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A 69-year-old male with diffuse systemic sclerosis, interstitial lung disease, end stage renal disease on hemodialysis, anemia, hypertension, hypoalbuminemia, secondary hypothyroidism, and gastric antral vascular ectasia (“GAVE”) had been referred to a gastroenterology clinic for evaluation of recurrent problems with weight loss and dysphagia.  It was assumed that the patient’s disease had progressed to esophageal scleroderma and that a percutaneous endoscopic gastrostomy (“PEG”) would be necessary to bypass his esophagus and would allow him to take in adequate nutrition without swallowing.  The patient was referred to the gastroenterology clinic for evaluation and a PEG.

On 6/25/2012, the gastroenterologist ordered a PEG, and she scheduled an esophagogastroduodenoscopy (“EGD” or upper endoscopy) and esophageal manometry for the afternoon of 6/25/2012, both elective, non-emergent diagnostic procedures, scheduled to be done on an outpatient basis.  On 6/23/2012 or 6/24/2012, the patient had been discharged from the hospital on antibiotics with home oxygen administration after treatment for aspiration pneumonia.

The gastroenterologist performed a pre-endoscopy history and physical examination in the early afternoon of 6/25/2012 and noted that the patient had active diffuse scleroderma complicated by renal crisis, diffuse systemic sclerosis, interstitial lung disease, GAVE with multiple cauterizations, and end stage kidney disease.  In past medical history, she listed “scleroderma renal crisis, “Started dialysis December 30, 2011,” and “Pneumonia. Admitted to er 6/24/12.”  She noted that the patient had had multiple upper endoscopies for gastrointestinal bleeding prior to this EGD.  Her physical examination listed “Lungs: Clear Auscultation. Clear percussion and Normal Symmetry and Expansion.”  She noted that she, not an anesthesiologist, was ordering sedation.

Sedation was to be administered by a registered nurse.  The gastroenterologist listed Airway as Class 2 and ASA Level (American Society of Anesthesiologists physical status classification system) as 3 (severe systemic disease).

On 6/25/2012 at 2:48 p.m. and ending at approximately 3:15 p.m., the gastroenterologist performed an upper endoscopy on the patient and took biopsies.  Nursing records indicate that sedation consisted of midazolam, 7 mg, administered over the 22 minutes; fentanyl, 175 mcg administered over the 22 minutes, and Cetacaine spray applied to the throat prior to the procedure.

The patient was transferred from the endoscopy procedure room to the recovery area under the care of a registered nurse.  The nurse noted that the patient was unresponsive to verbal and painful stimuli, with blood pressure 108/70, heart rate 86, and O2 saturation 89% on 2 liters delivered by nasal cannula.  A face mask was applied at 10 liters O2 and oxygen saturation went up to 97%.  When the gastroenterologist was notified, she ordered reversal medications: flumazenil 0.25 mg IVP over 15 seconds and Narcan 0.4 mg IVP at 3:40 p.m., and the patient was still unresponsive.  A second dose of flumazenil 0.25 mg IVP was given at 3:43 p.m., and the patient became responsive at 3:44 p.m.  Once the patient was responsive, the gastroenterologist performed the esophageal manometry procedure.  No time is entered in the medical record for this procedure although the gastroenterologist acknowledges that it was done and the results are recorded.

The gastroenterologist was later notified by nursing staff of concerns with the patient’s breath sounds, and the gastroenterologist noted stridor at 4:26 p.m.  She was notified at 5:19 p.m. that the patient’s oxygen saturation was 89% on 5 liters oxygen delivered by nasal cannula.  At 5:20 p.m., the gastroenterologist ordered a chest x-ray due to the inability to wean the patient off oxygen after the endoscopy.  A face mask was applied at 10 liters oxygen at 5:21 p.m., and oxygen saturation went up to 93%.  The chest x-ray indicated “a dense retrocardiac opacity and a left pleural effusion” and a “volume loss in the left lung with mild shift of the mediastinum towards the left.”

After the manometry procedure in the recovery room, the patient’s oxygen saturation was monitored, and when the oxygen saturation remained above 90% for 30 minutes on room air, the patient met endoscopy discharge criteria.  The patient was discharged home with instructions concerning any complications that might arise.

The gastroenterologist states that she arranged to admit the patient to the hospital, but the patient left against medical advice (AMA).  Neither notation of this nor a signed AMA release was found in the record.  Pathology results revealed gastritis and the manometry procedure revealed a condition consistent with esophageal scleroderma.

On 6/27/2012, the patient presented to the emergency department with shortness of breath and cough.  Chest x-ray showed new right lung patchy opacities, and the patient was cachectic.  He was admitted to the intensive care unit for treatment of pneumonia.  The admission diagnosis was “most likely persistent pneumonia, likely aspiration due to esophageal dysmotility.”  The patient failed to improve despite intensive hospital care.  Although the gastroenterologist had scheduled a PEG for 7/2/2012, it was decided that the patient would not go through with the procedure.  Instead, it was decided that the medical team would provide palliative care for the patient.

On 7/4/2012, the patient died with the cause of death listed as aspiration pneumonia due to esophageal dysmotility and end-stage scleroderma with severe malnutrition as a contributing factor.

The Board deemed the gastroenterologist’s conduct as falling below the standard of care for the following reasons:

1) The gastroenterologist failed to provide an accurate analysis of the patient’s suitability for the endoscopic and manometry procedures.

2) She classified the patient as an ASA Level 3, which denotes an individual with stable multiple system disease that limits daily activity without immediate danger of death.

3) At the time of the EGD and manometry done by the gastroenterologist, the patient had just been released from another hospital, where he had been treated for aspiration pneumonia and discharged on antibiotics and home oxygen.

4) By reason of the patient’s recent aspiration pneumonia and the necessity for home oxygen administration, his ongoing scleroderma renal crisis which necessitated hemodialysis, his persistent interstitial lung disease, and his frequent bleeding and cauterizations for GAVE, his condition was not stable, and elective procedures at this time were contraindicated.  The patient’s classification was clearly ASA level 4, which denotes an individual with severe, incapacitating disease, poorly controlled or end-stage, at risk for death due to organ failure.

5) The gastroenterologist failed to provide for an anesthesiology consultation, given the patient’s unstable and life-threatening condition, and instead elected to provide conscious sedation directed by the gastroenterologist and administered by a registered nurse.  The level of sedation administered to the patient during the upper endoscopy procedure was relatively large for an individual with so many co-morbid conditions, and an anesthesiologist or nurse anesthetist should have been in attendance.

