Missed Diagnosis of Appendicitis

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The diagnosis of appendicitis is fairly straightforward. The patient usually presents with mid-abdominal cramping pain that localizes, within 12 to 24 hours to the right lower quadrant of the abdomen. A rectal examination usually documents pain in the right lower side. A pelvic examination helps to rule out an infection of the Fallopian tubes (usually from gonorrhea). The temperature is usually about 100 degrees, and the white blood count is slightly elevated.

When in doubt, surgery is warranted. As the hours’ pass, there is a risk of the infected appendix rupturing (perforating), resulting in an intra-abdominal abscess and risk of death. In children, the passage from the onset of appendicitis to perforation is usually less than 24 hours, and their risk of widespread intra-abdominal infection is much greater than in an adult.

Tubal Ligation Sterilization Causing Intestine Perforation

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Laparoscopic tubal ligation surgery is performed through a narrow pipe inserted into the abdomen. Either a clip is placed in each fallopian tube, or it is cauterized (burned by the passage of electricity through a segment of each tube, causing it to char and seal).

Decades ago the electrocautery was of the “unipolar” design. This allowed the electricity to enter through the active electrode, while the current returned to the device through the body, and then via a ground electrode under the thigh. Unfortunately, the electric current had the risk of arcing into the nearby small intestine, burning a hole into this hollow organ. That would result in its leakage causing peritonitis (intra-abdominal infection) requiring emergency surgery.

The modern devices are called “bipolar” because the electric current flows only between each side of the pliers-like grasping instrument. Intestinal burns should never occur. If that happens, it is either from the surgeon negligently touching the metal end to the intestine, or the electrocautery was defective and not properly maintained by the hospital.

Missed diagnosis of Pre-Eclampsia

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If the patient starts out her pregnancy with 130/70 and the 70 changes to 80, it must be looked at, not necessarily treated, but looked at. If the 80 goes up to 85, then you have to be concerned about the possibility of early pre-eclampsia, a high blood pressure condition in pregnancy which can cause damage to the mother and the baby. When there is high blood pressure in the mother, blood flow to the placenta, which nourishes the baby, is impaired and there is a higher risk of the placenta separating from the lining of the uterus (abruptio placenta).

Patients suspected of having possible pre-eclampsia are also given urine tests. Protein will appear in the urine abnormally; we call it “spill out”. Actually, the protein leaks through the filtering system of the mother’s kidneys into the urine. The mother’s kidneys filter her blood to remove her impurities and those she absorbs into her blood from the baby through the placenta. With high blood pressure, the filtering mechanism is damaged.

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Infectious Disease Case Strategy

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The way to handle infection cases is very interesting. If you can show the operation was not indicated, then any complication from that unnecessary operation is a negligent act. Secondly, was the patient at higher risk for the operation? Were prophylactic antibiotics not given prior to, during and after surgery? Was the patient not timely seen with proper consultation and treatment for infection? In most large cities and/or teaching centers, there are specialists who do practically nothing else but consult and treat infections. Were there infections on or in the patient’s body at the time of an elective operation? If so, the surgery should have been postponed. Was the patient placed into a room before or after surgery where infected patients were located? This doesn’t always mean there’s a higher risk, but it’s good jury appeal.

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Cardiovascular Surgeon Traysol Review

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Trasylol/Aprotinin is a commonly used drug during heart surgery that is known to cause serious complications.  These complications include kidney damage, an increased risk of a heart attack, heart failure, and stroke. Trasylol is a drug that has been on the market for 13 years and is used to control bleeding.  This drug is used in as many as 1 million hearts and bypass surgeries per year. Trasylol doubles the risk of kidney damage but also increases the risk of heart attack by 48%. Heart failure risk is also increased by 109% and stroke by 181%. Because it is given intravenously, most people do not even know that they are receiving it. Also, this drug is so bad they stopped clinical trials as complications exceeded 35%.

