MONSTER Bellyache

This month’s monster case involves a 29-year-old woman who initially saw her primary care physician early in the day and who complained of abdominal pain, nausea, vomiting, diarrhea, and fever. Her PCP examined her and diagnosed her as having gastroenteritis. He encouraged her to go to the hospital for further evaluation, but she refused.

Later that afternoon, the woman felt worse, so she was instructed to go to the Emergency Department. Her PCP called ahead and let the staff know that the patient would be coming in with possible appendicitis. Several hours elapsed before the patient arrived.

Once she got to the ED, the woman had a two-hour wait before the emergency physician examined her. He noted that the patient had persistent pain, nausea, vomiting, diarrhea, and loss of appetite. His physical exam revealed right lower quadrant and suprapubic tenderness and guarding. He then ordered lab tests and an abdominal x-ray. The physician also performed a bedside ultrasound that exposed a mass on her right ovary. The urinalysis revealed no blood, no leukocytes, negative nitrates, and a negative pregnancy test. The patient’s blood tests showed a white blood cell count that was slightly elevated at 13,200, but the complete metabolic panel was normal. The emergency physician noted that the patient likely had had gastroenteritis and a possible ovarian cyst.

The ED physician then consulted with the on-call OB-gynecology physician. After hearing the patient’s history and the results of the bedside ultrasound, the consulting physician agreed that the patient likely had an ovarian cyst. The emergency physician then called the woman’s PCP and relayed his patient’s symptoms. The emergency physician’s note stated that the PCP agreed with the discharge. When he discharged the patient, the emergency physician told her that she didn’t have appendicitis and wasn’t going to need surgery. He indicated that she likely had gastroenteritis or possibly an ovarian cyst.

When the patient called her PCP the next day, he told her to follow the emergency physician’s instructions. The patient then contacted her gynecologist, who was under the impression that the diagnosis was an ovarian cyst and recommended bed rest. Three days later, the patient wasn’t feeling any better and had developed a vaginal discharge. She saw her gynecologist, who examined her and found a mass on her right ovary. He admitted her to the hospital and ordered a formal ultrasound, which was inconclusive. For the next several days, the patient was hospitalized and treated with intravenous antibiotics for a presumed diagnosis of pelvic inflammatory disease.

An exploratory procedure was performed on day four of the patient’s hospitalization (seven days after her initial emergency department visit). That’s when it was determined that the patient had a ruptured appendix. Infection had spread throughout her pelvis, and her right ovary and fallopian tube had to be removed along with her appendix.

The patient filed a medical malpractice lawsuit against the hospital and the emergency physician alleging that the emergency physician was negligent for failing to properly diagnose her appendicitis. She further alleged that this negligence was the cause of the eventual rupture of her appendix and loss of her ovary and fallopian tube. After a five-day jury trial, the jury returned a verdict against the hospital and emergency physician, awarding the patient $1,200,000 in economic and noneconomic damages.

While in many ways this case is classic, it is generally rare that missed appendicitis becomes a monster claim. Although missed appendicitis accounts for approximately 15 percent of total dollars awarded against emergency physicians, the incidence is usually high and the claims are relatively low. Typically, awards are in the $100,000 to $400,000 range due to relatively low economic and noneconomic damages.

There are several takeaways from this case, including three reasons that abdominal pain in women is a difficult presenting complaint. First, the differential diagnosis includes multiple high-risk diagnoses. My mnemonic for a differential diagnosis in female patients is:

  • AAA
  • Bowel
  • CAD
  • appenDicitis
  • Ectopic

Second, complications from a missed diagnosis are much more severe in women than in men. Finally, there are potential risks to radiological imaging and there is heightened scrutiny about imaging women of childbearing age.

It’s important to note that, when it comes to filing claims, patients generally like their primary care physician and gynecologist. It’s not surprising that, even though both physicians likely had some responsibility in this case, neither one was sued. It’s also striking that the primary care physician proverbially threw the emergency physician under the bus, stating that the emergency physician never told him the white blood cell count (WBC) was elevated and that, if he had, the PCP would have recommended admitting the patient.

This case illustrates a number of important lessons, including:

  1. It’s important to consider worst-case scenario diagnoses for all patients and to develop a system to consider all high-risk diagnoses.
  2. Never tell the patient they don’t have a diagnosis. You might tell them it’s unlikely, but there are no “nevers” in medicine.
  3. With all abdominal pain cases, instruct the patient to follow up in a timely manner with their primary care physician or have them return to emergency department.
  4. Thoroughly document your discussions with primary care physicians and consultant physicians, including all pertinent positive and negative laboratory and radiological studies discussed.
  5. Appendicitis may have an abnormal urine or elevated WBC. In fact, 95% of the time, patients with appendicitis have one or the other.
  6. No test absolutely rules out appendicitis. Even CT scans – if negative – are not conclusive in ruling out appendicitis. There is still a very small chance that the patient has early or intermittent appendicitis.
  7. Patients may have two diagnoses at the same time, such as intrauterine and ectopic pregnancy, or in this case, ovarian cyst and appendicitis.

Abdominal pain in women can be difficult to diagnose with certainty, but developing a diagnostic approach that considers worst-case scenarios will help you avoid monster claims.

The Monster Claim is the nightmare, $1,000,000 plus settlement or judgment (not including defense costs) that could happen to any unsuspecting physician or medical care provider. As in most cases in emergency medicine, it is a case of failure to suspect the diagnosis and involves a series of unfortunate events. We believe that it is important that all emergency providers become aware of these claims so they won’t repeat the same mistakes in the future.

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