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. Stories of med mal lawsuits can save lives. If you have a story to share click here.
Chuck Pilcher, MD, FACEP
Editor, Medical Malpractice Insights
Fibroids Found on Ultrasound
Classic case of confirmation bias, appendicitis missed
Facts: A middle-aged female with history of ovarian cysts and fibroids develops right lower quadrant abdominal pain rated as a 10 out of 10. She has a ‘palpable mass’ on pelvic examination. Labs reveal a WBC of 19,000 with slight left shift. The EP orders a trans-vaginal ultrasound which shows degenerating fibroids and is discharged home to follow up with her gynecologist. Two days later she returns to the ED. A CT scan shows a pelvic abscess due to a perforated appendix. She undergoes an open appendectomy with post-op drains. Her recovery is slow, she requires repeat hospitalizations, and she eventually develops a fistula that results in a colostomy. An attorney was contacted and a lawsuit filed for delayed diagnosis.
Plaintiff: I had right lower quadrant pain and an elevated white blood cell count. You should have ruled out appendicitis before anything else. The fact that I have a history of ovarian cysts and fibroids does not mean that I can’t have appendicitis. That should have been at the top of the differential and ruled out before anything else. When you saw the fibroids, you stopped thinking. I had tenderness in my RLQ and an elevated WBC. Yes, degenerating fibroids may elevate the WBC but that is also a sign of infection – especially appendicitis when my pain is new onset in the RLQ. If you had ordered the CT scan on my first visit, I would not have had to deal with all of my horrible complications.
Defense: Patients with degenerating fibroids can present with right lower quadrant pain and significantly elevated white blood cell counts. You had a mass on exam that was tender and palpation reproduced your symptoms. Degenerating fibroids found on the ultrasound were a perfectly reasonable explanation for your pain. Your care was appropriate, even if the diagnosis was missed. Hindsight is 20/20. It’s unfair to say that the emergency physician should have ordered a CT on the first visit.
Result: The EP and experts for both parties were deposed. The EP claimed that appendicitis was in his differential diagnosis, but refused to answer the question of whether or not he ruled out appendicitis – only that he found an explanation for her pain and lab findings. The case was settled pre-trial for an undisclosed amount.
Takeaways:
- This is a classic case of confirmation bias, aka the “I knew it!” bias. Once one orders a test that confirms one’s expectation, all other possibilities are eliminated.
- “Anchoring bias” is a step above confirmation bias. It could be called the “Stop! I’ve got it.” bias. Tests aren’t needed OR the results are ignored because I’ve made up my mind.
- Appendicitis is the most common serious abdominal pain presentation in medicine. Nothing in this case eliminated that possibility from the differential.
- Not definitively ruling out appendicitis in a case of RLQ pain and elevated WBC, regardless of alternative options, should justify a CT.
- An error in judgment is not the same as negligence and we can’t (usually) be sued for it unless there is a very clear standard of care. This doesn’t mean that we need to order the gold standard test for every condition, but our MDM must defend our decision if we don’t. Example: “I have considered appendicitis and it is my personal judgement – based on the clinical presentation and ultrasound findings – that additional workup for appendicitis is unnecessary.”
- Ultrasound provides less definition than a CT, likely more so in the hands of non-radiologists. The more we can see, the more we will know.
- Two quotations, come to mind:
1. Hickam’s Dictum: “A patient can have as many diagnoses at one time as they damn well please.” John Hickam (1914-1970), Chair of the Department of Medicine at the University of Indiana.
2. Greg Henry MD: ”It is more likely that a common disease will present in an uncommon fashion than that an uncommon disease will present in a common fashion.” - And a piece of advice from Tintinalli’s Emergency Medicine Manual: “[C]onsider appendicitis in any patient with acute atraumatic abdominal pain without a history of prior appendectomy.”