6) Since both procedures were elective, the gastroenterologist failed to reschedule the procedures for a time when the patient was stable and able to tolerate conscious sedation directed by the gastroenterologist and administered by a nurse.

7) The patient had a very unstable post-procedure course in the recovery room.  He was unresponsive to verbal and painful stimuli and oxygen saturation was below 90%.  Reversal medications had to be administered before the patient became responsive.  When the patient became responsive, the gastroenterologist performed the esophageal manometry in the recovery room.  This procedure was unnecessary to determine the need for a PEG and further endangered the health of the patient.

8) The respondent approved sending the patient home with instructions after his oxygen saturation was above 93% for 30 minutes.  The patient was a very high-risk patient for elective procedures and had had a very unstable post-procedure course in the recovery room, including the development or exacerbation of pneumonia.  Under these circumstances, in conjunction with his numerous co-morbidities, it was unsafe to send the patient home.  There was no record found of the patient leaving the clinic AMA.

The Board issued a public reprimand against the gastroenterologist.  Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.

State: California

Date: May 2017

Specialty: Gastroenterology, Hospitalist, Internal Medicine

Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Cough, Shortness of Breath, Weight Loss

Diagnosis: Gastrointestinal Disease, Pneumonia, Pulmonary Disease

Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with other providers, Lack of proper documentation

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

A patient was referred to a general surgeon specialized in colorectal surgery by his primary care doctor.  The patient presented to the general surgeon on 4/10/2012 as a 35 year-old-man with anal pain since age 16.

The patient’s medical history included a 12/30/2003 colonoscopy with biopsies by a gastroenterologist, who made a postoperative diagnosis of anal fissure, rectal polyp, and two small sigmoid polyps.  The biopsies revealed benign hyperplastic polyps.  In 2009, the patient had a lumbar discectomy at L4-L5.  In October 2011, the patient was referred to, and seen by, a cardiologist.  The cardiologist found “no evidence of any fixed coronary arterial disease in the left dominant system…elevated resting left ventricular end-diastolic pressure suggests left ventricular diastolic non-compliance likely due to history of hypertension and obesity.”  In sum, the patient presented to the general surgeon with morbid obesity, hypertension, dyslipidemia, post-two back surgeries, with a resulting DVT, cardiac complaints, and a list of prescription medications; and a social history including a one pack per day smoking habit, cannabis use, and occasional alcohol use.

The patient appeared with his wife for his appointment with the general surgeon.  The patient was given a two-page medical questionnaire to complete.  The patient filled in page one of the questionnaire and the patient signed page two, leaving blank the box on page two asking the patient to circle symptoms applicable to their current condition (e.g., headaches, shortness of breath, chest pains, blood in stool, etc.).  The patient was called out of the lobby by a medical assistant, who took his vital signs and questioned him about the information listed on the questionnaire.  The medical assistant learned that the patient was allergic to penicillin, which the patient had not listed on the questionnaire.  The medical assistant reported that the patient’s vital signs to the general surgeon on a yellow sticky note was as follows: “Temp-98.2 F, Weight-341 lbs., Height-72 in., BP [Blood Pressure]-139/77, Pulse-84, RR[Respiratory Rate]-21, BMI [Body Mass Index]-46.3.”

The medical assistant then escorted the patient to an examination room. The general surgeon entered and spoke to the patient. The general surgeon took notes by hand, indicating the following:

“hemorrhoids three times after laminectomy[1l in January; symptoms greatly increased over the last six months; Bowel Habits-small stools, tenesmus [urge to defecate, but cannot], and mucus discharge; hiatal hernia; colonoscopy negative; History of polyps; no sigmoidoscopy.”

The general surgeon and the medical assistant created the chart note for the patient’s visit, which reports out the following:

CC [Current Complaint]: Hemorrhoids

HPI [History of Present Illness]: The patient is a pleasant 35- year-old referred here by [his primary care physician]. He is here because of a 3-year history of hemorrhoids with progressive painful BM’s [bowel movements], tenesmus, BRBPR [bright red blood per rectum], and small stools last 6 months. Known history of fissure. Last colonoscopy negative.

ROS [Review of Systems]: General-denies fever, night sweats, weight loss; Neurological-denies loc [loss of consciousness], ha [headaches], diplopia [double vision], tinnitus [ringing in the ears], vertigo [dizziness], numbness, tingling, incoordination; Respiratory-denies sob [shortness of breath], wheezing, coughing, hemoptysis [coughing up blood]; CV [cardiovascular system ]-denies angina, palpitation, leg cramps, pedal edema, pnd [ difficulty breathing], nocturia [ excessive urination at night], orthopmea [shortness of breath while lying down], claudication [cramping leg pain caused by exercise]; GI [gastrointestinal system]-denies nausea, vomiting, hematochezia [fresh blood in stool], hematemesis [vomiting blood], jaundice, diarrhea, incontinence, heartburn, indigestion, dysphagia [difficulty swallowing], poor appetite, constipation; GU [genitourinary]-denies dysuria [painful urination], hematuria [blood in urine], incontinence, impotence, pneumaturia [passage of gas with urine], fecuria [fecal matter in the urine]; MS [musculoskeletal]-denies stiffness, arthralgia joint pain], weakness, atrophy, bone pain, Raynaud’s [severe blood flow reaction to blood vessels in the cold in fingers and toes]; Endocrine-denies heat intolerance, cold intolerance, dry skin, dry hair, hoarseness, polydipsia [abnormally large thirst], polyuria [production of abnormally large levels of diluted urine]; Hematologic-denies bleeding, bruising, ecchymosis [discoloration of the skin resulting from bleeding underneath], pk [Pyruvate kinase deficiency, one of the most common enzymatic defects of the erythrocyte].

PMH [Past medical history]: Medical-hypertension, dyslipidemia [high cholesterol]; Surgical-lumbar laminectomy, micro-discectomy.

SH [Social history]: Patient denies recreational drug use; Smokes 1 pack/day for 15 years; Occasional alcohol consumption.

FH [Family history]: Mother- 69 alive with hypertension [high blood pressure]; Father-DEC [deceased] at 65 heart attack; Siblings- 1 brother alive at 41 with CVD [cardiovascular disease], 2 sisters alive, 1 with diabetes another with CVD.

Allergies: Penicillin.

Meds:

acetaminophen-hydrocodone 325 mg.-7.5 mg. [Norco] oral tablet, folic acid 1 mg oral tablet, Xanax XR 0.5 mg oral tablet, extended release, zolpidem [ Ambien] 10 mg oral tablet.

