Description

A 9-year-old girl was seen in the ED three times over two days for abdominal pain, nausea and vomiting before a fourth visit resulted in a diagnosis of ovarian torsion, which required emergency surgery to remove an ovary and fallopian tube.

Key Lessons

Repeat visits for the same complaint are a red flag for a narrow diagnostic focus.
“Curbside” consults do not replace formal consults when the latter is clearly indicated
Patients and families need to know that complaints of pain and questions about treatment are taken seriously.

Clinical Sequence

A slightly obese 9-year-old girl saw her pediatrician in the hospital clinic for complaints of abdominal pain, nausea, and vomiting that started within the previous 24 hours. On exam, she was afebrile, her vital signs were stable, and she was tender to percussion in the right mid-lower abdomen. The physician noted “rule out appendicitis versus renal colic” in her record, and he sent the girl to the ED for CBC, urinalysis, urine culture, and KUB. The ED resident examined the patient and noted diffuse tenderness in the right lower quadrant, no guarding or rebound, and no pain jumping up and down. The patient denied any change in her bowel movements. She rated the pain as varying from 5/10 to 10/10 and stated it did not respond to Tylenol. The urinalysis and KUB were negative. Her CBC and electrolytes were normal except for slightly elevated neutrophils. Without obtaining a formal consult, the attending spoke to a pediatric surgeon and they concluded it was a non-surgical abdomen. The patient was discharged with a diagnosis of abdominal pain, and instructed to have a light diet and call her pediatrician if the pain or vomiting resumed.

The patient returned to the ED one hour later with increased abdominal pain and vomiting. She was examined by the same resident, who noted that her abdomen was diffusely tender, bowel sounds present, no guarding, and she was afebrile. The assessment was non-surgical abdomen, and the plan was to hydrate. The nurse noted at one point that the patient was screaming in pain, in a knee to chest position. She notified the attending, who examined the patient, reviewed the resident’s note, and indicated that the patient “looked well. No acute distress.” The patient’s mother questioned whether an ultrasound or other imaging test was needed. The attending dismissed the suggestion, telling her that the symptoms did not warrant it. The patient was discharged home.

The next day, the girl returned to the ED with right lower quadrant abdominal pain and vomiting (5-6 times). She described the pain as episodic. A different resident examined her: she was afebrile and had mild tenderness in both lower quadrants, no guarding, minimal rebound, and normal bowel sounds. No rectal exam was documented. She had not had a stool that day. The attending ED physician believed that the previous day’s attending obtained a surgical consult. He diagnosed constipation and ordered an enema, after which the patient reported feeling better. She was discharged home with instructions to increase fluid intake, take mineral oil, increase fiber in her diet, and contact her pediatrician to let her know how she was doing.

Three days later, the patient was seen by her pediatrician for continued complaints of abdominal pain and vomiting. She had a slightly elevated temperature and was orthostatic. Her abdomen was quiet with increased guarding, and she was sent again to the ED. Her white count and sed rate were elevated. A CT scan showed a normal appendix but the presence of a complex pelvic mass. Ultrasound showed torsion of the right ovary, and she was taken to the OR where infarction of the right ovary was confirmed. They removed the right ovary and fallopian tube, and the patient had an uneventful postoperative course.

Allegation

The parents sued the two ED attending physicians and the two residents, alleging a delay in diagnosis and treatment caused the permanent loss of one of the child’s ovaries.

Disposition

Following unsupportive defense expert reviews, the case was settled in the medium range.

Analysis

Clinical Perspective

The patient was seen three times in the ED for the same complaint, without additional imaging studies or a change in plan; the fact that the patient was afebrile and her initial labs were essentially normal seemed to influence the future decision making regarding the assessment and treatment.
Cognitive error is a common source of missteps in the ED. Protocols for common ED presentations, such as abdominal pain, can help with standardized testing recommendations and guidance to widen a diagnostic focus that becomes too narrow. Two or more patient calls or visits for the same complaint present clinicians with a warning sign. Continued symptoms suggest that either a more thorough workup or change in the differential diagnosis is indicated. It is always important to rule out a potentially life threatening diagnosis in the setting of another reasonable but less concerning diagnosis.
A formal surgical consult was never obtained despite ongoing symptoms.
Although a patient’s condition may show signs of improvement, continued episodic symptoms should be evaluated thoroughly. An initial “curbside” consult can offer false reassurance. If symptoms and the patient’s presentation warrant an expert opinion, a formal consult should be requested and documented. After a history and physical exam—and with the fuller information, standardized processes, and focus of a formal consult—the consulting clinician may make a different recommendation.

Patient Perspective

The patient and her mother felt that the physician was rude during the second visit, that he wasn’t listening to what they were saying about the amount of pain the girl was in, and that he was dismissive when the mother suggested obtaining an ultrasound.
Pain assessment can be challenging, especially in a child. However, minimizing a patient’s complaint is often interpreted as disrespect, rather than reassurance. Using pain scales and other objective measures, as well as discussing options for addressing pain, can help patients and families see that the clinician is taking their complaints seriously. Providers should keep the lines of communication open regarding the treatment plan, and explain carefully why a procedure is or is not appropriate. Listening to the patient and/or family’s concerns and clearly acknowledging their input will help to build a more trusting relationship

Risk Management Perspective

Documentation is unclear about what the attending physician at the second visit did with this patient; the attending during the third visit incorrectly believed a formal surgical consult had been obtained the day before.
A physician’s involvement in a patient’s care should be documented clearly to help defend the care if necessary, and to help subsequent treating physicians. Documentation should include at least all negative findings that are pertinent to the working differential diagnoses. Formal consults should be noted. Information that supports diagnosis, treatment, or follow-up plans—as well as the clinical rationale for the decisions, including ordering or not ordering diagnostic studies—is vital for continuity of care.

Legal Defense Perspective

Defense experts who reviewed this case believed that the standard of care was not met, especially at the third visit; given the amount of pain the patient was having, the previous KUB did not support the diagnosis of constipation; and a CT scan or ultrasound was needed to help detect indications of a surgical abdomen.
A malpractice defense in a failure-to-diagnose case can be hobbled when a clinician fails to order tests that could have revealed the true source of a patient’s complaints. Documenting the clinical rationale for a treatment plan is very important. When time is of the essence, slowness to order the tests is relevant to the question of whether a delay in diagnosis caused the patient’s harm. Jurors will empathize with a parent and child who were diligent about seeking treatment, but did not appear to receive the appropriate level of care.

Girl Loses Ovary After Repeat ED Visits, Delayed Diagnosis