On July 13 at 12:45 a.m., a 48-year-old man was brought to a hospital emergency department (ED) by air ambulance.
Earlier that night, the patient was driving a car that was involved in a rollover motor vehicle accident (MVA). At the scene of the accident at 10:50 p.m., he was seen by EMS who documented bilateral breath sounds with wheezing; tenderness and rebound in the left lower quadrant (LLQ) of the abdomen with some unspecified discoloration; and a left mid-forearm deformity with multiple abrasions.
An IV was started on the right wrist, and vital signs were blood pressure 192/118 mm Hg; pulse 93 bpm; respiration 16; and oxygen saturation 99% on a non-rebreather mask.
Upon arrival in the ED, the patient’s vital signs were blood pressure 189/91 mm Hg; pulse 95 bpm; respiration 19; temperature 98.3 degrees; oxygen saturation 100%; Glascow Coma Scale 15; and Revised Trauma Score 12. The patient reported pain in his head, neck, back, abdomen, left arm, and right hand.The patient did not experience loss of consciousness, hypotension, or respiratory distress at the scene of the accident or during transport to the ED.
Emergency Medicine Physician A saw the patient and ordered intermittent doses of morphine. The initial dose of 4 mg was given at 1:12 a.m., and the next dose given at 4 a.m. The patient also received ondansetron at 1:12 a.m. for nausea and vomiting, and ketorolac 30 mg at 4 a.m.
The physician examined the patient and noted dorsal spine tenderness. Exam notes do not include the patient’s report of abdominal pain. The physician ordered lab testing; x-rays of the left forearm, shoulder, hand, and chest; and CT scans of the cervical spine and abdomen.
Lab results all came back as normal. CT scans revealed two lesions in the spleen that Radiologist A diagnosed as splenic infarcts. Emergency Medicine Physician A discharged the patient at 6:30 a.m. with instructions to follow up with his primary care physician within a week and to return to the ED if symptoms worsened.
Later that morning, Radiologist B reviewed the CT studies and determined the splenic infarcts were splenic lacerations. He notified Emergency Medicine Physician B at 10:16 a.m. of the patient’s splenic lacerations.
After reviewing the radiologist’s report, Emergency Medicine Physician B had an emergency department nurse call the patient at 10:30 a.m. Multiple phone messages were left before the patient’s mother returned the call at 11:55 a.m. The mother stated that the patient had returned home to a different state, but she would relay the physician’s concerns to the patient.
At 12:54 p.m., the patient went to a hospital ED near his home. His vital signs were recorded as blood pressure 123/68 mm Hg; pulse 110 bpm; respiration 20; temperature 97.4 degrees; oxygen saturation 100%. Complete blood count and repeat CT scan were ordered.
The CT scan suggested interval worsening with active bleeding from the spleen. Lab data indicated the patient’s hemoglobin had dropped from 13 grams the night before to 10.7 grams. The patient was diagnosed with a lacerated spleen and transferred to a larger nearby medical center.
At 8:05 p.m., the patient arrived in the ED of the medical center. Vital signs were blood pressure 93/67 mm Hg; pulse 116 bpm; respiration 18; temperature 97.6 degrees; oxygen saturation 100%. There was a further drop in his hemoglobin and hematocrit to 8.7/26. He was given 2 liters of crystalloid fluids and orders were placed for 4 units of packed red blood cells (PRBC).
A general surgeon saw the patient. After an informed consent discussion with the patient and his family, the surgeon took the patient to surgery for an open splenectomy on July 14 at 1:15 a.m. During the procedure, the patient received 1.5 liters of crystalloid fluids, 4 units of PRBC, and 1 liter of fresh frozen plasma. The patient had 300 cc of urine output.
After surgery, the patient was transferred to the ICU. The patient’s pulse was 140 bpm and systolic blood pressure was in the 100-110 range by non-invasive blood pressure measurements. The tachycardia was attributed to the patient’s awakening and agitation. The patient was given morphine, and his pulse slowed to 70 bpm.
The patient’s condition changed in the ICU. He was noted as having a wide-open gaze, dilated pupils, an absent cough, gag reflexes, and was unresponsive. The patient coded but was resuscitated. The patient was given 4 units of PRBC and 1 liter of normal saline. His systolic blood pressure improved to 70 mm Hg and his color improved. When transfusions stopped, his blood pressure and color worsened.
The surgeon inserted a Cordis catheter for additional volume infusion, and an additional 4 units of PRBC were provided. The patient’s abdomen began to distend after each transfusion. The patient’s hemoglobin increased from 7 grams to 11 grams, but he remained acidotic and unresponsive with only Dopplerable pulses. While deciding whether to take the patient back to surgery, the patient died.
The medical examiner’s report listed probable cause of death as “multiple blunt force trauma due to motor vehicle accident.”
The patient’s family filed a lawsuit against Emergency Medicine Physician A. Allegations included:
- failure to admit the patient given the severity of the accident and injuries sustained;
- failure to recognize the abnormality identified in the spleen;
- failure to appreciate the significance of the abdominal CT findings;
- failure to admit the patient for 24-hour observation and surgical consultation; and
- failure to properly and accurately monitor, observe, assess, and document the patient’s physical and medical condition while in the ED.
