Missed Diagnosis of Appendicitis

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

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

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.

Read more

Infectious Disease Case Strategy

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.

Read more

Cardiovascular Surgeon Traysol Review

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%.

Read more

Hip Conditions and Knee Pain

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.

Read more

The Role of Joint Commission on Accreditation of Healthcare Organizations Standards

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.

Read more

Toxicity and The Risks of Environmental Lead Exposure

Lead is a naturally occurring element and does not break down. This means that lead will change chemically over time which influences its exposure but it will still be recognizable as lead. Lead used hundreds of years ago is still potentially available as a toxic chemical. Current regulations published by the USEPA are not eliminating all of the potential exposures to lead. Lead waste piles from mines and smelters dating back to the late 1800’s have been found to still present a lead exposure hazard. Lead-containing water service lines can be found in large older cities and water passing through the lines can present hazards to residents. Lead is still present in air from open combustion. Lead-based paint although now eliminated from use still has presents problems, especially for young children. Renovation work for remediation of lead-based paint must be done using the regulatory requirements of the EPA otherwise residential exposure to lead dust can result. Lead can be present in foods. All of these sources contribute to the total body burden.

Read more

The Two Most Dangerous Aspects of General Anesthesia

The two most dangerous aspects of general anesthesia are at the beginning, which is called the induction phase, and at the conclusion, which is called the emerging phase.

The general anesthesia patient has the endotracheal tube inserted into their windpipe. The anesthesiologist needs to view the vocal cords to be sure that the tube is passing between them and therefore into the trachea, the windpipe, and not behind it into the esophagus, the food pipe. Furthermore, when the endotracheal tube is probably inserted and its balloon cuff is inflated, then the anesthesiologist must listen to the chest to hear that the breath sounds are equal on both sides, and observe the exhaled carbon dioxide monitor be sure that it is recording exhaled air at 4%, versus room air which is less than 1%.

Read more

Laparoscopic Cholecystectomy

The gallbladder is a bile storage organ which is attached to the bottom surface of the liver. It stores bile which is an emulsifier for fat, and after a fatty meal, a hormone causes the gallbladder to contract, squeezing the bile into the common bile duct, the main bile duct, and from there into the first part of the small intestine, the duodenum. The problem with bile storage in some patients, particularly women who are over the age of 40, overweight and have had children, the stagnant bile can form gallstones. This can cause severe pain, and sometimes infection.

The modern way to remove a gallbladder is using the laparoscope. Small incisions are made into the abdomen, the gallbladder is grasped at its top surface, and the connection between the gallbladder and the common bile duct, the cystic duct, must be must be observed to be sure that the common bile duct is never injured. An injury to the common bile duct results in a serious lifelong disaster, with scarring and repetitive obstruction of bile flow, resulting in jaundice, liver failure, and sometimes infection.

Read more