Patient, 66-year-old female with a past medical history of hypertension, hyperlipidemia, uterine cancer status post hysterectomy 5 years ago, recent necrotizing pancreatitis status post laparoscopic cholecystectomy on 10/20/22, bilateral lower extremity DVT on Xarelto status post IVG filter on 11/17/22 who presented to an Emergency Department complaining of worsening abdominal pain.
Patient was previously admitted for abdominal pain on 11/01/22 in the setting of complex previous laparoscopic cholecystectomy with multiple ERCPs, she was noted to have necrotizing pancreatitis, she was seen and evaluated by GI and was discharged on 11/19/22.
According to her wife and daughter at the bedside, the patient was discharged on tramadol and Zofran and still was complaining of abdominal pain, she also has been having loose stools, shortness of breath with exertion and has been very weak since she was discharged. According to her family, she looked pale and jaundiced and had worsening abdominal pain the day prior to December 03, 2022 (Date of Incident).
However, patient returned to the Emergency Room on December 03, 2022. In the emergency room, she was found to be in septic shock and hypotensive with systolic blood pressure in the 60's and a lactic acid of 8.6.
While in the emergency room, she started vomiting bright red blood. Kcentra was given for reversal of xarelto and 2 units of PRBCs and 1 liter of fluid given and she was started on protonix gtt. The ICU intensivist APRN was consulted. An NG tube was inserted, she was started on Levophed and vasopressin and was intubated to preserve her airway.
General surgery and GI were consulted. While in the ICU, the patient condition worsen, the intensivist spoke to the spouse and daughter at the bedside about DNR code status, they both agreed with DNR and no escalation of care as well as withdrawal of all life support.
During the Summary on December 03, 2022, the General Surgeon noted that “The patient presented today with upper abdominal pain and nausea and gastrointestinal bleeding…I was contacted by the emergency room doctor with whom I discussed the case. I explained my recommendation which included…I also explained to them the urgency of gastrointestinal endoscopy to determine the source of the bleeding and the GI consultation was urgent.”
The General Surgeon also noted that “I contacted GI Doctor #1 [employed by hospital] to discuss endoscopy and the need to identify a mechanical source of this gastrointestinal hemorrhage, and I discussed with the intensivist the need for serial hemoglobins and prompt establishment of some source of this bleeding with an attempt at either endoscopy, interventional radiology, or surgical control of the acute hemorrhage.”
Due to the immediate need for the upper GI scope, several attempts were made to GI Doctor #1 which went unanswered, and a voicemail was left requesting a STATE return call.
Another STAT call was made to GI Doctor #2 who was on for GI Doctor #1. The initial call was made at 2:23 am on December 03, 2022. However, GI Doctor #2 did not return the STAT request until 2:50 am. During the conversation, GI Doctor #2, after knowing the immediate need for a upper scope, requested that the patient be placed in the ICU for "stabilization and that he would see the patient in the morning when he was able to see her."
Patient ultimately succumbed to the injuries after only a few hours in the ICU prior to a GI being able to perform an upper scope.
1. Was there a deviation from either GI Doctor #1 or #2 in disregarding the urgent need for the upper GI Scope? If so, how did they fall below the standard of care?
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No questions yet!
Do you believe there might have been medical error?
Surgeons are not qualified to determine the timing of endoscopy. The first step in GI bleeding is to stabilize the patient. I wouldn’t have said ‘she you in the morning’ but call me back after getting blood, etc . It sounds like the surgeon was panicking and trying to cover himself/herself.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Description doesn’t say what was the outcome. More details are needed.
What makes you a good expert for this case?
I have been handling complex GI bleeders for 30 years. I have taught in multiple universities. I have extensive experience working with ED and ICU attending with these kinds of cases.
How often do you encounter cases similar to this one in your practice?
Once a month maybe more given certain months.
Do you believe there might have been medical error?
Complicated case. While the delayed return call from the G.I. team is not a good look and they may have violated internal hospital policy, ultimate ownership of the patient belongs to what sounds like the ER/ICU team. Endoscopy is not necessarily the frontline treatment for massive upper bleeding in an unstable patient, in that case IR would likely be the best option so I would like to know if any attempt was made to reach them. This does not sound like a surgical case under any circumstance, however.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Complicated case. While the delayed return call from the G.I. team is not a good look and they may have violated internal hospital policy, ultimate ownership of the patient belongs to what sounds like the ER/ICU team. Endoscopy is not necessarily the frontline treatment for massive upper bleeding in an unstable patient, in that case IR would likely be the best option so I would like to know if any attempt was made to reach them. This does not sound like a surgical case under any circumstance, however.
What makes you a good expert for this case?
20 years of hospital based GI experience
How often do you encounter cases similar to this one in your practice?
Fairly frequently 3-4 per year
Do you believe there might have been medical error?
Depending on doctors 1's responsibility and when initial contact was attempted, there may be major deviation/negligence. If doctor 1 was not on call, he/she is not to be blamed; if on call, there is a major problem potentially (unless doctor 1 was, for instance, in another procedure already). Re: doctor 2, it's a bit less clear. A response time of 27 minutes in the middle of the night is not necessarily inappropriate or a deviation from the SoC, especially if that doctor was actually not on call. There is also the matter of hospital policy; e.g. some places require a response within 10 or 15 minutes. There is also concern, though, that the patient died only a few hours later; the cause of death is important, since if it was from septic shock, performing EGD or not performing it wouldn't be so consequential. Moreover, in many places, EGD is not performed in the ED, thus ICU transfer is necessary (or transfer to the OR) for EGD completion. Another point: while it is appropriate to first adequately resuscitate a patient prior to EGD (adequate antibiotics, blood pressure medications, blood transfusions, etc.), to say "I'll see the patient in the morning when I can" seems flippant in a scenario like this, and perhaps quite costly. When I'm contacted for a patient with massive bleeding, unless I'm told "this is just an fyi, we need to first scan or resuscitate or intubate (or whatever) the patient and then we'll let you know when we think the patient is ready for endoscopy", I go in immediately to assess the patient.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Causation depends in large part on the points I mentioned above in the first response/summary
What makes you a good expert for this case?
I'm a published expert in cases of GI bleeding and maintain a near 50-50 balance of defendant/plaintiff counsel matters, which I've handled at local, county, and federal levels
How often do you encounter cases similar to this one in your practice?
In general terms, several times per month. With these specific facets, less frequently, maybe a few times per quarter
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