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Thoracic Outlet Syndrome

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Thoracic outlet syndrome is a condition where the nerves in the arm, the brachial plexus, are squashed between the collarbone (clavicle) and the first rib beneath. When the patient repetitively raises their arms up (as in hanging sheetrock on the ceiling) they can have numbness and nerve difficulties with their arms. That doesn’t mean an operation is indicated, however.

They can be instructed to change their job, and physical therapy can be effective. If the condition is severe it must be confirmed by doing what is called an Adson Maneuver. This involves raising your arm up in the air and all the way back to where the pulse to your wrist is cut off. The artery goes through the same area the nerves are going through and will be compressed by the squeezing action of those two bones. If this test is positive it does not necessarily mean that surgery is needed; many people can have a positive test without any symptoms.

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Hip Conditions and Knee Pain

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Knee pain with no obvious x-ray or physical exam findings should bring up a red flag to automatically check the hip. It is well known and taught in medical schools, that the same nerve-the obturator nerve-innervates both joints. Therefore, an elderly patient commonly can present to an emergency room complaining of knee pain after a fall. Then after emergency room physician review of x-rays showing a knee without any acute fractures, the patient is sent home only to return the next day with complaints of hip pain with x-rays showing a displaced hip fracture requiring a major operation. The standard of care in this situation would be to both examine the hip and to x-ray the hip at the first presentation.

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Urology and the Potential for Medical Malpractice

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I was invited to write an article about potential medical malpractice situations in Urology. I thought about several areas of urology and what the common denominators were. The two I see most frequently are … failure to diagnose and/or treat appropriately and failure of communication in an understandable and comprehensive manner with the patient and designated second (if appropriate). I have chosen to discuss the failure to diagnose, evaluate and treat hematuria (blood in urine) in an appropriate manner.

Hematuria may occur in an isolated field (no associated symptoms) or associated with urgency, frequency, dysuria, abdominal pain. Fever is variable. Abdominal distention (swelling or bloating) is also variable. Usually, the first physician seen is the PCP who will usually institute treatment for a UTI. He should obtain a urine culture as the minimal workup along with a urinalysis. If this treatment does not work or the bleeding recurs in a short period of time, a referral to a urologist is indicated.

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The Role of Joint Commission on Accreditation of Healthcare Organizations Standards

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Lawyers often ask me to explain how I use the JCAHO standards in evaluating medical malpractice cases and whether this evaluation will assist them in their pursuit of justice for their clients. I usually start my explanation with a brief history of the Joint Commission and its role in hospital operations and reimbursement.

The JCAHO was formed in 1951 by several professional organizations: the American Hospital Association, the American College of Physicians, the American College of Surgeons, and the American Medical Association. Its mission is “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value”. To accomplish this mission, the JCAHO has developed standards for accrediting hospitals and other types of healthcare organizations that focus on the delivery of the highest possible quality patient care as well as ensuring a safe environment for patients and staff. While a hospital’s participation in the JCAHO accreditation is technically voluntary, the federal government requires hospitals to meet their standards in order to receive reimbursement from the Medicare and Medicaid programs. Obviously, this requirement essentially mandates that all hospitals meet the JCAHO standards or one of the few other organizations that are included in this payment mandate. While the process is voluntary, it is important to understand that the standards are mandatory and that receiving a full accreditation from the JCAHO is still the gold standard for a hospital’s quality of care.

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The Benefits of a Physician Assistant Expert Witness

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Physician Assistants have been involved in the American Health Care Systems for over forty years. The American Academy of Physician Assistants was founded in 1968 as the official body representing the profession with a mission “to provide quality cost-effective, accessible health care and to promote the profession and personal development of physician assistants”. There are more than 140 physician assistant programs in the United States. The U.S. Bureau of Labor Statistics (BLS) projected that physician assistant employment opportunities will grow 50% by 2014. This will make it the fourth fastest growing profession in the country

Physician assistants are either licensed or registered in every state in the union including Puerto Rico, Guam the District of Columbia and the Virgin Islands and have prescriptive authority in every jurisdiction. Forty‐four states allow PAs to prescribe controlled substances. PAs are required to register with the Drug Enforcement Agency and possess a valid DEA number to prescribe controlled medication.

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