Avoid Allegations of Failure to Diagnose Appendicitis
The first thing for emergency physicians (EPs) to remember to avoid missed appendicitis claims, says Kevin Klauer, DO, EJD, chief medical officer at Canton, OH-based Emergency Medicine Physicians, is that "nobody sends the classic presentation of anything home. Very few patients with appendicitis presenting with vomiting, fever, elevated white blood cells, and right lower quadrant pain are going to be missed."
For many high-risk conditions, including appendicitis, it's more likely that an ED patient will present with an atypical presentation than the classic presentation, says Klauer.
"If you wait for the textbook presentation, I guarantee you are going to miss appendicitis —probably more frequently than you are going to diagnose it," he says.
Klauer notes that appendicitis tends to be a migratory pain early in the disease course, and moves closer to the classic presentation over time. The problem is that by that time, the patient might be rapidly approaching a complication like sepsis and/or perforated appendicitis.
"It would be easy to tell everyone with abdominal pain, 'Just wait until things get really bad and then we'll know what's going on,' but you can't take that approach," he says. Klauer recommends these practices:
• EPs should not prematurely close the differential diagnosis for any abdominal pain patient without a definitive diagnosis.
In this case, all that should go in the chart are the patient's symptoms, not a diagnosis, says Klauer. He frequently sees claims in which the EP documented a diagnosis in the chart prematurely, with little to no evidence supporting his or her conclusions.
"The big issue that I see frequently is that many practitioners will feel forced to label somebody's symptoms with a diagnosis," he says. "If I could say one thing that would reduce risk of the misdiagnosis of appendicitis in emergency medicine, it would be never use the term 'gastroenteritis' as your initial impression or diagnosis."
• If patients have abdominal tenderness on palpation, the EP should suspect something other than viral gastroenteritis.
"Pain, perhaps. But actual tenderness? That's another story," says Klauer. "Most people have some sort of pain with diarrhea or vomiting. But tenderness to touch is a very different thing, that oftentimes people lump into the same category."
• Have "the appendicitis talk" with any patient being discharged with undifferentiated abdominal pain.
"If you tell the patient, 'This is probably nothing serious, and I think you can go home,' and it ends there, that's when you are going to have trouble," says Klauer.
Klauer tells patients, "Appendicitis fools us very frequently early on in the disease process. I don't think you have it right now, but if you do, these are the things that are going to start to happen. Your pain may to start to move to the right lower quadrant, or you may develop a fever. If that happens, I need you to come back, because although appendicitis is unlikely, it is still a possibility."
This way, if the patient does get worse, he or she will return to the original ED instead of going to another ED to get a second opinion — this time with high fever, vomiting, elevated WBC, and an obvious diagnosis.
"The next EP then says, 'I can't believe they missed this and sent you home,' which plants a seed in the patient's mind that something was done wrong," he says. "This is the beginning of the gestational cycle of a lawsuit."
• EPs should be clear on the limitations of diagnostics by stating, "CT scans are very good tests for appendicitis, but they are not perfect."
EPs often tell patients, "Your CT scan is normal and you don't have appendicitis; therefore, you have gastroenteritis." "That's a mistake," says Klauer. "The patient has to know that the tests aren't perfect and they may not have an answer every time."
• EPs should consider telling patients to return the following day for a re-check, and to come back sooner if symptoms worsen.
"Despite all of the advances in diagnostic technology, the single best test for identifying appendicitis is observation over time," says Klauer.
Follow up prevents claims
Scott Martin, JD, a partner in the Kansas City, MO, office of Husch Blackwell, has defended multiple appendicitis cases naming EPs. "Medical literature indicates that there is a significant risk of misdiagnosis of appendicitis, especially early in the process," says Martin.
Martin says that many missed appendicitis cases against EPs could have been potentially avoided with more diligent follow-up. "This certainly includes a primary level of responsibility by the patient and/or the patient's family," he acknowledges.
To the extent EPs develop a clear follow-up plan, document that plan, and obtain the patient's confirmation of the plan, says Martin, the patient has a better chance at actual timely follow-up.
"Alternatively, if the patient does not follow the plan to her detriment, the emergency room staff may have a complete defense or at least a comparative fault argument," says Martin.