June 6, 2024 (~10 PM)
PNC began experiencing severe abdominal pain and burning sensations. Thought it was menstrual-related. Took Midol, but symptoms worsened.
June 7, 2024 (1 AM):
PNC went to ER. She was triaged and given Morphine and Zofran. Positive for tenderness in RUQ.
Pelvic ultrasound and a CT abdomen/pelvis with contrast. Ultrasound negative for acute cholecystitis. CT abdomen read as normal but the radiologist notes that he was unable to visualize the appendix. Labs unremarkable, however, WBC 12.2, and urine positive for ketones. Provider sends the patient home around 5 am with an impression of gastritis.
MD suspected a hiatal hernia but also could not visualize the appendix. PNC continued to have fever and vomiting.
PNC was discharged at 5 AM with pain medication and Zofran. No offer of admission.
June 7, 2024 (~7 PM):
PNC returned to the hospital with worsening and unsolved pain in lower right abdomen.
Second CT does show “new prominent inflammation along the appendix which is dilated up to 2 cm and demonstrates multiple appendicoliths, suspicious for acute appendicitis.”
June 8, 2024:
Surgical consult who stated PNC should have been admitted earlier as the original CT scan indicated an appendix issue. Due to the delay, open surgery was required.
General surgery performed a lap appendectomy and found a severely dilated and inflamed appendix with associated perforation and feculent peritonitis.
June 9-10, 2024:
PICC line was placed, but white blood cell counts remained high.
June 11-16, 2024:
White blood cell count decreased slightly. PNC was discharged but struggled with managing symptoms, pain, and medication at home.
Our concern revolves around an inappropriate discharge on June 7 with ongoing pain, elevated WBC and lack of visualization of the appendix. PNC returned 6 hours later with perforation and required longer treatment and recovery.
Thank you in advance.
Files:
Q: Was there any repeat evaluation - physical exam, vitals, etc. before discharge?
A: Yes, pain was documented at a 6 out of 10 prior to DC. Only 2 full sets of VS were performed by nursing. I do not a specific "reassessment" performed other than a face-to face discussion about findings and diagnosis/referrals.
Do you believe there might have been medical error?
I believe if an error was made, it was on the part of the radiologist. If the surgeon states that changes concerning for appendicitis were noted on the original CT scan, then the error appears to be on the part of radiology, not the emergency physician.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The delay in care resulted in a worse outcome for this patient.
What makes you a good expert for this case?
I am the department chair for one of the busiest emergency departments in the country. I am head of the hospital quality review committee, member of the emergency department medical case review committee, and I am actively engaged in peer review of similar cases.
How often do you encounter cases similar to this one in your practice?
I evaluate patients with abdominal pain and elevated white blood cell counts most shifts. I believe the emergency physician acted appropriately in this case if the radiologist did not see the appendix nor see an associated inflammatory changes. If there were findings noted on the original scan not initially identified by the radiologist, then I believe there may be an error related to the reading of the imaging.
Do you believe there might have been medical error?
CT and exam were not consistent with appendicitis at first visit. It is very reasonable that this patient was discharged with return precautions to come back if worse, which is what happened
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Considering her appendix ruptured within hours of her discharge, there is a high likelihood it would have ruptured while admitted to the hospital and waiting for evaluation anyways
What makes you a good expert for this case?
Worked in the emergency room as an attending for over 6 years, including critical access rural hospitals without surgical consultation available
How often do you encounter cases similar to this one in your practice?
Abdominal pain of unclear origin is a frequent complaint in the emergency room
Do you believe there might have been medical error?
Based on the initial presentation and evaluation, the patient had an appropriate workup but did not have her appendix visualized on CT. Perhaps there was an opportunity to move to a different modality, or observe the patient for serial exams. Of course, the quality of the read is dependent on the radiologist, but here was mention of the first CT having findings which were not reported. This would require a peer review unrelated to the ER physician. I am not sure if the patient had persistent symptoms or if an exam had changed upon discharge. I would like to see the discharge instructions given to the patient,
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The radiology read needs to be reviewed.
What makes you a good expert for this case?
I have over 25 years of experience in Emergency Medicine and have had oversight over the quality programs at 3 different departments over the years.
How often do you encounter cases similar to this one in your practice?
I review hospital cases almost daily. Our department sees over 120 patients per day, and I also review hospital cases as the president of our medical leadership and medical board.
Do you believe there might have been medical error?
Classic case of missed appendicitis due to overreliance on imaging despite highly suspicious constellation of symptoms and leukocytosis. No offer of admission for serial abdominal exams, no surgical consult for a patient with inconclusive imaging but highly suspicious clinical presentation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is a greater than 50% likelihood that with a surgical consultation during the first visit or prolonged observation/admission for serial exams, a definitive intervention would have occurred sooner prior to perforation of the appendix.
What makes you a good expert for this case?
I am one of only a few physicians in the nation who is triple board-certified in Emergency Medicine, Emergency Medical Services (EMS, prehospital medicine), and Critical Care Medicine. I am a Fellow of the Academy of EMS, a Fellow of the American College of Critical Care Medicine, and a Fellow of the Academy of Wilderness Medicine. I am also a Registered Diagnostic Medical Sonographer. I am an Associate Professor at a large academic hospital at a top 5 public university. I serve as Vice-Chair and Chief of Critical Care Medicine within the Department of Emergency Medicine and as Executive Director of my health system's Critical Care Organization. I serve as Medical Director for Critical Care for a large municipal Fire Rescue agency. I have extensive experience in emergency medicine, prehospital care, and the Intensive Care Unit. I have taught hundreds, if not thousands, of medical students, resident physicians, fellows, advanced practice professionals (NP/PA), paramedics, and allied health professionals at all stages of their training and careers. I mentor junior faculty colleagues in all my (sub-)specialty areas. I see patients independently. I have over two decades of experience providing bedside emergency care. In my administrative roles, I serve on multiple hospital committees and provide peer review, guidance, and corrective action related to a wide range of patient safety and quality matters. I serve as a medical expert for defendants and plaintiffs and have experience providing my expert opinion. I respond to all inquiries within less than 24 hours and review medical records expeditiously.
