At 12:30 p.m., Tuesday, a four-year-old boy with a history of surgical repair of
a volvulus (at age two) was brought to the emergency department (ED) due to increased
lethargy, bilious vomiting for 18 hours, and constipation for two days. On admission,
the patient was afebrile, his pulse was 180, and his respiratory rate was 44. The
white blood count was 2.4, with a shift to the left; BUN was 27 with a serum bicarbonate
level of 20.
At 2:00 p.m., the ED flow sheet stated “awaiting general surgical consult.”
At 3:30 pm, KUB films showed “dilated loops of bowel, which may represent a partial
or early small bowel obstruction.” Placement of a nasogastric tube immediately drained
400cc of bilious fluid. The patient was given two boluses of 250cc of normal saline,
followed by five percent dextrose in half normal saline at 40cc per hour. The child
was diagnosed with “partial small bowel obstruction” and was admitted to the surgical
service.
At 4:00 p.m., the patient was seen by a surgical intern (PGY1). She took the X-rays
to the attending surgeon of record (who was in the operating room with another patient)
and his surgical assistant, a fourth-year general surgery resident. The attending,
who had performed this child’s first surgery two years prior, and the resident agreed
that the films showed a partial small bowel obstruction. The attending ordered that
IV fluids be continued, that additional labs be ordered, that an additional KUB
be obtained at 7:00 p.m., and that an infectious disease consult see the child once
he was moved to a surgical floor (which occurred around 6:00 p.m.).
At 6:00 p.m., when the attending surgeon finished his prior case, and just prior
to his leaving the hospital for the day, he asked the fourth-year resident to see
the boy with the bowel obstruction.
At 6:30 p.m., the resident found the patient’s abdomen non-distended with no signs
of peritonitis. She ordered that the repeat KUB and labs be obtained then, rather
than 7:00 p.m. She was aware that the blood count had a shift to the left.
At 6:45 p.m., the KUB films showed a worsening small bowel dilatation consistent
with a small bowel obstruction (Radiology’s official read would be Wednesday morning).
At 7:00 p.m., the resident phoned the attending surgeon with the results of her
exam: she believed that the patient looked stable, but had not yet seen the repeat
X-rays.
From 7:00-9:00 p.m., the general surgery resident was on evening rounds and, thus,
did not see the 6:45 film.
At 9:00 p.m., a nurse notified the resident that the child did not look right and
he was not responding to a needle stick. The resident left rounds and found the
child lethargic, with a heart rate in the 180s.
At 9:45 p.m. the general surgery resident then asked the senior resident (a pediatric
surgical fellow) to see the patient. He ordered a third set of films (the child
fainted in X- ray), which showed more clearly that a closed loop obstruction had
occurred, and contacted the on-call surgeon.
At 10:15 p.m., the on-call surgeon prepped for emergency surgery. Antibiotic therapy
was instituted and the patient was taken to the OR around 10:45 p.m. A 12-inch segment
of dead bowel had to be removed. During surgery, the patient suffered cardiovascular
collapse, lost his aortic pulse, and had to be resuscitated via CPR. The post-operative
course was complicated by hypotension due to overwhelming sepsis and terminal shock.
ECMO (heart-lung machine) was required to keep the child alive.
