26 yoa male was a restrained driver who was hit head on. He did not go to the hospital right away but went home. He presented on his own 12 hours after MVA to stand alone ED the next morning after having diffuse lower abdominal pain. Bowel sounds are normal. Abdomen is soft. 135/89 RR20 (97.9 °F) 99% WBC 12.79, Hb 13.9, Ht 39.3.
Initial CT Chest Abdomen Pelvis W IV Contrast at stand alone ED - Impression: Findings suggestive of traumatic soft tissue injury to the left pelvis. This is manifested by edema and thickening of the left-sided abdominal wall musculature including the rectus abdominis, internal and external obliques and transversus abdominis muscles. Additionally, there is diffuse intraperitoneal edema and mesenteric strandiness in the left upper and mid pelvis centered on a short segment of upper sigmoid colon. There are small pockets small amount of free intraperitoneal fluid in the bilateral pericolic gutters and pelvic cul-de-sac. The fluid in the left paracolic gutter is of high-density suggesting hemorrhage. There is no evidence of active extravasation of contrast material to suggest active bleeding. There appears to be focal wall thickening of a short segment of upper sigmoid colon in the epicenter of mesenteric edema. No evidence of bowel perforation. Tiny peripheral low-density focus in the right hepatic lobe measures 4 x 6mm. This is similar to small for confident characterization. No overt evidence of traumatic injury to the liver. No evidence of solid organ injury. No evidence of bony fracture. No infiltrates to suggest contusion, atelectasis, or pneumonia. He was urgently transferred to trauma center.
At the trauma center: There was a seatbelt injury noted across LLQ, abrasion dressed. Initial abdominal tenderness (mild) in LLQ but reported as soft no distention. Reported abdominal pain. No abdominal distention noted through admission.
Soft, nontender on exams on 02/16 (day 2).
HCT 29.5, Hgb 10.1 on 02/15 at 1944
HCT 34.6 Hgb 11.8 on 02/15 at 2142
HCT 27.1 Hgb 8.9 on 02/16 at 0003
Transfused 1 unit sometime between 0350-0403
WBC 9.1 02/16 at 0403
Hgb 11.8
Hct 34
C02 - 25 on 02/16 at 0403
WBC next day on D/C 9.1. Hemoglobin 11.8 hematocrit 27.1.
Vitals at discharge:
BP 128/71
Pulse: 87
Temp 37 °C (98.6 °F) (Oral)
Resp 20
Ht 1.778 m
Wt 79.4 kg
SpO2 97%
BMI 25.11 kg/m²
Smoking Status Former
BSA 1.98 m²
It does not appear any CTs were done at the trauma center, they relied upon the one done earlier that day at the standalone ED on 02/15. He was discharged home 1 day after admission to trauma center.
He returned 3 days later on 02/19 with severe abdominal pain to the free standing ED.
"Pt endorses that around 6 PM last night he began to feel very bloated. As the
night progressed, the pt began to feel worsening abdominal pain and shortness of breath. Pt's mother mentions that the pt has not had a bowel movement since the car accident even though they have been trying stool softeners. Pt denies any CP, N/V/D, back pain, dysuria, hematuria, fever, chills or any other associated sx at this time."
A repeat CT showed:
1. Interval development of small volume pneumoperitoneum with suggestion for localized wall defect along the posterior wall of the proximal sigmoid colon which would be worrisome for perforation. Redemonstrated is complex fluid about the distal descending colon and proximal sigmoid colon concerning for hemorrhagic fluid. Recommend urgent surgical consultation.
2. Mild interval increase in small volume fluid in the pelvis.
3. Redemonstrated is low density area involving the left rectus abdominis
muscle which could be seen as sequela of injury/contusion.
4.Suspicion for left lateral lower abdominal wall defect through which fat is herniating through.
Labs on 02/19:
WBC
RBC
Hemoglobin
Hematocrit
13.58 (*)
4.14
12.6
36.0
He returned to the trauma center wherein her underwent exploratory laparotomy, sigmoid colectomy on 2/19/2024 and reopening of previous ex lap, colostomy placement and closure on 2/21/2024.
Files:
No questions yet!
Do you believe there might have been medical error?
There was a significant delay in definitive care for this patient. When the patient was transferred from the initial ER to the trauma center (which was the correct management), the acute care surgery team should have taken this patient to the OR regardless of hemodynamic status based on the findings on the initial CT. The patient had a high speed mechanism with a positive seat belt sign which already is associated with high risk of intra-abdominal organ injury and warranted an admission. They mistakenly discharge the patient. Regardless of this, there was known intra-abdominal/RP free air and free fluid which is perforated viscus and belongs in the operating room for formal exploration.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Had the patient gone to the operating room on initial presentation to the trauma center, there is a possibility that the patient could have undergone a single definitive surgical intervention, had GI restoration at that time, and not have had complications that led to re-exploration and colostomy/the morbidity associated with this re-operation. I would have to review the records in full to see what the status of the patient was in the index operation as well as hemodynamic status, details within the operative report, etc to make a determination. Either way, avoiding delay in definitive management is the best practice for minimizing complications associated with surgical procedures.
What makes you a good expert for this case?