How often do you encounter cases similar to this one in your practice?
A young patient with abdominal pain and leukocytosis, but “negative” or inconclusive imaging is a fairly common presentation that I see several times a year (and appendicitis per se is a very common presentation that I see every other shift) this “missed appendicitis” scenario is also a classical teaching case.
Do you believe there might have been medical error?
The provided history is somewhat limited. The ED provider initially suspected a biliary tract issue given location of pain, and ordered an ultrasound which was negative. A CT was then obtained, but didn't identify the appendix. The patient had ongoing symptoms and fever in the ED. The ED provider suspected gastritis and possibly an hiatal hernia. No surgical opinion was asked for or obtained. The patient was discharged home, and returned 14 hours or so later, with a more typical picture of appendicitis confirmed by the second CT. The "classic" or textbook presentation of appendicitis occurs over time, beginning with anorexia (lack of appetite), vague peri-umbilical abdominal pain, and nausea with vomiting, with the pain progressing to the RLQ, peritoneal guarding and rebound tenderness, associated with fever, and labs with elevated WBC count. This leads to a surgical consult for an appendectomy. Most patients don't present in the textbook fashion, often making the diagnosis of appendicitis difficult. It used to be that the diagnosis relied on a skilled history and physical exam on by an experienced physician and frequently surgeons would admit these patients for observation or appendectomy, as the story was not always certain. The surgical teaching was that if a surgeon didn't remove enough normal appendices, they weren't doing enough appendectomies as they were likely under-diagnosing appendicitis. The development of CT scanning many years ago has decreased but not eliminated this diagnostic uncertainty. The visualization of a normal appendix on CT typically excludes the diagnosis of appendicitis, but if the appendix is not visualized, other findings suggesting appendicitis can be identified on CT, including peri-appendiceal fat stranding, fluid, or the presence of appendicoliths. If none of these exist, the diagnosis of appendicitis is far less likely. The details of the radiologist's reports are not provided here, but from the given information, the radiologist who read the initial CT scan may have missed some ancillary signs of appendicitis given the surgeon's comment about the original CT indicating an issue with the appendix. The first radiologist's report therefore figures prominently in this question. If clinical suspicion for appendicitis remains after a negative workup, the standard of care in the ED is for the emergency physician to ask for a surgical consultation and usually admission for observation on the surgical service. From the provided information, this was neither asked for or obtained. The report of the patient presenting initially with RUQ pain, then 14 hours later returning with "worsening and unresolved RLQ pain" is vague. This could have represented a variation of the peri-umbilical pain that often is the initial finding of appendicitis. Regardless, without a clear alternative diagnosis (gastritis is a diagnosis of exclusion), mild elevation of WBC count, and ongoing symptoms, there likely was enough evidence of an evolving surgical issue that would have led a prudent emergency physician to seek surgical consultation on the first visit. If this had occurred, then the patient would have likely undergone a laparascopic appendectomy, without the increased risk of an open procedure, and would have likely not had the perforation that led to the post-surgical complications necessitating PICC line and ongoing symptoms.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the diagnosis of appendicitis is made promptly, the likelihood of perforation, abscess, or other surgical complications is far lower, allowing for a lower-risk laparascopic procedure. Once perforation has occurred, as was the case in this scenario, post-operative course is far more complicated and associated with poorer outcomes. If the emergency physician had maintained a high index of suspicion for appendicitis and not relied on a non-diagnostic radiologic finding (non-visualization of the appendix), then he would have requested a surgical consult in the ED with admission. From the consulting surgeon's comment on the second presentation, If the surgeon had been consulted on the first visit and decided to admit for observation or perform an appendectomy, the diagnosis and treatment of appendicitis would have occurred far earlier, and would have, more likely than not, resulted in a far more favorable outcome for the patient.
What makes you a good expert for this case?
I am a board-certified, residency trained emergency physician with nearly 30 years of clinical experience in high volume, high acuity urban emergency departments. I served as founding and core faculty for an emergency medicine residency training program. I have received many quality of care awards, patient satisfaction commendations, have been named as a "top doctor" in my specialty multiple times by my local medical society. I recently retired from clinical practice in September 2024. I maintain an active medico-legal consulting practice, currently involved as an expert witness in several medical malpractice matters, providing opinions for both plaintiff and defense. I have experience with pre-litigation review for case merit, generation of written reports and affidavits in support of my findings, deposition testimony, deposition and consultation for settlement hearings.
How often do you encounter cases similar to this one in your practice?
Abdominal pain is among the most common complaints by patients presenting to the emergency department, representing approximately 10% of all ED visits. The evaluation of abdominal pain is associated with high medico-legal risk given the wide differential diagnosis and the variety of presentations. There is no substitute for experience in learning this skill. I have evaluated literally thousands of patients with abdominal pain over the course of my career, making the diagnosis of appendicitis countless times, and as a result, the scenario described in this case is quite familiar to me.
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