Medical Malpractice Insights: Don’t confuse me with the facts

Author: Chuck Pilcher, MD, FACEP (Editor, Med Mal Insights) // Editors: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Welcome to this month’s 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.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Don’t confuse me with the facts. 

Cognitive biases (anchoring bias, confirmation bias, diagnostic momentum) lead to ruptured appendix.

Facts: A 25-year-old male presents to an ED with 3 days of right sided abdominal pain. His only other symptom is “bloating.” He admits to alcoholism. On exam, he is afebrile and mostly tender on the right side with mild hepatomegaly. Rebound tenderness is not assessed. His WBC is 11,300, and LFT’s are normal. No lipase is ordered despite abdominal pain and tenderness in an alcoholic. No differential dx is recorded. He is discharged with a diagnosis of “alcoholic hepatitis” and “dyspepsia” and given DC instructions on “alcohol related problems.” Three days later he is admitted to a second hospital with a ruptured appendix. After his appendectomy, he develops intra-peritoneal abscesses and chronic pain and requires further treatment. He consults an attorney, and a lawsuit is filed.

Plaintiff: I had right sided pain for 3 days. You never checked for rebound tenderness. My WBC was elevated, and you should have done a differential on it. My liver tests were normal, yet you said I had hepatitis. And you never checked me for gastritis or pancreatitis, which were more likely than hepatitis. Your lack of a differential diagnosis shows that you ignored the facts, assumed I’m an alcoholic, didn’t give a damn, and jumped to your conclusion. Your care was below the standard for abdominal pain. If you had treated me appropriately, my appendix would not have ruptured or spread so much pus around my belly.

Defense: Our treatment was fine and consistent with your symptoms. You developed appendicitis after we first saw you.

Result: Settlement for undisclosed amount without trial.

Takeaways:

• Jumping to conclusions closes our minds and leads to error. We all do it. Be cognizant of potential bias, especially with patients with whom we have prior experience, or those who may be at high risk for a dangerous miss (IV drug abuse, alcoholic, elderly, immunosuppressed, etc.).
• Take and document a history. Do an exam. Pay attention to what you find.
• Include worst case scenarios in a reasonable differential diagnosis. Document why they can be eliminated. A well-reasoned clinical impression is often sufficient.
• Tests are not always needed to eliminate a diagnosis from one’s differential, but if ordered, make sure they are consistent with your assumptions. Don’t ignore negative findings when they don’t confirm your first impression.
• Appendicitis should always be on the differential for abdominal pain (even when the patient believes his/her appendix has been removed).

References:

• EM physician Justin Morgenstern writes about “Cognitive Errors” in his blog “First 10 EM”. See Part 1, Part 2, Part 3, and Part 4 for more.
• See this post from Anton Helman’s Emergency Medicine Cases.

Of course, I think that people are just waiting for that time when I make a mistake and they’re gonna jump on it…. There’s gonna be haters.

Justin Bieber