A prime lawsuit

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I work in a urology office, and often are doctors are called to do consult on admitted hospital patients. I know everyone makes mistakes and boy have we seen plenty from the hospitals, but what happened this week really takes the cake! We get a call saying Dr needed to do a consult on a post op 20 something male who had a very large kidney stone. Dr finds it odd that he would be post op and still have the stone so he calls the hospital to get the full story. The kid shows up to the ER with flank pain. The ER doc assumes it is his appendix and sends him for surgery without any pre op imaging. Turns out it wasn't the appendix, but his kidney stone that was the cause of pain. Poor kid lost an organ for nothing. Not to mention had to have 2 surgeries in 2 days! :banghead:

I never said I agreed with the lawsuit, but in today's world people sue over much less and win. I was just posting this because I thought it was an interesting case. I wasn't critical of the ER Doc I was just suprised that a quick KUB or non-contrast ct wasn't done. I never intended for this to be such a hot topic.

Ah. Your first post sounded like you agreed that the ER doc screwed up. Sorry we misunderstood.

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I'm an APN and would not question what other providers do. I feel bad that this young man had to undergo two surgeries in two days but wouldn't second guess the other providers' assessment.

Ummmm.....isn't that what a second opinion would be for? Sometimes providers get it wrong, and I sure as he-double hocky sticks wouldn't want to go to a healthcare provider who wouldn't welcome a double check on his/her diagnosis. It's ok by me if one doesn't know or isn't sure, but it is NOT ok by me for a provider to not know or not be sure and not be willing to check it out with someone else who might know for sure or have another view of the situation. The ego of a healthcare provider is NOT my priority when I am ill or a loved one is ill....

I might be an 'armchair quarterback' in this case, but it seems to me that an imaging study before surgery is kind of a 'given'. I imagine it costs less to do the test and perform the right surgery than it does to perform two surgeries. As to lawsuit....I suppose it might be justified in this case. I still have to mull that over.

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Specializes in Maternal - Child Health.

I think there is a big difference between requesting/providing a second opinion on a patient's condition vs. criticizing the assessment and actions of another provider based on scant information heard thru the grapevine.

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i agree. a ct of the abdomen takes maybe 3 minutes at best and would have revealed the stone as the problem.

actually it wouldn't have.

ct scans of the abdomen looking for appedicitis or other intraabdominal pathology use contrast material; either oral/rectal, iv, or both. this contrast is white on the films. kidney stones are white. if you have a bunch of contrast in the intestines, or worse, in the ureters (from the iv constrast), you can pretty much guarantee you won't see a kidney stone. if you suspect a stone, you do a noncontrast study, which is pretty worthless if you're looking for an appy.

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Actually it wouldn't have.

CT scans of the abdomen looking for appedicitis or other intraabdominal pathology use contrast material; either oral/rectal, IV, or both. This contrast is white on the films. Kidney stones are white. If you have a bunch of contrast in the intestines, or worse, in the ureters (from the IV constrast), you can pretty much guarantee you won't see a kidney stone. If you suspect a stone, you do a noncontrast study, which is pretty worthless if you're looking for an appy.

A cat scan without iv or oral will demonstrate an appy. A cat scan

with iv contrast will also demonstrate a kidney stone as well. The collecting system will illustrate this to the point of the stone.

Ex CT radiographer

Anyone presenting to the er with abdomen pain SHOULD always

get an acute abdominal series or a ct abd/pelvis. Period. Anything less

is incompetence!

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Specializes in Telemetry, Med Surg, Pediatrics, ER.
A cat scan without iv or oral will demonstrate an appy. A cat scan

with iv contrast will also demonstrate a kidney stone as well. The collecting system will illustrate this to the point of the stone.

Ex CT radiographer

Anyone presenting to the er with abdomen pain SHOULD always

get an acute abdominal series or a ct abd/pelvis. Period. Anything less

is incompetence!

Why dispute TiredMD's explanation? I think it is wrong to just throw around the term "incompetence". None of us know the full story. The OP works in a physician's office. None of us know how the patient presented or what tests were performed. Does anyone know that the patient did not have a hot appy? No. This thread is purely speculation and to call anyone incompetent is, well, incompetent.

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Specializes in Peds (previous psyc/SA briefly).

Oh my goodness.

