Narrow Diagnostic Focus in the ED

Description

A 29 year-old female, with a one-month history of peptic ulcer disease had a small bowel obstruction that eventually infarcted, requiring surgical removal and colostomy.

Key Lessons

Clinical Sequence

29-year-old female with a one-month history of treatment (Tagamet) for presumed peptic ulcer disease (PUD) presented late at night to the Emergency Department (ED) with 36 hours of severe left-side abdominal pain. The patient was evaluated by both a resident and an Emergency Medicine attending. She had a soft abdomen with left upper quadrant pain, epigastric tenderness, and guaiac negative stool. A KUB revealed no obstruction and no acute abnormalities. She received Zantac and Phenergan without relief; she later received IV fluids, Maalox, viscous lidocaine, and Demerol (25mg IV x 3) with improvement in pain. After six hours in the ED-with improved abdominal symptoms-the patient was discharged home with instructions to follow-up with her PCP as soon as possible.

When the patient saw her PCP later that day, she described her ED visit, stating that she was still experiencing some abdominal discomfort. After further tests, including a repeat KUB, did not reveal any evidence of bowel obstruction, the PCP sent the patient home with instructions to return with any worsening symptoms.Later that afternoon the patient passed some bloody stool, which she attributed to her PUD. Six hours later, feeling "out of it," her husband brought her back to the ED for another evaluation. She arrived tachycardic, hypotensive, pale, and in moderate distress.

In the ED, a repeat KUB revealed multiple loops of dilated small bowel consistent with a distal small bowel obstruction. In the OR, the patient was found to have bowel ischemia requiring two abdominal surgeries complicated by short-gut syndrome and a one-month hospital admission. The patient eventually returned home and to part-time work.

Allegation

The patient filed a suit against the ED resident, ED attending, and PCP, claiming misdiagnosis and delay in diagnosis resulting in significant expense, suffering, and adverse impact to her quality of life.

Disposition

Defense verdicts were returned for all three physicians.

Analysis

Clinical Perspective

1. The patient carried a presumptive diagnosis of PUD (no definitive study had ever been performed to confirm the presence of peptic ulcers) which may have inadvertently colored the subsequent diagnosis.

   A presumptive diagnosis should raise a flag for broadening the diagnostic process that might be (appropriately) narrowed by a confirmed condition.

2. A misunderstanding of the patient's pain may have ultimately affected her care. The plaintiff testified she had reported constant, unrelenting pain that required intravenous narcotics. The ED chart, however, documented that the patient's pain had resolved after small amounts of analgesia, and that she agreed to go home and follow up with her PCP.

   Unrelenting pain, as argued by the experts reviewing the case, should prompt further diagnostic studies (e.g., abdominal CT scan). Documentation of pain resolution supports the argument that evidence for bowel obstruction was lacking and that the decision to pursue further diagnostic studies as an outpatient was appropriate and within the standard of care.

3. Volvulus is very rare in this patient's age group.

   Although it would be on the diagnosis differential, it would be one of exclusion.

4. Although no surgeon was initially consulted when the patient presented to the PCP's clinic, this didn't indicate that the PCP wasn't following the standard of care.

   A set of labs, improved abdominal pain, and a recent ED visit would arguably make most PCPs feel that such abdominal pain should be monitored with close follow up and clear indications of what the patient should be looking for (fever, bloody stool, etc).

Patient Perspective

1. The PCP did not properly diagnose my volvulus when I saw her after the first ED visit.

   While this would be a difficult diagnosis to make in a clinic setting-given continued symptoms and repeat visits-a digital rectal exam and testing for occult blood might have changed the diagnostic process, or led to admitting the patient for observation.

2. I thought my bloody stool was from my PUD.

   While bloody stools generally scares patients to go immediately to the ED, or at least call their PCPs, this is not a universal response. Oral and written instructions must be very clear on "signs to look out for."

Risk Management Perspective

1. Return instructions and follow-up care were appropriate.

   The ED staff's insistence upon repeat examination by the PCP on the day of discharge was appropriate. While the patient recalls verbal return instructions relevant to her symptoms, written instructions would have been preferable.

2. The standard of care has changed for patients with severe abdominal pain.

   Since the date of this event (1995), ED protocol for patients with severe abdominal pain have changed-they usually always get abdominal CTs-so similar cases are now less likely.

Legal Defense Perspective

1. This case has several elements that can lead to a claim: multiple providers, presumptive diagnosis, narrowing diagnostic focus, rare diagnosis, and significant resulting morbidity.

   Expert testimony explaining the standards of care, and testimony noting the rarity of the specific event aid the defense team. Clear documentation of appropriate care is difficult for the plaintiff to refute, even when the outcome is unexpected and unfortunate.