Consultant physicians who reviewed the case for the defense were mostly critical of the care provided by Emergency Medicine Physician A. The physician was noted as providing appropriate trauma evaluations and pain management. But, due to the significance of the accident, most of the consultants felt that the patient should have been admitted overnight for observation and a general surgery consult ordered.
However, one consultant felt that the mechanism of the injury (MVA) alone did not warrant overnight observation of the patient since his vitals were stable and there were no signs of internal bleeding. This consultant felt the physician acted appropriately in discharging the patient based on his condition and the results of the CT and other tests.
One consultant felt that splenic infarcts in the absence of a prior hematologic disease or similar history would have been unlikely. Had the patient been admitted, further testing or review of reports would have led to a timelier splenectomy and better outcome.
Another consultant noted that Radiologist A played a significant role in this case, as the radiologist did not consider the context of the patient’s severe blunt abdominal trauma suffered during the MVA when creating his report. Had the radiologist considered the context of the injury, he may have given more consideration to splenic laceration over infarct in his report.
Emergency Medicine Physician A was further criticized for not providing the radiologist with more details of the patient’s history and examination to help him focus on areas of the images in question. Had the two physicians been in better communication, the radiologist may have reconsidered his preliminary interpretation. Instead, Emergency Medicine Physician A was criticized for “blindly accepting” the preliminary CT interpretation of the abdomen.
Consultants for the plaintiff were also critical of the physician. Two of these consultants felt Emergency Medicine Physician A failed to meet the standard of care in the following three categories.
Failure to appreciate the significance of the mechanism of injury sustained by the patient. One consultant felt the patient should have been admitted for 24 hours for observation, due to being injured during a roll-over MVA. Their reasoning being that patients involved in such accidents often have injuries that are not initially apparent on examination or even after diagnostic workup. Also, these patients are often unable to properly convey the extent of their injuries due to being given narcotics in the ED.
Failure to appreciate the significance of the abdominal CT result. These consultants believed the physician did not fully appreciate the findings of the preliminary abdominal CT report. It was argued that the physician should have been suspicious that an apparently healthy, middle-aged man had splenic pathology. These findings should have led to admission, observation, and further testing.
Failure to admit the patient for 24-hour observation and surgical consultation. Plaintiff consultants felt that the physician’s care was substandard for not admitting the patient for at least 24-hour observation.
The case was settled on behalf of Emergency Medicine Physician A.
Risk management considerations
MVAs are the most common cause of blunt abdominal trauma, with splenic injuries being the most common significant injury. (1) EMS documentation in this case indicated rebound tenderness and discoloration to the LLQ abdomen. Emergency Medicine Physician A documented his examination of the patient as finding a soft abdomen, non-distended, no rebound, and no guarding, but fails to mention whether there is evidence of discoloration. There were references to multiple contusions but no indication of location. The medical information listed for the CT abdomen/pelvis was “s/p mvc with abd. pain.”
It is the responsibility of the physician to provide the radiologist with as much information as possible so they may conduct an appropriate evaluation of the films. Radiologist A was not given information on the severity of the accident, including rollover, airbag deployment, and highway speeds. Had this information been provided, the two splenic infarcts may have been given more weight and attention in the patient’s care.
Further, the report lists these infarcts as probable and there is no documentation that Emergency Medicine Physician A and Radiologist A discussed the results of the CT scan. The Eastern Association for the Surgery of Trauma recommends that a hemodynamically stable patient with a positive CT scan be admitted for serial physical exams and observation. (2)
Signs and symptoms of blunt abdominal trauma include pain, tenderness, and/or peritoneal signs. Morphine alters the perception of and response to painful stimuli and produces central nervous system (CNS) depression.
As the patient was given morphine at his arrival in the ED, this medication may have masked abdominal pain or tenderness the patient was experiencing and resulted in a negative physical exam. Therefore, reassessment and reevaluation should be conducted at regular intervals to provide the most appropriate assessment.
Also, contradictions in medical records can pose a challenge in the defense of a claim. When the history of present illness (HPI) or chief complaint entered into an EHR includes contradictory information, the EHR will “default” to normal or negative in the review of systems or exam. Physicians need to be aware of this setting, and accurately update these areas to reflect the patient’s current complaints.
To ensure ideal patient outcomes, it is necessary to carefully and thoroughly document, communicate, evaluate, monitor, and follow up on a patient’s condition.
Kim GI, MD. Miller JC, MD. Assessing Patients in the Wake of Motor Vehicle Accidents. The Journal of Urgent Care Medicine. Available at https://www.jucm.com/assessing-patients-in-the-wake-of-motor-vehicle-accidents/. Accessed June 2, 2020.
Hoff WS, Holevar M, Nagy KK, et. al. Practical Management Guidelines for The Evaluation of Blunt Abdominal Trauma: The EAST Practice Management Guidelines Work Group. The Journal of Trauma Injury, Infection, and Critical Care. Volume 53, Number 3. 2002. Available at https://www.east.org/education/practice-management-guidelines/archived/blunt-abdominal-trauma-evaluation-of. Accessed June 2, 2020.