A 62-year-old complex male patient was seen in the ED with abdominal and back pain, and was admitted to the medicine floor for further evaluation. A surgical consult never arrived and the patient died from massive bleeding, due to an aortic enteric fistula.
- All worrisome symptoms and test results need to be followed until a conclusion is reached.
- A timely consult may help indentify an underlying rare condition, and thus save a patient’s life.
- When treating a patient with a complex medical history, it is important to evaluate all new information and not solely rely on past recommendations.
A 62-year-old male was seen in the ED on October 7th with complaints of abdominal pain for approximately two weeks. The patient had a past medical history of colon cancer, a myocardial infarction, an abdominal aortic aneurysm, as well as hypertension and hyperlipidemia. He reported cramping and diarrhea. The patient’s stool showed trace amounts of occult blood; WBC = 24.7, and Hct = 43.2. Chest x-ray was normal, but an abdominal CT scan revealed a 3.5 cm small bowel mesenteric mass. The scan was interpreted as worrisome for metastatic disease and the differential diagnosis included recurrent colon cancer, carcinoid tumor or lymphoma. The patient was discharged and told to schedule a biopsy of the mass.
The patient followed up with both his PCP and his oncologist. On November 12th, he underwent a CT-guided needle biopsy showed some inflammation, but no malignancy was identified. The patient also underwent a PET scan and an MRI, which was also negative for malignancy.
On the evening of December 26th, the patient returned to the ED and was seen by the same physician from his October visit. His chief complaint was abdominal and low back pain for the past two months, which had increased in intensity in the last two days, and was worse when he bent over. He was found to have a boggy prostate, fever (1033) and chills, 4+ guaiac positive stools, an elevated PSA, WBC = 19.3, and Hct of 30. The patient was given Tylenol and morphine, and cultures were obtained. The differential diagnosis in the ED included fever with probable prostatitis, abdominal mass and chronic abdominal pain. The patient’s PCP recommended that he be seen by the covering physician, who, after examining the patient, decided to admit him and start him on IV antibiotics pending the cultures. Potential diagnoses now included discitis, osteomyelitis, bacteremia, and endocarditis.
At about noon on December 27th, the patient was evaluated by the covering physician, who ordered an MRI and a lumbosacral spine x-ray as well as infectious disease and surgical consults. The infectious disease physician considered a possible spinal abscess, prostatitis, intra-abdominal process and endocarditis. He also ordered an echocardiogram and started him on a 3rd IV antibiotic. Three hours later, the patient refused the MRI due to pain. At this time it was noted that there was confusion over who was covering for the surgeon, and so the internal medicine physician reordered the consult; however the surgical consult was never done.
At midnight the patient was found unresponsive in his room. A code was called, but the patient was pronounced dead at 12:30 a.m. December 28th. An autopsy revealed that the patient died from a ruptured aortic enteric fistula associated with inflammation over the abdominal prostatic graft.
The patient’s family sued the emergency medicine, internal medicine and infectious disease physicians, alleging they failed to diagnose an aortic enteric fistula.
The suit was settled for more than $1 million.
- The patient presented to the ED on both occasions with positive stool occult blood that was never worked up to completion.
Patients with significant medical histories present complex problems in any health care setting. However, all symptoms, new or old, need to be worked up until an explanation can be reached. Relying on past diagnoses for current problems can limit the clinician’s differential diagnosis. This creates missed opportunities to seek the information necessary to make an accurate and timely diagnosis.
- On the second admission to the emergency department, the patient presented with a significant decrease in his hematocrit, which was not addressed.
Certain symptoms are more worrisome than others, and should be explored until a definitive diagnosis is made. Providers should consider the seriousness of the worst likely outcome when addressing problems and symptoms. When multiple pre-existing conditions exist, the challenge is to recognize when a complaint is related to a new problem, as opposed to the existing condition.
- The patient was in significant pain and unable to undergo an MRI.
If a patient is in too much pain to undergo a necessary diagnostic test, use the opportunity to expand the differential diagnosis. Increased pain can mean many different things, and does not necessarily change the clinical impression; however, if the patient is waiting for other tests and consults, it might be an opportune time to make sure the patient’s pain is being explained and addressed.
Risk Management Perspective
- The internal medicine physician ordered a surgical consult. After three hours, the consult was still outstanding and was resubmitted, yet the patient died nine hours later, having never been seen by a surgeon.
When calling for a consult, the following steps need to be acknowledged: identifying the need for the consult, timely contact with the consultant (or the consultant’s department), response time of the consult, and effective communication between the two specialties. As the requesting physician, it is important to be as clear as possible regarding the question that needs to be addressed and the urgency in which it needs to be answered. Additionally, it is essential that policies and procedures address the timeliness of requested consults.
Legal Defense Perspective
- Even though the patient’s final diagnosis was a rare occurrence, the experts were unable to support the care that was given (i.e. abnormal test results ignored and delay in obtaining a consult).
The defense team uses experts in a given specialty to review the case and conclude whether or not the care was reasonable (met the standard of care). When those reviews are negative, the decision to settle is often followed by mediation to arrive at a compromise on the amount of money to be paid to the plaintiff.