Medical Malpractice Insights: What should we do when acute flank pain is NOT a kidney stone?

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Chuck Pilcher, MD, FACEP

Editor, Medical Malpractice Insights

Facts: A young adult female experiences nausea and vomiting while on a 2-hour drive to the airport for a vacation with her husband. She develops severe flank pain before they check in and decide to cancel their trip and return home. She tries to sleep but can’t and goes to the ED of their small rural hospital in the middle of the night. On arrival she has 9/10 right lower lumbar pain. Past history includes hypertension and warfarin for atrial fibrillation, none of which is mentioned in the ED record. BP is 170/100 and not rechecked. A nurse documents “soft tissue tenderness” in the back; the EP’s note describes “no tenderness” and only decreased ROM of the back. A UA is normal with no RBC’s. Renal colic is suspected but no differential diagnosis is recorded. A non-contrast CT is ordered for “R flank pain” and is reported as normal. In her 3 hours in the ED, she is given Zofran x2, Phenergan x1, Dilaudid x2, and Toradol x1. Her pain decreases to 6/10 briefly but is 7/10 on discharge. Diagnosis is “Nausea with vomiting” and “Acute non-traumatic pain in the lower back. No radiation of back pain to the leg.” She returns home and collapses 2 1/2 hours later. Her husband calls 911. Paramedics are unable to resuscitate her, and she dies 6 1/2 hours after arrival in the ED. An autopsy reveals the cause of death as “acute intra-abdominal hemorrhage” due to “rupture of a right renal artery aneurysm.” The ED physician’s report is dictated 3 hours after her death and says “Symptoms much better. Discharged home in improved condition. Condition: good.” An attorney is consulted and a lawsuit filed against the EP and hospital.

Plaintiff: The EP’s history included nothing about the onset, course, qualitym or modifying factors of the pain – or that a long-planned vacation was cancelled at the airport. Her afib, warfarin, last INR, and hypertension were never mentioned, and her BP was taken only once. Her differential diagnosis included only 2 things: spine trauma and aortic aneurysm. When the non-contrast CT returned normal, you did not broaden your differential to find the source of her pain, nausea, and vomiting. You didn’t check her INR. The radiology report even advised “If this study fails to adequately explain patient’s symptoms, additional imaging may be indicated.” We agree that a renal artery aneurysm is rare, but a renal infarct is notuncommon. You did only a non-contrast CT. Had you included renal infarct in your differential, the standard of care would be to obtain a contrast CTA and the aneurysm would have been found. Yes, most aneurysms require a vascular surgeon, but we have 2 kidneys. Your general surgeon could have removed the damaged kidney in a matter of minutes. That nephrectomy would have saved her life. You focused only on relief of the N/V, not the cause of the pain, and discharged her with persistent 7/10 pain. Her chief complaint of back pain was not mentioned in her discharge Instructions. And you did not complete your chart until after her death. Your documentation is little more than EHR “clicktation,” notoriously prone to over-representing the work done by providers.

Defense: A renal artery aneurysm is extremely rare. There is no evidence of when the aneurysm actually ruptured. The warfarin had nothing to do with the aneurysm’s existence or rupture. She was on a stable dose of warfarin and did not need an INR, especially in the absence of hematuria. Any similarly trained prudent EP in similar circumstances would have managed the patient the same. Even if the diagnosis had been made before discharge, our hospital has only a general surgeon, no urologist, no vascular surgeon, so she died before anyone could have done anything. The doctor was not negligent.

Result: After 3+ years of litigation, a small pre-trial “sympathy settlement” was reached sufficient to cover legal expenses plus a token amount for the husband’s loss.

Takeaways:

• The more common renal infarct can mimic renal stone colic and should be included in the differential.
• If a kidney stone is suspected but not found, especially in the presence of pain and the absence of hematuria, a doppler US or CTA should be considered, as they will also identify the rare case of the more common renal infarct as well as the renal artery aneurysm (or an atypical AAA.)
• Any general surgeon can remove a kidney, or at least cross-clamp the renal artery. With 2 kidneys, repairing an aneurysm in this situation generally unwarranted.
• A report dictated post-mortem is appropriately open to pre-trial skepticism.

Reference:

1. Renal Artery Aneurysm. Gates L. Medscape eMedicine. Updated: Sep 11, 2023.
2. Renal infarction. Radhakrishnan J. UpToDate Online. Last updated Nov 14, 2023.
3. Renal infarction. emDOCs.net.