Allegation:
A delay in treatment for hepatic lesions in the untimely death of the patient.
The Case:
The patient, a 44 YOF (5’4”, 170 lbs.), presented to the hospital with symptoms of appendicitis. She reported that four days prior, she developed right lower quadrant pain that was intermittent and cramping. She then developed a fever of 102°F along with chills, nausea, and vomiting. Her past medical history included atrial flutter, hypothyroidism, v-tach, IBS, and psoriasis.
A CT of the abdomen and pelvis was ordered, and showed the appendix was dilated up to 16 mm in diameter with surrounding inflammation. Pelvic findings showed a fluid density structure in the right adnexa measuring 6 cm x 2.4 cm. Final impression was appendicitis and possible dilatation of the right fallopian tube versus right ovarian cyst.
The patient was taken to surgery that day for a laparoscopic appendectomy; the procedure was uncomplicated. She was discharged the following day. The pathology report was returned three days later and stated the site of perforation had not been identified. In the deposition testimony, the treating surgeon testified an answering service got a call on the evening the day after surgery in which the patient's husband reported she had a fever of 103 °F and was vomiting. The call was handled by a covering general surgeon associate who told the family to take plaintiff to the ER; however, this was not documented in the medical record.
Four days after initial discharge home, the patient presented to the same hospital with SOB and mild mid-sternal chest pain. She stated she called her surgeon’s office and they referred her to the ED. Upon arrival, she was tachypneic, diaphoretic, and her pulse ox was 40% on room air. Her respiratory exam showed severe respiratory distress with rales present to bilateral lower lobes, and she could only speak a few words. She was placed on a 100% non-rebreather mask and her O2 sats improved to the 70s, but she remained tachypneic.
An EKG showed sinus tachycardia with no ST elevations or depressions. The patient was placed on BiPap, which she did not tolerate; her O2 sats remained in the 70s, and she became drowsy with increased work of breathing. She was then intubated and her O2 sats improved to the 90s. She was taken to CT to rule out a pulmonary embolus, which was not seen. The radiologist noted diffuse bilateral air space disease consistent with PE, pneumonia, or acute respiratory distress syndrome (ARDS). He noted a hypodense lesion in the lateral aspect of the right hepatic lobe measuring 2.9 cm on image #215 series 2.
Because of her elevated WBC at 22,000, the emergency medicine physician started her on broad spectrum antibiotics. Her lactic acid was elevated at 7.1. She was admitted to the ICU. While in the ICU, the patient was attended by the defendant critical care physicians. Following her admission to the ICU, she was unable to be moved for a number of days due to her respiratory instability. There was an ID consultation two days after her second admission. The patient’s husband reported that the patient had an episode of emesis with a fever, and began to feel SOB five days prior. Her episode was associated with a dry cough, which was slowly progressive. She became immobile while at home and was very short of breath. ID noted she had been on Cipro® and Zosyn®; the Cipro was stopped that day due to reintroduction of flecainide, which the patient had been taking at home.
Two days prior, surgery was consulted for the source of the ongoing fevers and concern for an intra-abdominal source of infection. The plan was for an ultrasound of the abdomen and CT when the patient was more stable and able to be transported. Her WBC was 21,000, platelets 120,000, and lactic acid 1.8. The ID physician suspected aspiration pneumonia, due to the emesis that had been reported by her husband. He thought the diagnosis was aspiration pneumonitis resulting in ARDS and her current septic shock. The ID physician ordered an increase in vancomycin and the continuation of Zosyn. He planned to check for several infectious processes as well.
Eventually, the patient had a real time ultrasound of the abdomen which showed a 2.7 cm complex cyst in the right hepatic lobe. There was also evidence of hepatomegaly. She had a 2.7 cm indeterminate complex cyst on the right lobe of the liver at the dome. Diagnostic consideration included benign or malignant mass versus hepatic abscess.
The following day, the patient was stable enough to undergo a CT of the chest with IV contrast. The impression was diffuse ground glass pattern of density in the lungs. The CT of the abdomen and pelvis showed two areas in the liver suspicious for hepatic abscess. A multilocular new abscess in the lateral aspect of the inferior right lobe of the liver measured 44 mm. A second biocular lesion in the right lobe of the liver underneath the diaphragm measured 26 mm. The patient then had CT-guided drainage of the pelvic fluid collection with a tiny amount of pus being extracted; a drainage catheter was deployed. Cultures did not return with a final result for five days and showed a rare fusobacterium.
The day after the CT, a Code Blue was called in the ICU and the patient was eventually pronounced dead.
The plaintiff expert believed the critical care physicians failed to consider the abscess as the source of the patient’s sepsis and ARDS. Liver abscesses are a recognized complication of appendicitis and are known to cause sepsis and ARDS. The failure to recognize the liver lesions as an abscess and the source of the sepsis, and urgently arrange for drainage, fell below the standard of care. Had the drainage been performed sooner, the plaintiff’s expert testified the patient would have more than likely survived. One infectious disease expert for the plaintiff believed the failure to recheck the CBC and differential before discharging the patient fell below the standard of care.
Defense experts testified it was appropriate to discharge the patient the day after her appendectomy and there was no need to recheck her WBC. He testified it was not negligent to fail to recognize a new liver lesion on a CT of a chest. Defense experts believed that earlier drainage of the lesions would not have affected the patient’s outcome.
The Verdict:
The jury returned a verdict in favor of the defense.
---
If you have questions on this topic, please email RiskAdvisor@ProAssurance.com or call 844-223-9648.