December 9, 2024 ER visit
Clinical Context: Patient: 25-year-old, ~3 weeks postpartum (C-section).
Presentation: LLQ/flank pain, fever at approx 6:45pm. HR 110 and temp 100.5F. For unknown reasons was left in triage. Was eventually flagged as sepsis alert at 1045pm. Possible RN issue.
CT Abdomen/Pelvis: Gas in the endometrial cavity. Radiologist impression: “May represent moderate endometritis versus recent surgery/instrumentation or postpartum state. Recommend GYN evaluation.” (screenshot attached)
Labs/Vitals: WBC 16.2 w/ left shift, abnormal urine. Given 1G Rocephin, fluids.
ED Disposition: Diagnosed with UTI, discharged home with oral Bactrim DS, no OB/GYN consult.
Outcome: January 4, 2025; the patient re-presented w/ ABD pain, N/V, s/s of sepsis with: Uterine/ovarian abscess, postpartum endometritis.
Required exploratory laparotomy and left salpingo-oophorectomy. Postoperative complications including ileus, aspiration pneumonia, and acute hypoxic respiratory failure. Prolonged hospitalization and IV antibiotics. Admission was 3 weeks.
Expert questions:
Was the December 9, 2024 ER discharge appropriate? The CT and sepsis criteria required admission, IV antibiotics, and OB/GYN consultation?
Did this allow infection to progress unchecked, directly leading to abscess formation, sepsis, and loss of reproductive organs the following month?
Thank you in advance, questions welcome.
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Do you believe there might have been medical error?
The abnormal findings on the CT warranted close follow-up. Failure allowed the infectious process to progress.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It appears that infection was present on presentation to the ER in December. Failure to adequately address the issue resulted in progression.
What makes you a good expert for this case?
I am not a good choice for this case because I do not work in an ER.
How often do you encounter cases similar to this one in your practice?
Rarely. I see primarily geriatric patients and adults outside of child bearing age.
Do you believe there might have been medical error?
Given gas in endometrial cavity consider PID or acute endometritis. Pelvic exam and prob gyn consult indicated. Likely would have admitted. Consider urine and blood cultures, ask about recent gyn procedures Differential includes: pyelo, nephrolithiasis with infection, sepsis
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
uterine gas needs to be explained and uti does not explain
What makes you a good expert for this case?
ER or primary care physician with ER, urgent care or lots of outpatient experience.
How often do you encounter cases similar to this one in your practice?
lower abdominal pain and fever is a frequent complaint in the outpatient office I see patients and teach residents, med students
Do you believe there might have been medical error?
Unclear, possibly but this could reasonably be a presentation for a UTI that was treated appropriately in the ER as long as it had close follow up with gyn within the next few days or week. Without good follow up or if the patient did not look well at discharge, I would say that would be a mistake.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If there was not appropriate follow up or if the patient did not look well and was discharged anyway, this could result in the poor outcome that resulted.
What makes you a good expert for this case?
I have practiced family med with OB before and have seen patients in the ER as well. I am very familiar with care of women post op and have been in academic medicine teaching these topics.
How often do you encounter cases similar to this one in your practice?
Currently I do not practice in the ER but do see women with gyn issues
Do you believe there might have been medical error?
There is not enough information in the case presentation to state if there was a medical error. A postpartum female (3 weeks post-delivery) presented to the emergency department with fever, tachycardia, and left lower quadrant pain. Imaging revealed gas in the endometrial cavity and a small infiltrate, while laboratory studies showed leukopenia with a left shift. The appropriateness of emergency department discharge cannot be definitively determined due to insufficient documentation, including missing serial laboratory values, pelvic examination findings, urinalysis results, inflammatory markers (CRP/ESR), and details regarding mode of delivery. The differential diagnosis should extend beyond urinary tract infection to include pneumonia, given the small infiltrate on imaging and causes of gas noted in the endometrial cavity. Standard care for this presentation typically requires 24-36 hours of observation with trending of clinical parameters for improvement versus worsening symptoms prior to discharge. It is unlikely that the emergency department discharge directly caused the subsequent month's complications of abscess formation, sepsis, and loss of reproductive organs, appropriate OB/GYN follow-up should have been arranged upon discharge regardless of the disposition decision. Complete clinical documentation with comprehensive examination findings and appropriate specialist consultation would be necessary to properly evaluate the care provided.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again an abscess is a walled off area of infection, it does not typically cause fevers and would have been seen on the CT scan performed within the ER.
What makes you a good expert for this case?
Board certified family medicine physician who has treated over 50K patients in a variety of settings including treating pregnant and postpartum patients.
How often do you encounter cases similar to this one in your practice?
I have encountered abscesses, UTIs, pneumonia and sepsis in my practice.
Do you believe there might have been medical error?
Pt met sepsis criteria, was post partum and was told by the radiologist in their conclusion that there was likely a GYN related infection and that a GYN should be consulted. No GYN was consulted and pt should never have been discharged.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Has pt been admitted and an immediate GYN consult obtained, it is very likely that the pt would have had a better outcome and would likely not have needed the surgery she had. In other words, it could have been treated medically alone.
What makes you a good expert for this case?
I am FP trained and double boarded in FP and ER. I have 32 years of experience as a full time ER physician.
How often do you encounter cases similar to this one in your practice?
I frequently see post partum infections.
Do you believe there might have been medical error?
I have several questions to be able to come to a more clear conclusion as to whether med error or negligence occured on the initial ER visit: 1. Were other rule out sespis labs ordered during the first ER visit? These would be CMP, lactate, procalcitonin, CRP. 2. What were the abdominal exam findings by the ER doc on Dec 9th? This is a very important factor, as the CT scan findings are not definitive for an active endometritis. Clinical exam holds a lot of weight for that encounter. 3. Did the ER recommend follow up with an OB-Gyn or primary care visit at discharge on Dec 9? If so, did the patient follow up by seeing anyone between ER visits?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The Dec 9 visit was a point-in-time assessment of this person's clinical status. The assessment by the ER doc was presumably, that this patient did not have an acute abdomen warranting admission to the hospital at the time putting the CT findings together with his/her exam and lab results. The answers to the above questions will clarify causation.
What makes you a good expert for this case?
I have praticed family medicine in academic settings (residency training programs) for most of my career. I currently teach family medicine residents and also medcial students in the ambulatory setting. I am very familiar with similar clincal scenarios. I was a physician member of the Arizona Medical Board for 7 years through 2021, hearing and settling complaints, bad outcomes, and negligence cases on a month;ly basis.
How often do you encounter cases similar to this one in your practice?
I have supervised care for similar cases over the years, both from a persepctive of initial evaluation of post-partum abdominal pain, and evaluation of similar patients who are following up after ER visits such as this. Thanks, Ed Paul, MD
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