Boy Dies after Missed Ischemic Bowel

Description

A four-year-old boy with vomiting and abdominal pain was evaluated in the emergency department, treated there for gastroenteritis, and discharged home, where he died 12 hours later with an ischemic ileum.

Key Lessons

• Effective documentation of the differential diagnosis accounts for unexplained abnormal test results.
• Reevaluating high-risk patients prior to discharge may help prevent a too-narrow diagnostic focus that leads to a poor clinical outcome.
• Even with a bad clinical outcome, appropriate care with good patient instructions for follow-up that is documented can protect a defendant in a lawsuit.
• Communication with patients/parents after an event must be empathic, patient, accurate, and responsive in order to prevent further distress or a perception of dismissiveness.

Clinical Sequence

A four-year-old boy with no significant past medical history was brought to the pediatrician in the morning after a night of vomiting, abdominal pain, and an inability to tolerate clear liquids (no fever). The child was evaluated and diagnosed with influenza. The parents were advised to push fluids at home, but to go to the ED for IV hydration if he was still unable to drink and the vomiting continued.

At 1:30 p.m., his parents called the pediatrician's office to report that the symptoms were continuing; they were instructed to go to the hospital. The child was carried into the ED by his mother, an IV was immediately placed, and he was hydrated for the full three hours of his stay. An ED physician examined the child, and recommended an abdominal X-ray. Blood work revealed an elevated WBC and elevated platelet count. Chemistries were consistent with dehydration. Radiology findings read by the ED physician state "no obstruction."

During this time, the patient was only able to tolerate half a popsicle. At the end of three hours, the patient was discharged (no documentation of an examination by the doctor prior to discharge).

After discharge, a subsequent reading of the radiology findings indicated an ileus. The family is unclear as to whether they received discharge instructions or parameters for readmission; neither is documented in the record. When the family went home, each parent took a shift with the child during the night. He continued vomiting, was unable to tolerate either liquids or Tylenol, and began running a fever. At 3:00 a.m. the boy awoke vomiting and asked for his father who then assumed care. At 5:45 a.m., the father awoke when he heard his son make a "gurgling sound." He noticed his child was unresponsive, limp and clammy, and he called 911. The EMTs noted no spontaneous respirations or pulse, and his pupils were dilated. Resuscitation efforts at the hospital were not successful.

Following an autopsy, the medical examiner called the father and stated that death was caused by an ischemic ileum, a twisting of intestine that cuts off blood supply, which lasted for greater than 12 hours. In addition, the medical examiner told the father that the condition should have been picked up in the ED and on X-ray, and that this was a "classic malpractice issue."

The father requested a meeting with the hospital and the ED physician. He brought some Internet-based articles and drafted a set of questions to gain greater insight on why further tests were not ordered and why his child was not admitted. The family's perception of the meeting was that questions remained unanswered and the information obtained from the Internet were discounted. After the meeting, they sought legal representation.

Allegation

The parents sued the ED physician and the hospital, alleging failure to diagnose an intestinal obstruction leading to their son's death.

Disposition

The case settled in the mid range.

Analysis

Clinical Perspective

1. Although test results were consistent with the initial diagnosis in the ED, they also pointed to the possibility of infection and ischemia.
   Narrow diagnostic focus is a common factor in malpractice claims. Evaluation of test results with an eye toward expanding possible diagnoses rather than fitting data into a preexisting track is important when reviewing findings. The timeliness of securing radiology consults must correspond to the urgency and severity of the clinical danger to the patient. Discharge protocols should consider pending results that may greatly alter the treatment plan.

Patient Perspective

1. The parents felt their questions were not answered and their concerns minimized after their child's death, leading them to seek legal counsel.
   Self-awareness is essential before a family meeting following an adverse event. Feelings of defensiveness are common, and can undermine the effectiveness of the interaction. Patience and a careful focus on the family's needs are important in the support of families after a traumatic outcome. Effective communication skills will include recognizing and responding thoughtfully to questions and concerns, rather than minimizing or adopting a defensive posture.

Risk Management Perspective

1. Timely examination and provision of clear instructions reduced potential exposure to the pediatric practice.
   Prompt evaluation of a patient with worrisome symptoms conveyed on the telephone, as well as documented clear instructions about which symptoms would warrant further evaluation or a visit to the ED, optimize clinical care and reduce liability exposure. Easy access and clear instructions, including when to return, are important in providing successful primary care.
2. Lack of documentation of a repeat examination prior to discharge reduced defensibility of the claim against the ED physician and the hospital.
   Documentation of a physician review of the patient prior to discharge is critical to verify that the standard of care was met. A note indicating readiness for discharge, including improvement of symptoms, stabilization of condition, and review of all physical and diagnostic findings, is vital. Facilities need to develop reliable systems to notify patients and their providers—urgently if necessary—when subsequent or post-discharge readings of image studies or other tests are abnormal and different from initial interpretations.

Legal Defense Perspective

1. Two main factors led to a decision to settle the case: Experts for the defense were unable to support the ED physician's decision not to perform a physical examination at the time of discharge or integrate abnormal diagnostic results in the treatment plan; and the defendant was unable to maintain a professional demeanor during legal proceedings.
   Courts rely on evidence, including testimony of other physicians about the standard of care. A single negative expert review would not typically be enough to decide to offer a settlement instead of going to trial. Multiple reviews make a trial much less likely. Even the most supportive reviews, however, can be off-set by a physician who cannot be an effective witness for his or her own defense. Defendants are much more successful if they consider advice from defense counsel or liability claims professional and take advantage of such aids as psychological counseling or trial preparation professionals.
2. The medical examiner's remarks to the father about a "classic malpractice" case may have planted the seed for a lawsuit.
   Patients do not necessarily benefit from a malpractice suit, and providers almost certainly do not. Statistically, such litigation is unlikely to end up in financial reward. In general, physicians and other health care providers must be very careful in delivering their opinions about liability or the cause of an adverse outcome to patients and family. Opinions are often made without all the necessary information. Stating that a cause of death is due to negligence is likely to foster distrust that cannot be reversed with subsequent, exonerating information; this results in on-going pain for the patient or family that may be unnecessary. Further, such comments by subsequent treating clinicians or colleagues is likely to lead to subpoenas to testify as a witness in the resulting litigation.