Agree with many comments above. Physicians and occasionally PLPs or RNs do get VIP treatment and unnecessary care sometimes to their own detriment. I'm guilty of this because it's easier even if not entirely right. The principles of non-maleficence and beneficence conflict with patient autonomy. Anyone practicing for a while knows that frivolous patient complaints are soul and time sucking. Not worth the fight. Especially coming from someone in the medical community, particularly if you might have to interact with them professionally in the future. Our job is hard though and we've all had times where our comments or even our tone came out less than ideal even if not terribly inappropriate.
We all know that in acute hemorrhage that either doing nothing or giving blood is almost always better than giving IV fluids. However, it's not worth fighting over IVFs (or just some small amount of MIVFs) or even a pint of blood in this scenario if requested and perhaps not indicated.
Additionally, H&H lags in significant hemorrhage. Don't make the mistake of chasing your tail for a truly ill patient (not saying this patient was). The patient could have been experiencing class 1 or even class 2 (lack of tachycardia given beta blocker) hemorrhagic shock, but suspect would have been more likely to develop hypotension without compensatory tachycardia. However, I think the lack of hypotension would have made us all unlikely to transfuse with a normal H&H and visualization of only a mild to moderate amount of hematochezia. Certainly EBL is hard to quantify for patients, non-acute care physicians and even intermittently for acute-care physicians. Any hemorrhage is also often overly alarming to patients and non-acute care physicians. I suspect this patient overestimated the EBL, although it's certainly possible it was underappreciated by the EP.
If I was reviewing this case in peer review, I think care was appropriate within the standard and not grossly negligent. In many cases, GI isn't going to emergently scope acute hemorrhage in the middle of the night. I can count on one hand the number of times I've seen a Gastroenterologist in the ED. So the fact that they came in (let alone after a retirement dinner) and then that a repeat colonoscopy was done is beyond in my opinion what typically happens. Granted it was a post-colonoscopy bleed rather than random undifferentiated lower GI bleeding and so there is higher likelihood of requiring requiring intervention for post-polypectomy hemorrhage. The fact they scoped him does give a little credence to the idea that the patient may have been correct regarding the amount of blood loss. Sometimes though the progression of illness in the inpatient setting necessitates intervention that wasn't perhaps initially indicated in the ED. That's why we admit patients instead of having them followup closely - in case their illness experiences more rapid decompensation.
It's reasonably possible that you could develop an AKI from acute hemorrhagic shock secondary to GI bleeding that could progress to CKD exacerbating underlying CHF or cause some cardiomyopathy. However, I don't think the lack of IVFs and a blood transfusion in the setting of normal vital signs in the ED is specifically causative. Not sure why it would take the Mayo Clinic to figure that out. I suspect the patient was physician shopping just like he attorney shopped. The fact 6 malpractice attorneys declined the case also indicates that it's hard to fault the EP or even the Gastroenterologist for the patient's outcome. That doesn't mean the patient won't continue to attorney shop and eventually sue resulting in a settlement because it's easier to settle than litigate even if not at fault. That's the major problem with our mediolegal system.
My only hope is that the patient has given up on litigation using publication to seriously self-reflect and process as well as improve care for other patients if viewing in a positive light, or equally likely using a cynical lens they are lashing out at others because health isn't for granted and often not in our control despite access to medical care.
Anyone else picture
@southerndoc receiving cardioversion in the ED mid shift still providing EMS medical direction over the phone as the Propofol is going in? Ha. Obviously not that there is or should be a need to be that macho. Makes it more exciting though.
