A prime lawsuit

[xoemmylouox]

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!

[DutchgirlRN, ASN, RN]

actually it wouldn't have.

actually it would have. it is extremely difficult to get a patient with a suspected hot appy to drink 40 ounces of gastrografin so we end up scanning them without any oral contrast only iv contrast. we give the gastrografin rectally. using this protocol the ct takes maybe 3 minutes. this is the 3 minute scan i was referring to. the controversy was over a diagnosis of appendicitis.

ct scans for kidney stones are always noncontrasted.

i still say the whole story makes no sense.

[DutchgirlRN, ASN, RN]

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 while i understand and support diagnostic imaging, the importance of a good h&p has all but been replaced by technology.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.

a good h&p should always be performed but it should also be followed with scanning. physicians cannot see inside the patients body. we get patients in with abdominal pain. we scan them. the results can be anywhere from diverticulitus, obstruction, ovarian cyst, cancer, kidney stone, hernia, appy, perforation, torqued tube to an abdominal abcess. technology has replaced guessing at a diagnosis. physicians are very thankful for the medical imaging services. there are things which must move into the future.

[XB9S, BSN, MSN, EdD, RN, APN]

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.

We are lucky that we have some protection from our hospital trusts with vicarious liability, because this is standard practice at the moment we are not sued very often for negative appendix. We are more and more having a peek with a laproscope first to see if the appendix is to blame before proceeding.

Interesting about the 50% negative, I can feel an audit coming on, I may enlist a few of our junior docs to get some figures to present at our audit meeting.

Another constraint is the availability of the CT's. We are one of the largest trusts within the Uk and have 4 CT scanners. This means 1 is dedicated to neuro, one to vascular and the others well they deal with everything else. If you want a CT you have to get passed the Radiologists and you have to clinically justify it, and usually with the fact that we only have 1 emergency theatre and the pateints may have to wait for 8 hours before they go if they are not appendix they are getting better. This is not a good part of the NHS, but that is a whole other thread.

Consent, when we get our patients to sign consent there is a bit on the form that states and any other procedures felt needed at the time. This is explained to them so they don't have to sign it but it does allow the surgeon to proceed with consent if there are unexpected findings

What this does all mean is that when you take a history and do the examination you have to do it really well, if you want imaging your really have to justify it, and only a good clinical examination is going to give you that information. It is very hands on and keeps the old brain cells active because if you don't have an idea of a diagnosis and have requested imaging the radiologists get really really scary :uhoh21:

[TiredMD]

actually it would have. it is extremely difficult to get a patient with a suspected hot appy to drink 40 ounces of gastrografin so we end up scanning them without any oral contrast only iv contrast. we give the gastrografin rectally. using this protocol the ct takes maybe 3 minutes. this is the 3 minute scan i was referring to. the controversy was over a diagnosis of appendicitis.

i see what you're saying.

yeah, when they're sick they aren't going to drink. and yeah, if you got a big fat perf (especially if there's an abscess) you can often see it on a non-con or iv-only scan. still not ideal though. our protocol is to do rectal contrast with iv contrast, which is probably the best for visualization, as long as you get the contrast up high enough.

[TiredMD]

What this does all mean is that when you take a history and do the examination you have to do it really well, if you want imaging your really have to justify it, and only a good clinical examination is going to give you that information. It is very hands on and keeps the old brain cells active because if you don't have an idea of a diagnosis and have requested imaging the radiologists get really really scary :uhoh21:

I like your philosophy, and it's the kind of surgeon I'm trying to become.

What I hate (hate hate hate) is justifying scans to the radiologists, which I also have to do in my facility. They're bright guys, but they don't see patients every day, so when I tell them about atypical cases, they always give me a lot of crap. Yes, I understand the story isn't the best for appy, but not everyone get fever and anorexia, followed by periumbilical pain that migrates 24hrs later to the right side . . .

If you ever do get numbers on your negative appendixes, I'd love to know what they are. However, I suspect you'll be quite a bit below 50%. If your pathologists are anything like ours, they "help out" your surgeons by calling the appendix positive even when it's . . . questionable.