Vitals: T [temperature]-98.2 F, Wt [weight]-341 lbs., Ht [height]-72 in., BP [Blood Pressure]-139/77, P [pulse]-84, RR [Respiratory Rate]-21, BMI [Body Mass Index]-46.3.

PE [Physical examination]: General-WD/WN [well­-developed/well-nourished] in NAD [no abnormality detected]; HEENT[head, eyes, ears, nose, throat]-PERRLA [Pupils equal, round & reactive to light & accommodation], EOMl, [extraocular movements intact], ENT [ear, nose, throat] wnl [within normal limits]; Neck-not thyromegally [enlargement of the thyroid gland] or masses, no ND [jugular venous distension] or bruits [a systolic murmur heard in the neck]; Chest-clear to auscultation and percussion; Cardiac-no murmur or gallop; Abdomen-no masses or organomegaly [enlargement of the viscera], non-tender; Extremities-no clubbing, cyanosis or edema, full range of motion; Neuro-grossly intact; Anorectal­: inspection showed posterior fissure, with spasm, no further exam. Large skin tag RPQ [right posterior quadrant]. Cannot rule out hemorrhoids.

A/P [assessment/plan]:

#ANAL fissure (565.0);

#HYPERLIPIDEMIA OT/UNSPEC (272.4);

#HYPERTENSION UNSPEC (401.9).

Fissurectomy, lateral sphincterotomy, possible hemorrhoidectomy. The risks, benefits, and alternatives, including the slight chance of incontinence, are discussed.

Following the examination, the patient signed two information and consent forms: Hemorrhoids-Surgical Hemorrhoidectomy and Anal Fissure-Fissurectomy and Sphincterotomy.

No surgery was scheduled, and the patient left the general surgeon’s office. The general surgeon did not request the patient’s medical file from the primary care doctor.

On 4/23/2014, at approximately 9:00 a.m., the patient called the general surgeon’s office, complaining of terrible pain and pleading for relief. At the time, the general surgeon was in surgery at a surgery center. The general surgeon was contacted in the operating room (OR) by his office on behalf of the patient. Although the general surgeon was scheduled for a full day of surgeries, he offered to operate on the patient at the end of his surgical schedule that day. The patient accepted. The general surgeon’s office transmitted a Pre-Admission form, with Physician’s Orders, to the surgery center at approximately 10:00 a.m., requesting the patient have the following tests prior to surgery: “EKG [electrocardiogram]; CBC [complete blood count], without Differential (includes Platelets); UA[urine analysis]/Culture if indicated.”

At 3:44 p.m., the patient was admitted to the surgery center for his surgical procedures. The Admission’s Nurse completed the Admission Profile with the patient and the wife, noting, among other things: “Previous hospitalizations/surgeries-microdiscectomy 2010, lumbar laminectomy 2009, with DVT after laminectomy; Comprehensive Pain Assessment­ pain scale 10, rectum, onset at 16 years old, burning; Cardiovascular-high blood pressure, weird heartbeat about 8 months ago at cardiologist; Hema/Hepatic/GI-hemorrhoids, fissure; Psychiatric-Anxiety; Social Habits-smoker 1 PPD [pack per day], alcohol 2-4 times per month.”

The general surgeon completed a Short Form history and physical for the patient, noting: “Chief Complaint-Anal pain; History of Present Illness-severe pain secondary to anal fissure. Past Medical/Surgical History: HTN [hypertension]; Current Medications and Allergies: See-home medication list; Physical Exam-Head/Neck-normal,-Airway normal,-Neuro normal, Chest/Lungs normal, Heart normal, GI normal, GU normal, Extremities normal; Significant findings-anal fissure with right posterior skin tag; Diagnosis-Anal fissure; Plan-fissurectomy, sphincterotomy, and hemorrhoidectomy; Pre-Sedation Assessment For Procedure Without an Anesthesiologist-ASA2 II – mild systemic disease.”

At 4:12 p.m., a patient provided a urine sample and blood was taken for labs. At 4:53 p.m., labs revealed normal sodium, potassium, hemoglobin, and hematocrit. At 5:11 p.m., a pre-anesthetic evaluation was completed on the patient by an anesthesiologist. At 5:29 p.m., the patient was placed under general anesthesia. At 5:46 p.m., the general surgeon performed a hemorrhoidectomy, fissurectomy, and a right lateral sphincterotomy on the patient. The surgery was completed at 6:42 p.m., and the patient was in the recovery room at 7:00 p.m. The general surgeon prescribed the patient “Norco 10/325 mg., one tablet every four hours, as needed for pain; Valium 2 mg., one every six hours, as needed for pain; and Toredal (sic) 10 mg., one every six hours.” At 8:15 p.m., The patient was discharged.

The general surgeon drafted an Operative Report, noting, among other things:

“Preoperative Diagnosis-anal fissure; Postoperative Diagnosis-anal fissure and hemorrhoids; Procedures Performed-hemorrhoidectomy, fissurectomy, right lateral internal sphincterotomy; Anesthesia-general; Findings-anal stenosis with deep posterior anal fissure with large 3-quadrent (sic) hemorrhoids in the usual distribution, in the right anterior quadrant hemorrhoidal group there with chronic strangulation and gangrenous changes.”

On 4/24/2014, Post-Surgical Day 1 (PSDl), the patient’s wife called the general surgeon’s office four times: at 9:46 a.m., 10:32 a.m., 3:10 p.m., and 4:38 p.m. At 9:46 a.m., the patient’s wife reported that the patient had blood in his urine; the patient’s wife was told that the patient had a urinary catheter during surgery and blood in the urine was normal on PSDI. At 10:32 a.m., the patient’s wife reported the patient was vomiting and had diarrhea; the patient’s wife was told this was normal for PSDl. At 3:10 p.m., the patient’s wife reported the patient was still vomiting; a prescription for Reglan (anti-nausea) was called in. The patient’s wife collected the prescription, but the patient could not keep the Reglan down.

At 4:38 p.m., the patient’s wife reported the patient was still vomiting, with diarrhea, and feels hot, although his temperature is normal; the patient’s wife was told that the symptoms are normal for PSDl, and get fluids into the patient. The general surgeon did not return the calls from the patient’s wife on 4/24/2014.

On 4/25/2014, Post-Surgical Day 2 {PSD2); at 5:58 p.m., the patient’s wife called the surgery center and reported the patient was still vomiting, with diarrhea, and feels hot; the patient’s wife was told the symptoms were normal for PSD2, but to call the general surgeon’s office. The patient’s wife called the general surgeon’s office, spoke to the answering service, and requested a callback.

