Claims allege failure to diagnose peritonitis
Patients sent home without a proper evaluation
The surgical complication of a perforation of the bowel is not necessarily malpractice, says Kathleen Flynn Peterson, JD, a partner at the law firm of Robins, Kaplan, Miller, & Ciresi in Minneapolis. Rather, it’s the failure to diagnose and treat that complication that results in a successful claim.
"These are strong cases that get a strong reaction from juries. The majority of them settle," she says.
Peterson is seeing many more claims involving patients who are sent home without proper evaluation and experiencing complications such as compartment syndrome, bowel perforation, peritonitis, and wound infections.
"At any given moment, we have half a dozen cases where a disaster has occurred because a bowel perforation with resultant peritonitis was not recognized," she reports.
In some cases, the perforation in the bowel leading to peritonitis is discovered only at autopsy. "We have patients that become septic, slide into acute respiratory and renal failure, and end up on a ventilator and on dialysis. And still, no one recognizes the source of all this misery," says Peterson.
Here are some of the root cause of these malpractice cases involving missed peritonitis:
• The cases show too much reliance on imaging studies and inadequate clinical bedside examinations.
Phyllis Miller, RN, a legal nurse analyst in the Minneapolis office of Robins, Kaplan, Miller, & Ciresi, says, "We often see entries in the record where the physical exam is documented as being WNL [within normal limits] and the nurses have documented distended, uncomfortable, hard, round, painful.’ That tells me that somebody is not doing a very good exam."
• The cases indicate failure to take into account that peritonitis might be obscured if the surgeon placed mesh at the time of the surgery.
• The cases indicate discounting the finding of persistent free air in the postoperative setting as a potential cause for concern.
• The cases show failure to see tachycardia as the first potential sign of peritonitis.
"Tachycardia is usually symptom number one for patients with a bowel perforation," Miller says. However, surgeons tend to assume tachycardia is due to fever, heart disease, or pain and never consider a potential intra-abdominal cause.
"The bariatric community has begun to recognize tachycardia as a first potential sign of peritonitis, and lo and behold, they are seeing far fewer cases of unrecognized or delayed treatment of peritonitis," she says. "But general surgeons doing other types of abdominal surgery have not made that leap."
Many patients have ended up with multisystem organ failure as a result, Miller adds. "A lot of surgeons believe that when they closed, everything was fine, so they just don’t seem to believe there could be a perforation" she says.
Even if none of their patients have ever developed postoperative peritonitis, Miller notes that surgeons "need to watch for it all the same."
• Failure to consider infection or inflammation as a potential cause of postoperative ileus.
When an abdominal CT scan is read to include a diagnosis of ileus, many surgeons assume it is essentially benign and due to anesthesia, bowel manipulation, and narcotics.
"However, inflammation or infection can cause ileus too," says Miller. "Surgeons need to look at the whole clinical picture, including abdominal exam and vitals and fluid status, before deciding if the ileus is benign or not."