[DutchgirlRN, ASN, RN]

i see what you're saying.

yeah, when they're sick they aren't going to drink. and yeah, if you got a big fat perf (especially if there's an abscess) you can often see it on a non-con or iv-only scan. still not ideal though. our protocol is to do rectal contrast with iv contrast, which is probably the best for visualization, as long as you get the contrast up high enough.

thanks. :wink2:

yes, while iv isovue and rectal gastrografin is not ideal it's certainly much better than no contrast when looking for an appy.

i'm totally blown away about radiologists refusing scans. i've never seen that happen. we have some 40+ radiologists and their only say so is to read the scan. what the doctor orders is what gets done. we do go to the rad for questions like don't you think we should be using or not using contrast? we get orders for sinuses with contrast, and the like and we con't contrast those. many physicians do not know how to properly order a scan.

on the issue of scans. we do have some patients who don't get a scan that is ordered for them but that is an insurance issue, precert issues and the like

[IKSONAK]

I was a legal nurse consultant at one time. The "suit" would depend on if there was negligence and did the result of that negligence cause the patient permanent harm or injury?

If a vital organ had been removed, the jury would have something to ponder. But, I think we'd all do better without our appendix anyway! And surely the surgery did not cause permanent harm. And, the jury would be considering if the ER doc's fast action was really negligent.

Things to think about!

[Warpster]

My own story went the other way. I went in with a hot abdomen and told them I suspected it was a flare up of appendicitis I'd had before. They drew blood. Then they came in and told me they were working me up for kidney stones I knew I didn't have thanks to an IVP a few months earlier. I had another IVP and a bunch of imaging studies and got back to the ER. The doc said he was sending me home because my white count was not elevated. I asked him what the differential count showed since I was leukopenic due to lupus, something right in the history I'd given. He blanched, they drew more blood, and I went to surgery an hour later for a then burst appendix. My white count was 6900 with 99% neutrophils.

I didn't sue, but I'm sure he did CBCs instead of simple hemograms on everybody with a hot abdomen after that.

[santhony44, MSN, RN, NP]

What I hate (hate hate hate) is justifying scans to the radiologists, which I also have to do in my facility. They're bright guys, but they don't see patients every day, so when I tell them about atypical cases, they always give me a lot of crap. Yes, I understand the story isn't the best for appy, but not everyone get fever and anorexia, followed by periumbilical pain that migrates 24hrs later to the right side . . .

Sometimes you get textbook cases, and sometimes what you get is a really uncomfortable feeling about a patient.

Usually, to me, an appy just looks like an appy.

The last one I had was textbook. The one before that was an 8 yo with the abdominal pain, could've been gastroenteritis, white count normal, but he just looked like an appy. I talked with my doc; he said he didn't think it was, but if I wanted to send him, go ahead.

We sent him to the children's ER about 40 miles away, his white count was 20K, an hour and a half later, he was in OR.

I'm not saying I'm never wrong; I once sent a girl in I was convinced was an appy; it was an ovarian cyst. She was giving an Oscar-worthy appendix performance. (Not implying she was faking, she wasn't, she was in a lot of pain, but it was very typical of appendicitis; I couldn't do a CBC at that location).

I suppose if I'm the patient, or if it's my son, then I'd rather someone do the surgery than not.

[caliotter3]

I agree with traumaRUs. I might have made the same decision had I been the person on the hot seat.

[aeauooo]

When I had appendicitis I started out feeling pressure, then pain on my LEFT side - I felt like I had really bad gas that I couldn't pass: referred pain.

The moral of the story is that presenting symptoms aren't always textbook.

Incidentally, I was checked for kidney stones.

The kicker was that the surgeon thought since I had had malaria a year or so before I was having a relapse. I kept telling him it wasn't malaria - I'd know it if it was. When the ID guy walked in the room the first thing I said was, "I don't have malaria!" He said, "I know." He checked for rebound tenderness, then told me I had appendicitis.

[tandlsmom]

XOEMMYLOUOX,

What organ did he loose?

Ann RN