert for this case?
I am an Acute care surgeon with 18 years experience
How often do you encounter cases similar to this one in your practice?
I treat SBO all the time, at least 2 patients a week
Do you believe there might have been medical error?
SBO was mismanaged! Seems as though they sat on high grade SBO too long. Patient in addition developed a stress gastritis that led to his UGIB in association with probable significant electrolyte imbalance. Should have gone to the OR after 24-48 hrs of failed conservative therapy!
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
High grade SBO with electrolyte imbalance led to possible aspiration and stress gastritis. He failed conservative management and should have been in the OR. He was not going to ambulate in his debilitating state to open up his high grade SBO . Ambulantion helps with ileus and not mechanical obstructions.
What makes you a good expert for this case?
Acute care surgeon, trauma surgeon with critical care board certification. for about 30 yrs
How often do you encounter cases similar to this one in your practice?
Almost weekly we see SBO . Several times per month we see high grade SBO as well.
Do you believe there might have been medical error?
It is certainly within the standard of care to treat a bowel obstruction by conservative measures. NPO, IVF and NGT. The initial CT is concerning. However, once there is clinical signs of sepsis like confusion, renal insufficiency etc, then surgical intervention is indicated. In fact, if a patient cannot keep an NGT in place, that is not appropriate medical care and surgery is the next step. Not having and NGT is NO medical therapy.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This is a preventable complication. Seems like there are enough clinical signs of failed medical therapy for a bowel obstruction, and surgery would have prevented the eventual outcome.
What makes you a good expert for this case?
This is the kind of patient I treat weekly. There is definitely judgment of when to convert a patient from medial to surgical therapy, however, that judgment needs to remain within the standard of care. Once medical failure if apparent, urgent surgical intervention is needed.. I have opined on this kind of case in the past, and currently have some ongoing. This does not sound like a “bad outcome” case, but a failure to treat a small bowel obstruction that most reasonable prudent physicians would do in any circumstance.
How often do you encounter cases similar to this one in your practice?
Weekly. Bowel obstruction is a very common admission to our hospital. They ALL get admitted the our surgical service.
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