I am board certified in general surgery as well as surgical critical care (emergency general surgery, trauma surgery). have managed hundreds of patients with motor vehicle collisions/blunt traumatic injury and am well versed on the pre-operative planning, intra-operative procedures and decision making, and the post-operative management of these patients. I have also reviewed similar cases from a medical legal perspective. I have experience with leadership and developing clinical practice guidelines on blunt traumatic injury algorithms both from the operative standpoint as well as the ICU post-operatively standpoint.
How often do you encounter cases similar to this one in your practice?
Similar cases are part of my routine practice.
Do you believe there might have been medical error?
When there is free fluid in the abdomen after trauma with the absence of solid organ injury, there should be a high suspicion of hollow viscus injury. This is especially true in males. (Women can have some physiologic intraperitoneal free fluid.) The concern is especially high with prominent seatbelt sign.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the injury would have been noted at the first admission, it may have been that the patient could have avoided bowel resection, or, more likely, could have avoided a colostomy. I With prompt diagnosis, a primary repair may have been possible. One approach could have been exploratory laparoscopy to see the character and possible source of the intraperitoneal fluid and further intraoperative decisions made based on that information.
What makes you a good expert for this case?
I have been a full-time trauma and acute care surgeon at a busy level one academic trauma center for 16 years.
How often do you encounter cases similar to this one in your practice?
I see blunt trauma patients virtually every day I am on the trauma service which is about 7-9 days a month
Do you believe there might have been medical error?
Hollow viscus injuries in the setting of trauma, especially blunt trauma are tricky as one needs to rely on two things to decide on exploration of the abdomen: 1. Abdomen exam (e.g. signs of peritonitis or diffuse abdominal pain), and 2. proxy imaging findings (e.g. mesenteric stranding, bowel wall thickening, free fluid). It is rare to see frank and clear signs of hollow viscus injury on initial CT (e.g. free air or a defect in the wall). As such, this patient inital CT images were very concerning for a hollow viscus injury and the fact that he had significant abdominal pain should have led, more likely than not, to longer period of watching or a low threshold to explore the abdomen in an open or laparoscopic fashion.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is no causation as to the injury, but there is likely delay in recognition of the injury and decision to operate or transfer for operation. Those CT imaging findings were very concerning for fhollow viscus injury and the patient had diffuse abdominal pain upon representation (evolution of symptoms from day of injury).
What makes you a good expert for this case?
1. I am an attending trauma surgeon with a total of 21 years of surgical experience, 12 of which as an attending surgeon at the busiest trauma center in the New England area (MGH), a level 1 university affiliated center. I am also a professor of surgery at Harvard Medical School 2. I am currently the Trauma Medical Director at MGH, and oversee all trauma-related activities, including QA, M&M, and peer review for the entire trauma center. 3. I am the hospital director of quality and safety, and oversee all safety/quality related activity at the hospital level, including root cause analyses and safety analysis of all safety events.
How often do you encounter cases similar to this one in your practice?
I encounter similar cases directly or for review every week.
Do you believe there might have been medical error?
Patient was a restrained driver in MVC, with typical presentation of hollow viscus injury/mesenteric injury after blunt trauma. He complained over time of lower abdominal pain that progressed over time, again classic of bowel/hollow viscus/ mesenteric injury. Had some bleeding in lower abdomen/pelvis with drop in hgb/hct. Mild leukocytosis also developed.Ct scan initally revealed evidence of abdominal wall contusion, sigmoid colon edema and free fluid which ina male is totally abnormal. He should have had an exploration miniimally a laproscopic exploration within several hours , convert to open if injuries are appreciated or if unable to visualize the entire bowel well by laprascopic exam.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
He developed perforation with development of severe sepsis due to delay in laparotomy. Injury may have been fixable primarily, rather then need for colostomy and resection. He should have been observed closer during his first hospitalization, made npo, and perhaps a repeat CT scan would have facilitated his care sooner.
What makes you a good expert for this case?
I have been a Trauma Medical Director for many years, caring for many patients with this type of injury mechanism. Fellowship trained in Trauma Surgery and Surgical Critical Care.
How often do you encounter cases similar to this one in your practice?
10 -20 cases/year of RD/MVC presenting with seat belt sign and abdominal pain.
Do you believe there might have been medical error?
The patient was transferred to the trauma center with abdominal pain and a CT scan demonstrating bowel injury and intraabdominal fluid after an MVC. The patient should have undergone diagnostic laparoscopy or laparotomy to rule out bowel perforation in response to the combination of clinical presentation and CT scan findings. Instead, patient was discharged the following day. No surprise the patient returned a few days later with intraabdominal sepsis!
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Had a diagnostic laparoscopy or laparotomy been performed at the time of initial presentation, the bowel perforation would have been treated sooner. This is a case of delay in diagnosis. The missed bowel injury led to ongoing perforation and leakage, causing the patient to deteriorate and then ultimately need emergent laparotomy.
What makes you a good expert for this case?
I routinely manage cases just like this. I also have many years of experience as a surgeon and expert witness.
How often do you encounter cases similar to this one in your practice?
I manage patients with bowel perforation on a daily basis.
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