I have a nephew who had a lap appy "mistakenly" - ya know what my brother (a cop) and his wife (a Walmart manager) said? That the ED doc really thought it was appendicitis - and at least now he couldn't get appendicitis in the future. Not much more.

Glen presented with acute abd pain that was relieved by position, + rebound, increased WBCs, fever, diarrhea - and a rigid abdomen. I don't know why they didn't do imaging, but I'm sure they either 1) didn't feel like they could get it fast enough for whatever reason or 2) were completely convinced. Glen was 11 or 12 at the time - and it turned out to be just a wicked gastro.

It's a bummer... but I don't think it ever even occured to anyone in my family that the docs were to blame. Of course, they have a younger child with a very significant seizure disorder, so they are pretty hospital savvy.

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Specializes in FNP, Peds, Epilepsy, Mgt., Occ. Ed.
Tweety - my point is that I would not second guess another provider's assessment unless I had more to go on then what is here. I will say that my opinion has changed dramatically since becoming an APN. In this lawsuit-threatening world in which we live, I do not say anything in public against another provider. What's the point?

I agree completely.

You make the best decision you can with what you have at the time. It's a lot different when you're the one under the gun with someone's life in your hands.

I've had my share of Monday morning quarterbacks, and so has Trauma, I'm sure. I'm the one I have to live with, though.

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A cat scan without iv or oral will demonstrate an appy. A cat scan

with iv contrast will also demonstrate a kidney stone as well. The collecting system will illustrate this to the point of the stone.

Ex CT radiographer

Anyone presenting to the er with abdomen pain SHOULD always

get an acute abdominal series or a ct abd/pelvis. Period. Anything less

is incompetence!

Everything you wrote in this post except "Ex CT radiographer" is wrong.

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Specializes in Advanced Practice, surgery.

I have to be honest I have read this thread with much interest. I am a surgical NP in the UK. Here appendicitis is a diagnosis made from a clinical examination, we do not CT routinely anyone with abdo pain it has to be clinically justified and is usually only used for those who are obstructed, ? perf'ed or who are sick with abdo pain and are difficult to diagnose.

With a patient who presented with RIF pain, with the clinical signs that may suggest appendix we may to an plain abdo film to look for renal calculai, Dipstick urine to look for UTI / blood. If nothing showed up then they would be booked for theatre.

If female we may do an ultrasound scan to look at pelvic organs.

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I have to be honest I have read this thread with much interest. I am a surgical NP in the UK. Here appendicitis is a diagnosis made from a clinical examination, we do not CT routinely anyone with abdo pain it has to be clinically justified and is usually only used for those who are obstructed, ? perf'ed or who are sick with abdo pain and are difficult to diagnose.

With a patient who presented with RIF pain, with the clinical signs that may suggest appendix we may to an plain abdo film to look for renal calculai, Dipstick urine to look for UTI / blood. If nothing showed up then they would be booked for theatre.

If female we may do an ultrasound scan to look at pelvic organs.

And this really isn't a bad approach, as long as you don't mind a significant number of negative operations. Historic rates in the U.S. were as high as 50%, which was fine until folks started suing for incorrect diagnosis and unnecessary surgery. Most General Surgeons I work for now usually require a CT-proven appy before they'll cut, though like everything else in life there are exceptions.

Most here question the utility of the plain film for renal calculi, since smaller stones in the ureters themselves can mimick (to some degree) an appy but not be visible on xray. The presence of calculi within the kidneys themselves is a common finding in normal, asymptomatic patients, so it's more indirect evidence than anything else. The dipstick is good though, and pretty much standard of care here as well.

The nice part of the CT scan, in addition to detecting perf/abscess like you mentioned, is that it will sometimes pick up pathology you might not have been expecting. An active ovarian torsion can be seen on CT, as well as colitis, cancer, etc. Nothing worse than opening up a "routine" appy only to discover something you didn't expect, and didn't consent the patient for.

However, I do like your approach. It appeals to the clinical side of me, the side that says a surgeon's exam is more reliable than imaging. Even if it's not entirely true. There are studies out there that show admission and serial abdominal exams by experienced surgeons have superior sensitivity/specificity than a single ED CT scan.

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Yep, in the world of defensive medicine, the art of the physical exam is dead. While I understand and support diagnostic imaging, the importance of a good H&P has all but been replaced by technology. A dangerous trend IMHO.

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