At 6:40 p.m., the general surgeon telephoned the patient’s wife. The patient’s wife reported pus at the surgical site and that the stitches looked ripped open and yellow; the general surgeon said they were breakaway stitches and the appearance was normal for PSD2. They did not discuss the patient’ s symptoms from PSD 1.

On 4/26/2014, the patient began speaking nonsensically. He complained about pain in his legs. The patient’s wife called the general surgeon’s office at 12:36 p.m. and 12:40 p.m., but the office was closed for lunch and the patient’s wife did not leave a message with the exchange.

The patient’s wife then telephoned the surgery center at 12:46 p.m. and 12:47 p.m. The patient’s wife reported the patient was speaking nonsensically, with purple, blotchy legs, purple lips, and slurred speech; the patient’s wife was told to bring the patient into the hospital. At 12:58 p.in., 911 was called. Paramedics appeared and transported the patient to the surgery center.

The patient arrived at the surgery center at 1:35 p.m. In the ambulance, the patient was intubated and described by EMS as “acutely cyanotic and mottled.” Upon arrival, the patient was treated by an ED physician in the ED for two hours.

The ED physician drafted an ED Report, indicating, among other things: “This is a 36-year-old white male who comes to the emergency room by ambulance in extremis [at the point of death]. He was intubated in the field by the paramedics.”

“On arrival in the department he was purple mottled, unresponsive with a heart rate in the 60s which later proceeded to become bradycardic into the 20s.” ” … [A] temperature of 41 Centigrade [105.8 Fahrenheit] was noted.”

“Examination of the rectum revealed maceration and postoperative changes. It does appear consistent with an infection in the area.”

“Labs later returned showing renal failure with a creatinine of 9. Potassium was elevated.”

“Diagnosis-septic shock, renal failure, perineal infection, status post hemorrhoidectomy. His prognosis seems exceedingly poor.”

“Total critical care time 120 minutes.”

At 2:50 p.m., the ED physician contacted the general surgeon regarding the patient, reporting sepsis, renal failure, hyperlipidemia, recent hemorrhoidectomy with local infection. The general surgeon telephoned the surgery center to reserve an OR for the patient, scheduling the first available OR at 5 p.m.

At approximately 3:30 p.m., the patient was admitted to the surgery center and his care was transferred to an internist. After 5:00 p.m., the patient was taken to interventional radiology (IR) for placement of an IVC [inferior vena cava] filter (5:35 p.m.) and a temporary dialysis catheter (5:43 p.m.).

At 5:50 p.m., the patient was moved from IR into the OR, where the general surgeon waited. On arrival to the OR, the transport staff reported a change in heart rhythm. A Code Blue was called at 6:05 p.m. Resuscitative measures commenced but were unsuccessful, and time of death was called at 6:41 p.m.

The internist charted a Discharge Summary, noting: “Discharge Diagnosis-(1) patient died, (2) severe septic shock, (3) most likely perirectal phlegmon [inflammatory process with pus] versus fasciitis [inflammation of connective tissue]. History of Hospital Stay-This was a 36-year-old gentleman admitted at [the hospital] with septic shock. He was hypotensive, unresponsive, intubated in the field. While in the emergency room, the patient had episodes of bradycardia [abnormally slow heart action]. He was found to have multi-organ system failure with acute kidney insufficiency. He was taken to the OR for an emergent exploratory laparotomy [a surgical incision into the abdominal cavity, for diagnosis or in preparation for surgery]. Unfortunately, he coded on the OR table.”

The general surgeon wrote a Death Note in the chart, indicating: “Patient came in with septic shock. Code blue called in route to OR. CPR commenced in the OR per ACLS [advanced cardiac life support] protocol. Planned perineal debridement and colostomy never took place. Code was called after 22 min of resuscitative effort then resumed after seemingly having spontaneous cardiac electrical activity and pulse, but this was transient, and soon patient became pulseless without meaningful cardiac activity. Patient after hemorrhoidectomy and has perineal gangrene.”

An autopsy was performed on April 28, 2012, at the Fresno County Coroner’s Office. A blood culture was taken, revealing gram-negative rods isolated [bacterial infection]. The cause of death is listed as probable cardiac arrhythmia due to idiopathic hypertrophic cardiomyopathy.

The general surgeon was placed on probation for three years with stipulations of completing an education course and undergoing monitoring by another physician.

State: California

Date: May 2017

Specialty: General Surgery, Internal Medicine

Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Fever, Nausea Or Vomiting, Pain, Urinary Problems

Diagnosis: Sepsis

Medical Error: Delay in proper treatment, Failure of communication with patient or patient relations, Improper treatment

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 1/6/2010, an 84-year-old patient was admitted to the hospital with complaints of dizziness, anemia, and possible GI bleeding.  On 1/8/2010, a gastroenterologist provided a GI consultation for the patient. The gastroenterologist’s handwritten note on that date was cursory and lacking in detail without documenting a comprehensive history, comprehensive physical examination, and/or the gastroenterologist’s medical decision-making.  The gastroenterologist submitted billing for the consultation using CPT billing code 99223, which was not supported by the gastroenterologist’s documentation of the visit.

On 1/9/2010, the patient underwent a gastroscopy.  Small gastric natural ulcers and a bulbar duodenal ulcer, which was 2.5 cm in size, were identified and cauterized.  Sometime later in January 2010, the patient was readmitted to the hospital with complaints of nausea, vomiting, diarrhea, weakness, and interval decline in hemoglobin.  The patient underwent laboratory tests, which showed anemia with borderline iron deficiency.

On 1/27/2010, the patient underwent both a gastroscopy and a colonoscopy.  Small oozing angiodysplasias were found in the duodenum and were cauterized.  Small adenomatous polyps were excised from the distal colon. On 2/1/2010, the patient underwent a second colonoscopy due to concerns that pathology may have been missed due to suboptimal bowel preparation during the first examination.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed a medically unnecessary second colonoscopy on 2/1/2010 within days of an initial colonoscopy, his documentation was cursory and some of the physician’s handwritten notes were illegible, and he submitted billing using the CPT billing code 99223, which was not supported by the physician’s documentation of his care and treatment of the patient.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: February 2017

Specialty: Gastroenterology

Symptom: Dizziness, Diarrhea, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Weakness/Fatigue

Diagnosis: Gastrointestinal Disease

Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 2

Link to Original Case File: Download PDF

Sometime in May 2009, a patient presented to a gastroenterologist with a history of sporadic rectal bleeding and chronic reflux-type complaints.  An index colonoscopy conducted on 5/7/2009 demonstrated predominantly left-sided colitis. The patient was treated with oral and topical mesalamine preparations.  Initially, the patient’s symptoms responded to the treatment, but then worsened several months later.

