Practice of Medicine

Claims Lesson

Importance of Accurate, Timely and Effective Communication of Abnormal Imaging Findings in the Emergency Department Setting

November 26, 2013

 

The Case

A woman was the front seat passenger in a head on crash with a drunk driver. She was wearing a lap and shoulder belt. Within 5 minutes EMS arrived. She was alert and oriented, moved all extremities, and complained of shoulder pain and pain from the mid chest to the pelvis, thought to be secondary to seat belt injury. At the scene, her vital signs were: BP 107/63, HR 88, RR 20. Paramedics reported no abdominal tenderness.

Within 35 minutes of the MVA she arrived at the nearest Emergency Department. On ED admission her vital signs were: BP 117/97, HR 90, RR 20. The initial assessment form read “MVA-minor injury”. Ten minutes after ED admission her vital signs were: BP 96/52, HR 67, RR 22. These are the last recorded vital signs in the ED. On physical exam she had right flank ecchymosis. Her abdomen was tender, but soft and flat without guarding and with normal bowel sounds. The remainder of the physical examination was within normal limits.

1 hr and 10 minutes after arrival in the ED, a CT chest/abdomen/pelvis with intravenous contrast was completed. Because it was after hours, the exams were transmitted via teleradiology to the radiologist on call. One hour after the CT exams were performed a hand-written preliminary report was faxed to the ED by the radiologist. This report identified moderate ascites (no mention of “blood”), no visceral injury, and a prominent pancreas body. (The final report rendered by another radiologist the following day was substantially the same.) There is no record of this report being received by the attending ED physician.

Three hours and 55 minutes after arrival in the ED, the patient had a cardiopulmonary arrest. She was intubated but chest compression was not started for 13 minutes. Her cardiac rhythm was initially ventricular fibrillation, then asystole. A normal rhythm was established after one hour of resuscitation. During the code her HGB was 8.9 and HCT 27.1.

Five hours and 25 minutes after arrival in the ED, the patient was taken to the OR for an exploratory laparotomy with a pre-operative diagnosis of hemorrhagic shock due to intra-abdominal bleeding. At surgery more than 2 liters of blood and clots were evacuated. There was extensive mesentery laceration at the mid-ileum and ileocecal levels, a complete small bowel tear at the proximal to mid ileum, and a small bowel perforation at the distal ileum. Bowel was resected from the proximal ileum to the distal ascending colon with a primary anastamosis.

Post-operatively the patient did not wake up, was unresponsive to painful stimuli and flaccid in all four extremities. She is in a chronic vegetative state secondary to hypoxic anoxic encephalopathy.

Allegations

The patient’s family sued the ED physician, the hospital, and the radiologist. It was alleged that the radiologist failed to correctly interpret the CT abdomen/pelvis, and failed to emergently communicate the abnormal findings to the attending ED physician.

Disposition

Upon expert review the CT abdomen/pelvis demonstrates considerable free fluid around the liver and spleen, throughout the peritoneal cavity, in the paracolic gutters and in the pelvis. An interloop fluid collection is present in the right abdomen. The wall of the 2nd duodenum and distal small bowel is thickened. There is edema within the mesentery and small bubbles of air in the anterior mesentery. The bowel wall enhances.

The case was settled in the high range.

Risk Management Commentary

This patient suffered a classic “seat belt injury”, feared by Emergency physicians and Trauma surgeons. Emergency physicians must heavily rely upon their Radiology colleagues to interpret CT studies, as they typically have no training in this area.

From a clinical risk management perspective, examining physicians should attempt to rule out intra-abdominal injury when patients wearing restraints are involved in high velocity road accidents, and have complaints of abdominal or shoulder pain.

Bowel and mesenteric injury (BMI) following blunt abdominal trauma occurs in 1% of patients undergoing CT for blunt abdominal trauma and 3-5% of patients undergoing laparotomy for blunt abdominal trauma. Since clinical signs are absent in >50% of patients with BMI, CT abdomen/pelvis is the best method of evaluating these patients. Direct CT signs of BMI are bowel discontinuity, free intraperitoneal contrast or air, and intramural air. Indirect CT signs of BMI are free intraperitoneal fluid (especially in the absence of solid organ injury), bowel wall enhancement or thickening, and mesenteric edema. When CT signs of BMI are present, exploratory laparotomy is indicated.1,2

The presence of free intraperitoneal fluid following blunt abdominal trauma (even without identifying other positive findings) suggests the possibility of BMI.

When a significant finding that may alter the immediate course of patient care is found on an imaging exam, personal communication (in person or by phone) between the radiologist and the attending physician is required. In an emergent care setting, personal, direct or telephone communication is the only reliable way to communicate significant findings.

References:

1 Rizzo MJ, Federle MP, Griffiths BG. Bowel and mesenteric injury following blunt abdominal trauma: evaluation with CT. Radiology 1989; 173: 143-148.

2 Brody JM, Leighton DB, Murphy BL, et al. CT of Blunt Trauma Bowel and Mesenteric Injury: Typical Findings and Pitfalls in Diagnosis. RadioGraphics 2000; 20: 1525-1536.

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