Legal Review & Commentary

Classic appendicitis goes undetected, leads to death

News: A man with no prior abdominal problems presented to an emergency department (ED) complaining of severe abdominal pain in the area of his appendix. Based on X-ray findings, two physicians made an incorrect diagnosis of gastroenteritis and discharged the patient from the ED without performing a CAT scan. The next day, the patient rushed from his home to a second ED. Despite evidence of a distended abdomen, wildly fluctuating white blood count, and subnormal temperatures, a CAT scan was for the second time not performed. The patient eventually began to lose consciousness and died from a full cardiac arrest that evening. After the patient’s family brought suit against both hospitals and the attending physicians, the parties settled the case prior to trial for $1.6 million.

Background: A 34-year-old male with no previous medical complaints or underlying conditions presented to the ED of Hospital No. 1 for care and treatment. He had experienced an eight-hour bout with extreme nausea and vomiting combined with severe abdominal pain. The pain was specifically located around the umbilicus. Upon examination, the patient’s bowel sounds were hypoactive, and he was remarkably tender to palpation. The ED physician ordered chest X-rays, and the flat and upright exposures revealed the presence of a 3.7 by 2.7 centimeter calcification in the right lower quadrant.

Based on the X-ray findings, the ED physician requested a surgical consult. The consulting physician evaluated the patient by ultrasound and ultimately ruled out the possibility of gallbladder disease. Nevertheless, the consulting physician recommended proceeding with a CAT scan, which never was actually ordered or performed. Without performing any additional evaluation, the two physicians made an incorrect diagnosis of gastroenteritis and discharged the man.

On the following morning, the patient was taken by ambulance to Hospital No. 2’s ED, where he was seen and admitted. Before his transfer from the ED to the surgical floor, 2,000 cc green fluid were removed from the patient by means of a nasogastric tube. The patient continued to register clear complaints of intolerable abdominal pain and reported he had been unable to eat; he was posturing in excruciating pain and there was evidence of decreased bowel sounds. Medical personnel administered morphine, which had no effect on his reports of pain. A CAT scan was ordered but never performed.

The attending physician noted the patient’s abdomen was distended, with increased pain on palpation. By this time, his white blood count was 8,000, with the first bands being recorded at 24%. Later in the morning, his white blood count fluctuated from 8,000 to 1,900, then back to 3,600. Neither the attending physician nor staff reacted to the lab results and, during the course of the afternoon, medical personnel continued to ignore the patient’s abnormal lab values. The patient also registered subnormal temperatures, which went unnoticed and, when morphine failed to relieve the patient’s pain, Demerol was ordered instead. By the time the attending physician ordered X-rays, the patient could hardly stand. By 3:45 p.m., a Swan-Ganz catheter had been inserted and a nasogastric tube was draining "coffee-ground material" with evidence of discolored discharge. By 5 p.m., the patient’s abdomen was again noted to be taut and distended, with no detectable bowel sounds. Shortly thereafter, for an unknown reason, the patient was transferred to a post-anesthesia care unit, but an anesthesiologist did not see him until 6 p.m. The anesthesiologist recognized that the patient was in tremendous pain, was experiencing difficulty breathing, and was in a life-threatening crisis. The patient’s vital signs were taken, and his blood pressure reading was obtainable. The patient began to lose consciousness and ultimately went into full cardiac arrest at approximately 6:15 p.m. Resuscitative efforts were unsuccessful, and the patient was pronounced dead at 6:45 p.m.

The decedent’s survivors brought claims against the three treating physicians and both hospitals for the negligent care and treatment of the patient. The plaintiffs argued that the patient presented with a surgical abdomen, and they alleged that Hospital No. 1 and its two physicians were negligent in their failure to diagnose the presence of simple appendicitis. The plaintiffs argued that despite the decedent’s classical, clear presenting signs and symptoms, the defendants failed to follow up with the standard of care mandated to affirmatively rule out the presence of appendicitis through the use of a CAT scan and/or other diagnostic modalities — none of which were ever ordered or performed. The plaintiffs further averred that had those diagnostic studies been performed, the decedent would have been able to undergo a timely appendectomy and would been able to make a successful recovery with no residual deficits. Rather, those defendants made an incorrect and negligent diagnosis of gastroenteritis, after which they discharged the patient from the ED.