On 8/24/2009, the patient underwent a second colonoscopy.  The patient was prescribed oral budesonide to treat what was believed to be an extension of the colitis.  The patient continued to have ongoing symptoms. On 11/9/2009, the patient underwent a third colonoscopy, which showed reduced activity of disease.  On 1/8/2010, the patient underwent a gastroscopy and a fourth colonoscopy in order to determine the course of future treatment. The colitis was believed to be inactive, and the patient was continued on oral mesalamine preparations.  The patient’s increased bleeding was believed to be hemorrhoidal in origin, and internal hemorrhoids were cauterized. The biopsy from the distal esophagus demonstrated inflammatory changes without Barrett’s metaplasia.

The patient had difficulty swallowing (dysphagia) and abdominal pain.  The patient underwent gastroscope on 2/15/2010, 3/25/2010, 5/20/2010, and 4/19/2011.  In each instance, biopsies from the gastric antrum and distal esophagus/gastroesophageal junction were obtained, and mild chronic inflammatory changes were observed.  In each instance, the gastroenterologist did not obtain biopsies from the esophageal body. Repeated esophageal dilutions were performed in order to alleviate dysphasia symptoms.  The gastroenterologist did not document the presence or absence of constricting pathology.

The patient underwent additional colonoscopies on 8/24/2010, 4/11/2011, and 12/7/2012.  The patient underwent additional gastroscopies on 12/30/2011, 4/3/2012, 9/21/2012, 1/11/2013, and 3/1/2013.  In each instance, biopsies form the distal esophagus demonstrated inflammatory changes without Barrett’s metaplasia.

The gastroenterologist maintained handwritten notes of each visit.  Some of the handwritten notes were not legible. The gastroenterologist consistently failed to note any assessment and/or plan based on the assessment.  The gastroenterologist consistently billed using CPT billing code 99213, in the absence of documenting any expanded problem focused history or medical examination or medical decision-making.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated colonoscopies and gastroscopies of the patient without medical indication or necessity, failed to maintain adequate and accurate medical records of his care and treatment of the patient, and submitted billing for his care and treatment of the patient using the CPT billing code 99213, which was not supported by the physician documentation of his care and treatment of the patient.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: February 2017

Specialty: Gastroenterology

Symptom: Bleeding, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Abdominal Pain

Diagnosis: Gastrointestinal Disease

Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

A 58-year-old had a history of diabetes and generalized atherosclerotic vascular disease.  On 12/18/2009, the patient underwent an outpatient colonoscopy to assess complaints of diarrhea and abdominal pain.  The study was interpreted to show mild colitis, but biopsies were normal.

On 2/10/2010, the patient complained of abdominal discomfort and reflux-type symptoms.  The patient underwent a gastroscopy with finding of mild esophagitis and gastritis. Following placement of a stent and initiation of anticoagulation therapy, the patient presented with GI bleeding with bloody stools and hemoglobin decline necessitating multiple transfusions.

On 3/15/2010, the patient underwent a second gastroscopy, which the gastroenterologist interpreted to show multiple bleeding gastric ulcers.  The gastroenterologist cauterized the bleeding gastric ulcers with a BICAP probe. The patient continued to have bloody stools.

On 3/18/2010, the patient underwent a second colonoscopy and a third gastroscopy.  The gastroenterologist again interpreted the gastroscopy to show hemorrhagic erosions, which he again cauterized.  The colonoscopy was technically inadequate due to retained blood and debris.

On 3/20/2010, the patient underwent a third colonoscopy.  The gastroenterologist interpreted a finding of sigmoid diverticulosis.  On 6/4/2010, the patient was re-hospitalized with complaints of nausea, vomiting, weakness, and dark stools.  The patient was receiving antiplatelet therapy following a vascular intervention. On 6/4/2010 or 6/5/2010, the patient was seen by the gastroenterologist for GI consultation.  The gastroenterologist’s dictated consultation note was cursory, making no mention of the patient’s complaints or contributory medications. The gastroenterologist billed for the consultation using CPT billing code 99254, indicating a Level 4 consultation, which was not documented in the gastroenterologist’s consultation note.

On 6/5/2010, the patient underwent a fourth gastroscopy.  The gastroenterologist, again, cauterized “hemorrhagic erosion with evidence of slow bleed.”  On 6/7/2010, the patient underwent a fourth colonoscopy due to concerns of a lower GI tract contribution to bleeding.  The patient was found out have internal hemorrhoids, which the gastroenterologist cauterized.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated upper and lower endoscopic examinations of the patient in the absence of important pathology to justify the repeat studies, failed to maintain adequate and accurate medical records of his care and treatment to the patient, and submitted billing for his care and treatment of the patient using the CPT billing code 99254, which was not supported by the physician’s documentation.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: February 2017

Specialty: Gastroenterology

Symptom: Diarrhea, Blood in Stool, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Abdominal Pain, Weakness/Fatigue

Diagnosis: Gastrointestinal Disease

Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 2

Link to Original Case File: Download PDF

A patient had been seen by a gastroenterologist, as an outpatient, since sometime in 2005 for chronic gastroesophageal reflux disease (GERD).  The patient had received long-term treatment with acid-reducing medications and prokinetic agents. Between 2005 and 2009, the patient underwent 23 separate endoscopic studies.  The gastroenterologist’s hand-written documentation of his care and treatment of the patient was scant, illegible, and failed to state the gastroenterologist’s thoughts regarding evaluating and/or modifying the patient’s clinical course.

Sometime in June 2010 and again in July 2010, the patient was admitted to the hospital with upper GI tract bleeding.  On 7/13/210, the gastroenterologist dictated an admission summary, which failed to provide any meaningful historical details regarding the patient.  The gastroenterologist used PT billing code 99223 indicating a “complex” level of assessment for the consultation.

