Medical Malpractice Insights: Alcoholic hepatitis? Dyspepsia? Appendicitis?

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

Chuck Pilcher MD FACEP

Editor, Med Mal Insights

Alcoholic hepatitis? Dyspepsia? Appendicitis?

“Please don’t confuse me with the facts!”

Facts: A 25-year-old male presents to the ED with 3 days of R sided abdominal pain. His only other symptom is “bloating.” He admits to alcoholism. On exam, he is afebrile and mostly tender on the right side with mild hepatomegaly. Rebound tenderness is not assessed. His WBC is 11,300, LFT’s are normal, and no lipase or amylase is ordered despite abdominal pain and tenderness in an alcoholic. No differential diagnosis is recorded. He is discharged with a diagnosis of “alcoholic hepatitis” and “dyspepsia” and given discharge instructions on “alcohol related problems.” Three days later he is admitted to a second hospital with a ruptured appendix. After his appendectomy, he develops intra-peritoneal abscesses with chronic pain and requires further treatment. He consults an attorney, and a lawsuit is filed.

Plaintiff: I had right sided pain for 3 days. You never checked for rebound tenderness. My WBC was elevated, and you should have done a differential on it. My liver tests were normal, yet you said I had hepatitis. And you never checked me for gastritis or pancreatitis, which were even more likely than hepatitis. Your lack of a differential diagnosis shows that you ignored the facts, assumed alcoholism was the problem, didn’t give a damn, and jumped to your conclusion. Your care was below the standard for abdominal pain. If you had treated me appropriately, my appendix would not have ruptured or spread so much pus around my belly.

Defense: Our treatment was fine and consistent with your symptoms. You developed appendicitis after we first saw you.

Result: Settlement for undisclosed amount without trial or depositions, suggesting the defense acknowledged the weakness of their case.

Takeaways:

• Don’t jump to conclusions. That’s “anchoring bias”, which stops all further thought.
• Take a history that includes pertinent positives and negatives.
• Document a reasonable differential diagnosis. In patients with abdominal pain, appendicitis should almost always be on the list.
• Ask oneself “Are lab results consistent with my assumptions?” Ignoring findings that don’t confirm your first impression is classic “confirmation bias.” When lab findings are inconsistent with assumptions, look further.

Mistakes are for learning, not repeating.

For more on appendicitis, see:

– http://www.emdocs.net/appendicitis-pearls-and-pitfalls-in-adult-and-pediatric-populations/

– http://www.emdocs.net/em3am-appendicitis/

– http://www.emdocs.net/appendicitis-mimics-ed-focused-management/