Medical Malpractice Insights: Missed Appendicitis and Heparin Dosing in PE

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.

This month’s presentation includes 2 cases with basic reminders:

Case 1: Don’t assume the best when the worst could be true.

Case 2: If your hospital has specific written dosing protocols for certain drugs (e.g., anticoagulants), follow them.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Missed appendicitis: Would you have sent this patient home?

The correct answer is “No.”

Facts: A 51-year-old woman is seen in the ED for a 24 hour history of abdominal pain, nausea, vomiting, and diarrhea. ROS, PMH, FH, and SH are poorly documented. Exam is negative for significant tenderness, rebound, or guarding. A CBC shows a WBC of 18,000 with 10% bands. She is given 3 doses of hydromorphone, the last dose only 40 minutes before discharge. She feels better and is discharged home with a diagnosis of “gastroenteritis.” No follow-up instructions are given. Four days later she returns, is found to have a ruptured appendix, and develops bowel control problems post-op. She consults an attorney, and a lawsuit is filed.

Plaintiff: You took a superficial history, did an incomplete exam, did not document a differential diagnosis that included appendicitis, missed or disregarded my CBC result, covered up my pain with narcotics, and gave me no instructions about follow-up. Appendicitis should be considered in every case of abdominal pain. Even if you were right and my abdominal exam was negative, my history and CBC were enough to order a CT scan to rule out appendicitis.

Defense: What I documented was what I found. Of course I thought of appendicitis, but I didn’t think you had it so you didn’t need a CT scan. My care was reasonable.

Result: Jury verdict for $150,000.


  • Gastroenteritis does not present with pain so severe that it requires narcotics.
  • Narcotics treat the pain, not the problem. Clouded judgement can result in a patient “cooperatively leaving” the ED despite serious illness.
  • A WBC of 18,000 with left shift is highly suspicious for a bacterial source. Consider potentially life-threatening conditions.
  • Evaluating an abdominal complaint that later is found to be appendicitis may be acceptable if the MDM is thoughtfully documented, lab abnormalities are addressed, good discharge instructions are given, and early (<1day) re-examination is assured.

Failure to follow proper anticoagulation protocol leads to fatal PE

If you make the rules, follow them

Facts: A 63-year-old obese male returns to the ED 1 week following a successful CABG with complaints of pain and swelling in his left calf. An ultrasound confirms the presence of a DVT. He is admitted and placed on a heparin regimen. Three days later he has a fatal PE. A retrospective review reveals that
the heparin dose given was only half of that prescribed by the hospital’s own written dosing calculation protocol for DVT/PE prophylaxis.

Plaintiff:  You didn’t follow your own hospital’s protocol for anticoagulation for patients with DVT. I would not have had a fatal PE if you had given me the proper dosage of heparin.

Defense: Our treatment was fine. Your heparin dosage was adequate.

Result: Settlement for $960,000.

Takeaway: It’s hard to defend a failure to follow your hospital’s written protocols (without documented justification.) If there is an established protocol, especially for anti-coagulation, follow it.


The value of experience is not in seeing much, but in seeing wisely.

Sir William Osler

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