From 6/16/2010 through 10/9/2010, the gastroenterologist performed a total of 7 endoscopic studies to evaluate the patient.  The studies demonstrated that the patient had severe ulcerative esophagitis, secondary to reflux and/or vomiting. The gastroenterologist documented that he cauterized areas of hemorrhagic mucosa in the esophagus.  However, the gastroenterologist’s dictated procedure reports failed to document any additional anatomy or physiology related to these studies and treatment.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he failed to properly manage the patient’s reflux disease, performed an excessive number of endoscopic procedures that provided no relief to the patient’s symptoms or improvement in clinical outcome, failed to maintain adequate or accurate records of his care and treatment of the patient, and submitted billing using the CPT billing code 99223, which as not supported by the physician’s documentation of his care and treatment of the patient.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: February 2017

Specialty: Gastroenterology

Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Bleeding, Nausea Or Vomiting

Diagnosis: Gastrointestinal Disease

Medical Error: Unnecessary or excessive diagnostic tests, Improper treatment, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 2

Link to Original Case File: Download PDF

On 12/5/2011, a patient underwent knee replacement surgery.  In the course of his post-operative recovery in the hospital, the patient developed a rapid heartbeat.

On 12/6/2011, he was seen by Hospitalist A in the morning.  Hospitalist A attributed the patient’s rapid heart rate to his pre-existing atrial fibrillation and ordered an oral beta-blocker.  The patient’s heart rate was soon restored to a more moderate level.  The patient was transferred to the telemetry unit for closer monitoring at about 11:00 a.m.  Hospitalist A saw the patient again the following morning, noting that the patient was on nasally-administered supplemental oxygen, that his cardiac rhythm was irregular, that he was anemic, and that he had diminished bilateral breath sounds.  The hospitalist ordered chest x-rays and a blood transfusion.  The hospitalist’s order for a chest x-ray read “?chf” under “Indications.”

On 12/8/2017 at 8:40 a.m., nursing notes stated that the patient was receiving 2 liters of oxygen per minute via nasal cannula and his oxygen saturation level was 94%.  Hospitalist A’s chart entries made at about 10:40 a.m. indicate the patient was anemic, displayed some mental confusion, and had abdominal distention.  Hospitalist A opined that the distention “(m)ay be ileus due to oral morphine SR plus PRNs But r/o bleeding.”

Hospitalist A ordered x-rays of the patient’s abdomen, which confirmed the presence of an intestinal ileus.  Hospitalist A did not obtain a CT scan of the patient’s abdomen.  At about 3:50 p.m., Hospitalist A directed a nasogastric tube be placed to decompress the ileus.  Nursing notes from that evening indicate that the patient’s abdomen was “very distended, rounded” with hypoactive bowel sounds.

On 12/9/2017 at 2:30 a.m., a chart entry by Hospitalist B noted that the patient was “extremely uncomfortable with increased abdominal distention.”  She ordered a Harris flush procedure to reduce the patient’s intestinal pressure.

On 12/9/2017 at 3:58 p.m., the patient’s oxygen monitor alarm was sounding.  His oxygen saturation was 74% despite 2 liters per minute of supplemental oxygen.  Nurses repositioned the patient in bed and increased the oxygen flow rate to 5 liters per minute.  The indicated oxygen saturation increased to 88%.  The nasal cannula was moved to the patient’s mouth and the indicated oxygen saturation increased to 91-93%.  Hospitalist A was notified of the patient’s condition.

At 4:30 p.m., the attending nurse again called Hospitalist A to report that the patient was extremely short of breath with “labored” respirations and an indicated oxygen saturation “in the low to mid 80s.”  Hospitalist A directed that the patient be repositioned higher in bed; the nurse informed Hospitalist A that the patient was in the highest possible position.  Hospitalist A gave no new orders regarding the patient’s care.

The attending nurse’s chart entry for 5:10 p.m. states the following:

“(p)t’s condition continues to worsen.  Pt unable to hold O2 sats about low to mid 80’s on 5 liters NC.  Respiratory called to put on non-rebreather mask.  Pt’s LOC is decreased.  Pt repositioned up in bed.  NG tube flushed.  Pt requiring one-to-one nursing care.  Follow-up call to break and relief nurse’s call to [Hospitalist A] to ask that he come to the floor to see pt, d/t pt’s deteriorating respiratory status.  [Hospitalist A] still not answering the phone.”

The attending nurse placed a “Rapid Response” call to summon a physician to assess the patient at 5:20 p.m.  Hospitalist A came to the patient’s room, and his notes state that the patient’s oxygen saturation improved when he was repositioned in bed, “up to the 90s and stayed above 92” per measurement by the respiratory care provider.  Hospitalist A decided to continue with the current treatment on the medical floor rather than transferring the patient to the intensive care unit.

The medical record indicates that at 5:50 p.m., the patient’s oxygen saturation level is “in the 90’s but the O2 sat is variable with sat going down into the 80’s.”  The patient was still receiving supplemental oxygen via the 100% non-rebreathing mask.  The nursing notes for this time state that the patient’s daughter, a nurse, believed the patient should be monitored in the intensive care unit rather than on the medical floor and conveyed that desire for transfer to nursing staff, the nursing supervisor, and to Hospitalist A.

Nursing notes for 6:45 p.m. state the following:

“BP 92/63 HR 120’s.  Pt minimally responsive, respirations increasingly labored.  Telemetry and O2 sat monitors frequently alarming.  Pt requiring RN at bedside at all times.  pt hands cyanotic and remain cool to touch and forehead now appears slightly bluish in color.  [Hospitalist A] aware.  Family tearful, verbalizing anger w/staff regarding pt not being transferred to ICU.”

At 7:05 p.m., Hospitalist B ordered the patient to be transferred to the intensive care unit, apparently in deference to the fact that the “family, rn, supervisor want the pt moved to icu though it was discussed with all by the rounding hbs that there are not criteria for icu…”  The patient was taken to the intensive care unit at about 7:35 p.m.

The intensive care nurse’s notes state that the patient arrived at the ICU unresponsive with his oxygen saturation reading in the 70% range despite being on 15 liters of supplemental oxygen per minute via non-rebreather mask.  The patient’s fingers and toes were cyanotic and his body mottled.

On 12/10/2011 at 3:10 a.m., the patient died despite additional care.

The Board expressed concern that Hospitalist A practiced below the standard of care by failing to order an abdominal CT scan in a patient with an identified bowel obstruction that was not responding to care.  He failed to recognize clinical indicators of early septic shock and make a timely transfer of the patient to a higher level of care.  He failed to recognize and respond to the patient’s acute respiratory distress.

The Board issued a public reprimand.  He was ordered to take a course in early recognition of septic shock.

State: California

Date: January 2017

Specialty: Hospitalist, Internal Medicine

Symptom: Shortness of Breath, GI Symptoms (GERD, Abdominal Distention, Dysphagia)

Diagnosis: Sepsis, Acute Abdomen

Medical Error: Delay in proper treatment, Diagnostic error, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Failure to properly monitor patient

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF

A 73-year-old woman was referred to a general surgeon for surgical management of a gastric outlet obstruction, gastric stasis, and erosive esophagitis, secondary to pyloric stenosis, which were discovered during an endoscopy in May 2010.

