A 31-year-old man died of a cardiac arrest due to overwhelming septicemia secondary to sigmoid bowel perforation following discharge from an emergency department at which he had been evaluated that day for abdominal pain.
- Avoid over reliance on the patient as diagnostician
- A standard process helps avoid a narrow diagnostic focus, especially when the answer seems “obvious”
- Assure patients at discharge that their care has not ended
A 31-year-old male presented to the emergency department (ED) at 9:00 a.m. for evaluation of bilateral low abdominal pain, vomiting, and diarrhea that began earlier that morning. He was seen by a triage nurse who documented a set of vital signs (T 96.0, P 81, BP 115/60); a history significant for a right anterior cruciate ligament reconstruction; and a medication list that included Plavix and Oxycontin. The triage note also included a statement by the patient that he had been seen, at another ED, for similar symptoms two weeks prior and diagnosed with narcotics withdrawal.
A nursing flow sheet begun at 9:30 a.m. noted that the patient appeared diaphoretic and pale. He was doubled over with “multiple ecchymotic areas over his entire body,” and states “he is withdrawing from Oxycontin.” The on-duty physician (a moonlighting gastroenterologist) examined the patient and an intravenous line was established; he was treated with 1000 ml of normal saline. A second set of vital signs was recorded at 10:00 a.m. (HR 67, RR 20, BP 96/45).
The physician’s evaluation noted “moderate distress,” and on abdominal exam “faint bowel sounds, soft, nontender except for mild tenderness bilaterally in the lower quadrants… no rebound or guarding.”
Laboratory evaluation revealed a white blood count of 12.3; hematocrit normal; platelet count 346,000; and normal basic chemistry and liver function tests. Radiographs (KUB and upright) were interpreted to reveal a non-specific bowel gas pattern. The physician made a diagnosis of narcotic withdrawal, referring to the patient’s history of opioid dependence for chronic pain following his knee operation, as well as to a recent visit for abdominal pain to another hospital, where he was diagnosed with narcotic withdrawal. After treatment with Compazine and clonidine, improvement in the patient’s symptoms was documented.
The patient declined a referral to a detox center. He was discharged at 3:00 p.m. with a prescription for a clonidine patch and instructions to follow up for detox. He filled his prescription and went home. Later that evening, his wife found him on the bathroom floor, unresponsive. EMS providers, who were dispatched at 9:00 p.m., found him to be in an asystolic cardiac arrest; CPR was performed. He was transported back to the hospital, where CPR was continued, but died at 10:30 p.m.
Autopsy identified a sigmoid perforation with associated peritonitis and septicemia as the cause of death. A later finding of Ehrlers Danlos syndrome in the patient’s daughter raised the possibility of a predisposing condition.
The patient’s wife filed a suit against the ED physician alleging failure to diagnose a rupture of the sigmoid colon, leading to his death.
The case was settled for more than $1 million.
- A young patient who admitted drug abuse and told of a prior complaint being attributed to withdrawal, narrowed the ED physician’s diagnostic path. In effect, the physician’s mind was made up before sufficient objective information was acquired.
Patients should be encouraged to be open about past medical history. A self-diagnosis offered by a competent patient is also valuable, but should not be used as a substitute for a thorough history and physical. Symptoms and test results that “confirm” the patient’s story can also direct the diagnostic process away from a broader review. Open consideration of a broad range of differential diagnoses reduces the risk of missing a serious problem.
- The physician did not demonstrate any concern for, or argument against, a surgical abdomen. To that end, the physical examination was incomplete and testing that might have identified the bowel perforation (i.e., CT scan) was not ordered.
Physicians evaluating (otherwise healthy) patients who present to the ED with abdominal pain may have to accommodate for the expectation of a benign cause. A paradigm of excluding life-threatening conditions and compulsive re-evaluation of the patient diminishes the chance of jumping to the wrong conclusion.
- The patient was not given discharge instructions that impressed a need to return to the ED for worsening symptoms. He inferred that he was not at risk for having a life-threatening diagnosis.
At discharge, patients take their cues from the tone of that process. If their impression is that “this care encounter is over,” they may hesitate before returning to the ED if they experience recurring or new symptoms. Instructions, both oral and written, should outline specific signs or symptoms that warrant a call or return to the ED. Encourage patients to err on the side of caution if they feel the need to return.
- Despite a condition that might have been missed during the initial ED visit—even with optimal care—this case was rendered indefensible by the missteps involved: a missed life-threatening diagnosis; an assigned diagnosis that is socially stigmatizing; a sudden and unexpected death; limited documentation; and incomplete discharge instructions.
Jurors/arbitrators presented with a litany of substandard care are unlikely to favor a defense based solely on causation. The risk of a jury determining damages for the death of a young family man justified settlement.