Delayed diagnosis of appendicitis? (Case #294)

• Medical Probability: 6 / 10
• Medical Error Summary: To begin with, a few pieces of clinical information which I discuss below are necessary to answer the question with more certainty. This is a difficult case as the CT findings are equivocal but not n...
• Causation Probability: 6 / 10
• Causation Summary: Similar to my above discussion, it is reasonable to suspect the patient's symptoms and equivocal CT findings were indeed the early stages of appendicitis. So if the emergency physician did not involv...
• Expert Summary: I am a practicing emergency physician in 2 high volume/high acuity emergency departments with over 24 years of ED and urgent care practice experience. Evaluation and diagnosis of appendicitis in the ...
• Similar Summary: I evaluate patients with suspected appendicitis very frequently, nearly every shift I work. I have seen unusual presentations of appendicitis on many occasions. As I often say, patients don't read t...

15-year-old with adverse drug reaction (Case #308)

• Medical Probability: 6 / 10
• Medical Error Summary: The question that was posed primarily was "Should the patient have been admitted to the hospital earlier?" The patient was prescribed Wellbutrin on 06/17/22 and that was stopped by the mother on 07/...
• Causation Probability: 6 / 10
• Causation Summary: The fundamental question would be, "Did any delay in admission result in undue injury to the patient"? The treatment for DRESS syndrome, in addition to removal of offending agent, is steroids, IV fl...
• Expert Summary: 25 years of clinical emergency medicine practice in ED with significant pediatric population. Faculty of an emergency medicine residency program.
• Similar Summary: DRESS syndrome is very unusual. Most patients presenting with adverse drug reactions present with urticaria or respiratory issues. I don't believe I have ever personally diagnosed DRESS syndrome in ...

Foot infection after foreign body leads to gangrene, toe amputations (Case #311)

• Medical Probability: 10 / 10
• Medical Error Summary: Initial treatment was reasonable with removal of the foreign body, with the exception of an xray prior to foreign body removal, which was not done. The case overview the patient had history of diabete...
• Causation Probability: 10 / 10
• Causation Summary: Had the history of diabetes been recognized on the 6/15 visit, the patient would have had the appropriate workup, leading to earlier identification of the severity of the infection, with appropriate c...
• Expert Summary: As an emergency physician with over 25 years of clinical experience, I am an expert in the evaluation and treatment of foreign bodies in the foot, foot cellulitis in diabetics, and the pitfalls of und...
• Similar Summary: The evaluation and treatment of patients presenting with foreign bodies of the foot, diabetic foot infections, and the complications thereof, are a common occurrence for me in my daily practice. Fort...

Stab wound, necrotizing fasciitis, death (Case #326)

• Medical Probability: 4 / 10
• Medical Error Summary: Necrotizing infections develop quite quickly in patients. Perhaps if the patient had presented to ED after calling EMS on 12/26 rather than refusing transport, an earlier diagnosis could have been ma...
• Causation Probability: 4 / 10
• Causation Summary: Given the facts presented, other than delay in antibiotics, no obvious medical error from the ED side. Early surgery involvement with significant delay to OR time. ED physician cannot control this l...
• Expert Summary: I practice in a high volume, high acuity ED. I evaluate patients for wounds and wound infections on a daily basis in my practice. I have seen necrotizing infections many times during my career with ...
• Similar Summary: Not a common presentation to the ED, so I would estimate I see necrotizing infections 3-4 times a year, but remember each of them due to the stormy clinical course and high mortality. I evaluate pati...

ER Treatment of Rocephin-Induced Anaphylaxis (Case #379)

• Medical Probability: 10 / 10
• Medical Error Summary: The patient clearly was exhibiting signs of anaphylactic shock. The life saving drug that should have been administered immediately was subcutaneous epinephrine. The patient should have had this adm...
• Causation Probability: 10 / 10
• Causation Summary: Patients still die of anaphylactic shock despite optimal care. Fortunately this is rare as the medications and interventions commonly used are highly efficacious in the treatment of anaphylactic shoc...
• Expert Summary: I have nearly 30 years of experience in high volume, high acuity emergency departments and encounter patients presenting with allergic reactions on a regular basis. I am teaching faculty at an emerge...
• Similar Summary: This is "bread and butter" emergency medicine. Allergic reactions present on a daily basis to my emergency department, and I'd estimate I such a case at least every few shifts. Anaphylactic shock, t...

ED visit with abdominal pain, elevated WBC, discharged yet returns later same day with perforated appendix (Case #431)

• Medical Probability: 8 / 10
• Medical Error Summary: 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 ...
• Causation Probability: 8 / 10
• Causation Summary: 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 perfora...
• Expert Summary: 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 facult...
• Similar Summary: 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 ...