After conducting a preoperative evaluation, the general surgeon scheduled the patient for surgery on 6/24/2010.

On 6/24/2010, the general surgeon performed an exploratory laparotomy, excision of a mass around the pylorus, distal gastrectomy, and placement of drains.

The mass was not biopsied prior to being excised.  In addition to the mass, the general surgeon also removed a portion of the patient’s pancreas.

On 6/29/2010, the patient was discharged.

On 7/5/2010, the patient returned to the hospital with abdominal pain and green colored discharge from her abdominal incision and drain.  Test results showed fluid collection under the liver.

On 7/8/2010, the patient was taken back to the operating room for a second surgery.  The general surgeon performed an exploratory laparotomy, abdominal washout, lysis of adhesions, and an oversew of a presumed duodenal hole and application of glue.

Postoperatively, the patient continued to have copious output from her drains and was not doing well clinically.

On 7/14/2010, she returned to the operating room.  The general surgeon performed another exploratory laparotomy, abdominal washout, presumed duodenal hole oversew and placement of glue and drains.

The patient’s condition still did not improve after the third surgery on 7/14/2010.  The patient was seen by multiple consultants and additional studies were performed, which revealed a bile leak at the distal common bile duct and inability to cannulate the duodenum, consistent with a common bile duct injury.

The patient was then transferred to a higher level of care.  Numerous procedures were performed on the patient but her clinical condition continued to deteriorate and she ultimately died on 11/20/2010 while in hospice care.

The Board judged the general surgeon’s conduct as having fallen below the standard of care for several reasons.  The standard of care, when presented with an unexpected mass, is to biopsy the mass prior to resection.  Biopsying the mass is even more warranted when the mass is in a part of the body close to a number of vital structures, as was the patient’s mass.

The patient’s mass was determined to be pancreatic tissue.  Had the general surgeon performed a biopsy instead of removing the mass along with part of the patient’s pancreas, major injury to the pancreatic head, and what eventually turned out to be the adjacent common bile duct, could have been avoided.

The general surgeon’s notes did not mention the unintended removal of a significant segment of the pancreas.  The Board notes that the standard of care when a patient shows signs of possible major intra-abdominal injury is early intervention.  After the patient returned to the hospital on 7/5/2010, there was evidence of copious drainage from the implanted drain and the incision would itself, indicating a possible uncontrolled intra-abdominal leak.

The general surgeon did not intervene surgically and instead ordered a series of tests that pointed to a biliary leak and possible bile duct injury.  Per the Board, the standard of care would have called for immediate surgical exploration.  The general surgeon did not intervene until 3 days after admission.

The Board also notes that the general surgeon performed the same operations on 7/8/2010 and 7/14/2010.  During both surgeries, he oversewed a presumed duodenal hole without clearly identifying its location and correlation with adjacent structures.  After the 7/8/2010 surgery failed to correct the problem, the standard of care required that the general surgeon study the hole intra-operatively to properly identify its anatomy.  Further, given the location of the hole, the general surgeon should have considered whether the hole was in the common bile duct and not the duodenum.  Per the Board, the general surgeon committed a simple departure from the standard of care when he blindly oversewed a hole without knowing its anatomy amidst post-operative inflammatory changes and in an anatomically dangerous area.

The general surgeon was placed on probation for three years.  Stipulations included enrolling in the Physician Assessment and Clinical Education Program and undergoing monitoring.

State: California

Date: December 2016

Specialty: General Surgery, Gastroenterology

Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Abdominal Pain

Diagnosis: Post-operative/Operative Complication, Acute Abdomen

Medical Error: Procedural error, Delay in proper treatment, Lack of proper documentation

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 4

Link to Original Case File: Download PDF

On the morning of 6/17/2013, a 79-year-old male underwent a scheduled colonoscopy by his gastroenterologist due to symptoms of chronic abdominal pain, weight loss, and anemia.  The colonoscopy revealed a tumor in the ascending colon. A general surgeon was called in for a surgery consultation. The general surgeon met with the patient and his family and obtained an informed consent from the patient to perform surgery later that same day.  The general surgeon failed to document this consultation with a written or dictated note in the patient’s medical record. Later that same day, on the evening of 6/17/2013, the general surgeon performed a laparoscopic-assisted ileocolectomy with a stapled anastomosis on the patient and removed the tumor.

During the first 2 days following the operation, the patient began to show signs of complications.  He had mild leukocytosis and bandemia as well as no obvious gastrointestinal function. Late in the day of 6/19/2013 and into 6/20/2013, the patient began having increased abdominal pain and increased abdominal distention.  On 6/20/2013, the general surgeon ordered an increase in the patient’s IV fluids. The general surgeon reported that she made a focused exam of the patient, but she failed to note any details describing the quality of the patient’s abdominal tenderness in the medical record.  Later that same day, the patient experienced greater abdominal pain and became tachycardic with an elevated heart rate. The patient’s family became increasingly concerned and repeatedly asked for something to be done to help the patient. At 12:40 a.m. on 6/21/2013, the nurse called the general surgeon.  The general surgeon’s only intervention at that time was to give verbal orders to the nurse to increase the patient’s pain medication, place a catheter, and order partial blood work. The general surgeon did not come to the hospital and did not examine the patient. Yet, when the general surgeon was interviewed by the Medical Board, she stated that at this point “it was clear that something wasn’t as it should have been.”

The standard of care requires that at this point, if not sooner, a work up for Systemic Inflammatory Response System (SIRS) or Sepsis should have been ordered, including possibly starting IV antibiotics, ordering specific lab tests and diagnostic imaging, and doing a focused physical exam.

Over the next 4 to 5 hours on 6/21/2013, the patient complained of severe abdominal pain, had increased tachycardia, and a worsening appearance.  At 5:03 a.m., the nurse again called the general surgeon. The general surgeon again gave verbal orders only for fluids, increased pain medications, and an x-ray.  At 6:15 a.m., it was first documented that the patient had a fever of 100.2 F, which increased to 103.1 F by 7:55 a.m.  The patient had also become hypotensive with low blood pressure.  At this point, it should have been clear to the general surgeon that the patient was in septic shock.