With respect to Hospital No. 2 and the third treating physician, the plaintiffs claimed that they, too, failed to timely diagnose and treat what was a clear case of appendicitis. The plaintiffs also placed considerable fault on the staff of the hospital for not properly monitoring the patient and failing to alert the attending physician when abnormal lab results began appearing and when the patient’s pain would not subside with medication.

The parties settled the case prior to trial for $1.6 million. The breakout of damages among the defendants is unknown.

What this means to you: This case highlights several causes of preventable hospital errors, including poor communication among staff, overworked or minimally trained workers, a shortage of appropriately trained staff, and a faulty system of checks and balances.

"Unfortunately, this case illustrates how the lack of fail-safe mechanisms in the health care delivery system can expose patients to unnecessary injury, including death," says Ellen Barton, JD, CPCU, a risk management consultant in Phoenix, MD.

The sequence of events at the ED first visited by the patient illustrates the importance of providing appropriate medical care throughout a patient’s stay. "While it appears that the ED physician in Hospital No. 1 initially treated the patient appropriately by scheduling X-rays and a surgical consultation, the lack of follow-through on the recommendation for a CAT scan was an error in judgment by the ED physician and by the consulting physician," states Barton.

Errors in judgment often can be prevented by protocol. "When the consulting physician recommended a course of action, the ED physician needed to have affirmatively accepted or rejected the recommendation, thus providing an opportunity for further consideration," she continues. Thus, it is likely that it was a system error in that the recommendation for a CAT scan was not responded to as a matter of procedure.

Hospital No. 2 also committed a series of errors that led directly to the patient’s death. "First, the fact that the patient had been seen the previous day in another hospital’s emergency department is a clear signal to heighten scrutiny," says Barton.

But while the patient was appropriately admitted to the surgical unit, it appears that there were significant errors in judgment and system failures. "The second hospital failed to provide appropriate medical care for the plaintiff by ignoring the patient’s lack of response to morphine and Demerol, never performing a CAT scan despite an order to the contrary, and failing to react to the patient’s lab results or additional symptoms. Further, the patient’s transfer to a post-anesthesia care unit is unexplained by the facts presented and appears to be inappropriate," Barton says.

EDs must have appropriately credentialed medical and nursing staff. In this case, the physicians failed to order appropriate tests for what turned out to be a classic case of appendicitis. But the problem runs deeper than individual errors in judgment. "Given the particularly volatile nature of emergency departments," Barton says, "a hospital must have systems in place that would have concurrently reviewed the care. . . . Both the nursing staff and attending physician would have benefited from systems that would have triggered alerts both when the CAT scan was not performed and when no action was taken in response to the patient’s continuing pain."

Thus, despite correctly admitting the patient, Hospital No. 2 subsequently failed on numerous occasions to adhere to the appropriate standard of care. In addition to eliminating the preventable errors that surfaced throughout this case, hospitals should also ensure their own financial protection in cases where physician negligence is the sole cause of injury. In this case, it is likely that the first ED physician was under contract with the hospital and operating as an independent medical practitioner.

"In such cases," Barton advises, "it is important that the hospital contract for physician services include: 1) a provision requiring adherence to JCAHO [Joint Commission on Accreditation of Healthcare Organizations] and other regulatory standards; 2) a hold harmless/indemnification clause protecting the facility from physician liability; 3) ED group acknowledgment that each physician is engaged in the private practice of medicine and is not an agent of the facility; 4) specified limits of professional liability insurance coverage, with a carrier acceptable to the facility; and 5) a dispute-resolution provision.

"It is also important that signs are posted in the emergency department triage and treatment areas notifying patients that the physicians providing care are independent contractors. In addition, emergency department physicians should not wear lab coats or badges that contain the name of the hospital. Finally, the emergency department admission form should clearly state that the physicians providing care in the emergency department are independent contractors," she adds.

From the patient’s perspective, this case also illustrates how important it is for the patient to have an advocate. "While a patient advocate is never a substitute for appropriate care, someone who knows the patient, can accompany the patient to the hospital, can ask questions, and will insist that the nursing and physician staff be responsive to the patient’s needs could make the difference between life and death," states Barton.

She concludes, "It is no surprise that this case was settled prior to trial."


Baltimore City (MD) Circuit Court, Case No. _______.