Med Mal: Gastric Bypass Patient in the ED

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Case 9: Abdominal Pain

www.medmalreviewer.com

Patient comes into the ED a few days after gastric bypass surgery.

Full workup in the ED, surgeon is consulted via phone, discharged home.

Bounces back a few hours later. HR 140s. No repeat labs or CT, no repeat consultation. Discharge home.

Dies a few hours later.

 

[Birdstrike]

Case 9: Abdominal Pain

www.medmalreviewer.com

Patient comes into the ED a few days after gastric bypass surgery.

Full workup in the ED, surgeon is consulted via phone, discharged home.

Bounces back a few hours later. HR 140s. No repeat labs or CT, no repeat consultation. Discharge home.

Dies a few hours later.

Peritonitis, urgent surgical consult, broad spectrum antibiotics, sepsis protocol, admit.

 

[TooMuchResearch]

Peritonitis, urgent surgical consult, broad spectrum antibiotics, sepsis protocol, admit.

Don't over think things. If you don't know what's going on, you can admit. If you think they might need antibiotics, you can give antibiotics.

 

[Mat the coolcat]

And there was no internal hernia on the initial CT (the full workup)...? Could have developed in those couple days. Bypass surgeon told me that anytime ever a bypass pt comes in with belly pain = CT in light of this sneaky/deadly dx.

 

[deleted109597]

Yeah, that CT says fluid under the liver. And they have purulent drainage. WTH.

 

[Zebra Hunter]

This is the exact kind of case which is what malpractice is for, for both presentations. How do you send home a febrile, tachycardic, ecchymotic, pus draining surgical wound, with significant free fluid around the liver? And then when the gods of EM shine down upon this patient and give her the foresight to return to the ER so that another doctor might do the right thing, you send her home again despite markedly abnormal vitals.

 

[southerndoc]

I usually make it a habit not to discharge people I marked as "moderately distressed" unless it's something easily treated quickly (anaphylaxis, asthma).

 

[DrGasPasser]

That patient registered on the first visit with a HR of 114 and, more importantly, a RR of 28. That folks, is God talking to you.

Unless the first EP documented a resolution of those abnormalities (particularly that RR), I’d say there is a strong case against the EP on the first visit based on persistent, unexplained abnormalities alone....

 

[betamale]

Case 9: Abdominal Pain

www.medmalreviewer.com

Patient comes into the ED a few days after gastric bypass surgery.

Full workup in the ED, surgeon is consulted via phone, discharged home.

Bounces back a few hours later. HR 140s. No repeat labs or CT, no repeat consultation. Discharge home.

Dies a few hours later.

Terrible. I use to work as a place that had a bunch of bariatric surgeons and so a lot of pt w/ bypass. I was very cautious about giving toradol for a while because sometime forget to share that they are gastric bypass/partial gastrectomy. I almost missed a perf once because of a bad radiology read; good thing I looked at the scan.

Multiple learning points but always have a very low threshold for CT scans but should try to give oral gastrograffin contrast at 1 hr then 10-15 mins before scan or at least a small volume 15 mins before scan to look for extrav. The contrast really saved me as the perf can be so subtle and the pneumoperitoneum very small. Always look at the belly using lung windows for thoroughness

 

[turkeyjerky]

Terrible. I use to work as a place that had a bunch of bariatric surgeons and so a lot of pt w/ bypass. I was very cautious about giving toradol for a while because sometime forget to share that they are gastric bypass/partial gastrectomy. I almost missed a perf once because of a bad radiology read; good thing I looked at the scan.

Multiple learning points but always have a very low threshold for CT scans but should try to give oral gastrograffin contrast at 1 hr then 10-15 mins before scan or at least a small volume 15 mins before scan to look for extrav. The contrast really saved me as the perf can be so subtle and the pneumoperitoneum very small. Always look at the belly using lung windows for thoroughness

Do you ever have trouble with the patients refusing to drink the contrast? Ive had a few just refuse to take it because of the volume.

 

[Birdstrike]

Do you ever have trouble with the patients refusing to drink the contrast? Ive had a few just refuse to take it because of the volume.

Just get as much in them as you can.

 

[thegenius]

Case 9: Abdominal Pain

www.medmalreviewer.com

Patient comes into the ED a few days after gastric bypass surgery.

Full workup in the ED, surgeon is consulted via phone, discharged home.

Bounces back a few hours later. HR 140s. No repeat labs or CT, no repeat consultation. Discharge home.

Dies a few hours later.

Discharging a HR of 140? This is slam dunk negligence. The second ER doc was no good
Perhaps even the first one too.