At 8 a.m., the general surgeon, who was still not in the hospital, gave the nurse the order over the phone to transfer the patient to the critical care unit.  The first documentation that the general surgeon was present in the hospital was a nurse’s note at 8:30 a.m. Upon examination, the general surgeon suspected the patient was suffering from peritonitis in addition to septic shock.  The patient was taken to the critical care unit between 8:45 a.m. and 9 a.m. and emergently to the operating room at around 9:30 a.m.

The general surgeon performed an exploratory laparotomy on the patient, where feculent fluid was found coming from a small disruption of the ileocolic anastomosis.  The fluid was suctioned, the abdomen irrigated, the ileocolic anastomosis resected, and another anastomosis was created. The patient remained hemodynamically unstable throughout the procedure and was transferred to the critical care unit still intubated on multiple pressors for blood pressure support.  The patient’s primary care was transferred to the critical care unit doctors. The patient likely aspirated during intubation. For the next several days, the patient remained in septic shock and dependent on a ventilator. He suffered progressive multi-organ failure, which led to his death on 6/28/2013.

The Medical Board of California judged that the general surgeon’s conduct departed from the standard of care because she failed to conduct an adequate work-up and significantly delayed coming to see the patient, who was exhibiting worsening abdominal pain and clinical signs and symptoms, which met SIRS criteria, and then progressed to septic shock.  The general surgeon also performed a primary ileocolic anastomosis without a fecal diversion in a hemodynamically unstable patient in septic shock, who had feculent fluid peritonitis.

The Medical Board of California issued a public reprimand and ordered the general surgeon to complete a medical record-keeping course and education course for at least 40 hours.

State: California

Date: November 2016

Specialty: General Surgery

Symptom: Abdominal Pain, Fever, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Weight Loss

Diagnosis: Post-operative/Operative Complication, Sepsis

Medical Error: Failure to order appropriate diagnostic test, Delay in diagnosis, Failure to examine or evaluate patient properly, Improper treatment, Lack of proper documentation

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

On 8/9/2011 at 3:55 a.m., a 35-year-old non-English speaking, unemployed male presented to the emergency department complaining of 3 days of abdominal pain, nausea, and vomiting with anorexia and was seen by an ED physician.  The patient had no documented prior similar episodes, but had a history of heavy alcohol consumption. Vital signs included a temperature of 98 F and a pulse of 86 bpm. Physical examination indicated normal bowel sounds and mild periumbilical tenderness, and distension.  Rebound or guarding was not addressed. The nurse’s notes indicated that the last alcohol consumption was 1 day prior to admission, and abdominal pain had persisted for 3 days. 4/10 pain level was noted.

At 4:06 a.m., the patient’s treatment began with 2 L wide-open normal IV saline, GI cocktail, 5 mg morphine IV, and 4 mg Zofran IV.  Laboratory results revealed a mildly elevated WBC count of 13.2 with a left shift. Blood glucose was markedly elevated at 260 mg/dL (normal fasting 70-100 mg/Dl; normal non-fasting 125 mg/dL or less; at >200 mg/dL, diabetes is presumed) without evidence of acidosis.  Lipase level was below normal, and liver function tests were elevated. No alcohol was detected in the blood sample.

At 6:15 a.m., the patient was noted to be resting comfortably with a pain rating of 1/10.  Vital signs included a temperature of 99.1 F and a heart rate of 93 bpm. The patient’s temperature and heart rate had risen despite fluid IV and pain medication.  The ED physician approved the patient to be discharged home at 6:30 a.m. with oral instructions given through an interpreter to return if worse.

The patient was returned by ambulance to the emergency department at 10:40 a.m. again complaining of abdominal pain, this time at a level of 10/10.  Physical examination noted abdominal tenderness and distention without rebound or guarding. The patient’s temperature was now 100.4 F and a pulse rate was 95 bpm.  Laboratory findings noted the opiates administered at the previous visit, but also barbiturates of unclear source. WBC count was markedly low at 6.4, and a blood glucose level was now 421 mg/dL.  Further, the patient reported experiencing increased thirst and urination for the last 3 days. A CT scan revealed a possible appendicitis with free fluid and inflammatory mass in the right lower quadrant.  The patient was taken to surgery at 5:00 p.m., where appendicitis was confirmed. The patient was also admitted with a diagnosis of diabetes mellitus and treated with insulin drip to control blood sugar.

The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because he failed to obtain an appropriate history and laboratory studies to rule out life-threatening illness.  The ED physician had not elicited information concerning recurrent abdominal pains under similar circumstances without a surgical cause, and yet he presumed that the patient’s alcohol use was the overriding factor in his abdominal pain.  The ED physician failed to order a urinalysis, a valuable test in the work-up of abdominal pain.

The ED physician’s final diagnosis did not follow from the history, physical, and work-up of the patient.  The patient had WBC count and liver function abnormalities and had a history of heavy alcohol consumption, so the ED physician’s diagnosis of alcoholic gastritis was a reasonable differential diagnosis, but the ED physician did not consider and rule out possible causes of the pain, such as appendicitis and gallbladder disease, which would require surgical intervention.  The ED physician ignored the patient’s high WBC count, which could have been an indication for appendicitis.

The observation period for the patient was inadequate.  The ED physician did not allow enough time to adequately assess the patient’s condition and the risk of serious decline.  The ED physician did not wait until the narcotic pain medication wore off to reexamine the patient over time for a possible surgical abdomen.  The duration of morphine analgesia in 4 to 5 hours, and it was appropriate to relieve pain during the work-up, but repeat examination reporting that the patient was comfortable during the duration of analgesia was inadequate to fully appreciate the course of the illness.

The ED physician failed to record a history for the patient’s high blood glucose level and perform tests to determine the nature and severity of the abnormal finding.  The blood glucose level of 260 mg/dL was suggestive of diabetes, and this was not previously diagnosed and required further history and laboratory studies. Ketones were not tested for in either blood or urine, but serum CO2 level was normal.

The ED physician’s discharge plan was inappropriate.  The patient was given instructions in Spanish at discharge, and he did not record these instructions, but indicated that he would have instructed the patient to return if worse.  No information was given concerning the elevated blood glucose. The ED physician failed to identify and ensure appropriate follow-up for a remarkably elevated blood glucose level.

For this case and others, the Medical Board of California placed the ED physician on probation for 5 years and ordered the ED physician to complete a medical record keeping course, an education course (at least 40 hours per year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The ED physician was assigned a practice monitor and prohibited from supervising physician assistants.

State: California

Date: September 2016

Specialty: Emergency Medicine

Symptom: Abdominal Pain, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Urinary Problems

Diagnosis: Acute Abdomen, Diabetes

Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to follow up, Improper treatment, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 4

Link to Original Case File: Download PDF