A child undergoing surgery for a ruptured appendix sustained brain damage following a perioperative cardiac arrest.
An 11-year-old boy was taken to the emergency department on a Saturday afternoon after three days of vague, diffuse abdominal pain, with concomitant low grade fever. The patient's significant past history included chronic abdominal pain, obesity, and a mild bout of gastroenteritis. He had been treated with Paregoric four days before for diarrhea. The diarrhea had stopped but the pain remained. He reported no loss of appetite.
Assessment of the patient by a junior medical resident revealed temperature of 100ºF and a slightly elevated WBC. Abdominal examination was positive for slight guarding and X-rays revealed "no free air." The junior medical resident obtained a consultation1 from a senior surgical resident. The boy was admitted to surgery under the care of the chief surgical resident for observation.
1- Providing both adequate supervision and an autonomous experience for house staff, in order to ensure the quality of patient care, is a constant challenge in physician training. Proper procedures for the level of supervision necessary should be clarified at all levels of the training hierarchy.
The chief surgical resident briefly examined the child after midnight (Sunday morning), but did not write a note2 in the medical record. As per standard procedure, a junior resident was assigned primary responsibility for the patient on admission, including documentation. However, transfer of overall responsibility for the patient at the attending level was being implemented at the request of the patient's local pediatrician. Tests done at 8 a.m. revealed a precipitous drop in the WBC.3
2- Standard procedure may not have required the chief resident to write a note in the record, but he should have ensured that a junior resident was documenting the care being given to the child and why.
3- Abnormal test results should be addressed as soon as possible after the report is received by the provider in charge. A note should be written concerning the plan of treatment to be followed. The change in the WBC was not noted nor addressed in the medical record in this case.
The patient's symptoms continued until late in the day when he began to vomit coffee ground material, and "almost arrested" according to the record. When the child's condition worsened, the junior resident informed the staff surgeon. (The junior resident believed the staff surgeon now had responsibility for the patient, but had not yet examined him.4) The staff surgeon asked the senior surgical resident to transfer the patient to the ICU and to report any further findings. The junior surgical resident called to inform him that an X-ray taken in the ICU at 6 p.m. showed a question of "free air," and that the patient was unstable and hallucinating.
4- The assignment of a staff physician who is unfamiliar to the patient or family can cause further confusion about who is responsible for the patient's care. While the staff surgeon may have been suggested by the patient's local pediatrician, the patient and family did not know him and there is no evidence in the record that he met with the patient and family before surgery was performed.
A barium enema order by the staff surgeon showed a perforated appendix. The child sustained a cardiac arrest during the procedure, but was resuscitated. An exploratory laparotomy was begun, during which he arrested again and was stabilized. The surgery was completed. The child suffered brain damage as a result of the arrest prior to or during the operation.
The child's parents brought suit, naming only the chief surgical resident and a radiology5 resident as defendants; neither the staff surgeon not the junior resident were named. The primary allegation was that a delay in diagnosis of appendicitis caused the child to arrest.
5- After the surgery was performed, a radiology report was discovered that showed a fecalith had been present on the initial X-rays a clear indication for doing the surgery much sooner.
The case was settled for $1.5 million.
Several experts who reviewed the record were critical of the apparent lack of supervision given to the junior surgical resident. Two other experts who reviewed the case were supportive of the care given to the patient, but poor documentation made the case difficult to defend.
Lack of communication among caregivers was a major factor in this case. Physician-to-physician communication in the record was nearly non-existent. The family was not kept informed about who was taking care of their child, what care was being given, what care was planned, and why.
