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The story:
Mrs. AP was a 48-year-old woman who developed painless hematemesis after drinking a glass of milk during dinner. She had a past history of peptic ulcer disease with a bleeding ulcer 3 years ago that required hospitalization. Her past history was otherwise unremarkable and she denied known liver disease or excessive alcohol intake. Her family called for an ambulance as Mrs. AP felt like she was going to pass out. Her systolic blood pressures in the field were 85-90 mm Hg with heart rates above 100 bpm. Intravenous saline was initiated before arrival to the emergency department.
The ED triage nurse recorded a blood pressure of 91/57 mm Hg with a heart rate of 91 bpm. The nurses documented that they cleaned up Mrs. AP, as she had blood on her nose, face, and hands. The ED physician assessed Mrs. AP and noted that she suffered hematemesis followed by presyncope. There was minimal epigastric tenderness on examination. Labs were drawn and Mrs. AP remained on normal saline at 250 cc/hour. A short time later, the nurses document that Mrs. AP had a large brown stool.
Mrs. AP’s lab results returned the following: white blood count 16 K/L, hemoglobin (Hgb) 10 g/dL, and an INR 1.36. Electrolytes were normal except for serum bicarbonate of 15 mmol/L. Mrs. AP’s blood pressures were still running in the 90s/50s mm Hg with IV saline. The ED physician called Dr. GI for admission, but Dr. GI deferred to be primary and asked that the hospitalist on call be contacted. Over the next 2 hours, Mrs. AP remained in the ED. Orthostatics were ordered and were documented to be normal, despite a blood pressure that remained in the low 90s/50s mm Hg. The final blood pressure recording for Mrs. AP in the ED was 101/57 mmHg with a heart rate of 98 bpm. The ED physician specifically documented that he had performed a tilt test that was negative.
A little after midnight, Dr. Hospitalist saw Mrs. AP for the admission history and physical. Dr. Hospitalist noted the last set of vitals in the ED and described Mrs. AP as "hemodynamically stable." Dr. Hospitalist ordered vital signs per routine (Q4 hrs on medical telemetry), Hgb/Hct checks every 4 hours, an intravenous proton pump inhibitor, and continued IV fluid support. His plan of care noted that "GI was consulted and they will see the patient. ... I talked and discussed case and agree with plan."
At 3 a.m., Mrs. AP’s Hgb of 8 g/dL was reported to the nursing floor charge nurse. Her blood pressure and heart rate at that time were 141/62 mm Hg and 82 bpm, respectively. Approximately an hour later, Mrs. AP is complaining of nausea. Shortly after 5 a.m., Mrs. AP suffers a large-volume hematemesis with aspiration in the presence of her nurse. Her oxygen saturation dropped precipitously, and she went into cardiopulmonary arrest. Dr. Hospitalist was on the floor and responded immediately to run the code. Mrs. AP was intubated and a nasogastric tube was placed, which demonstrated a large volume of bright-red blood. Mrs. AP regained her pulse and stabilized briefly. A blood transfusion was initiated, but Mrs. AP lost her pulse again and she was unable to be resuscitated. Mrs. AP was pronounced dead at 6:30 a.m.
The complaint:
Mrs. AP’s husband quickly filed a negligent/wrongful death claim following her death. The negligence claim highlighted that her initial Hgb of 10 g/dL in the ED was already indicative of a significant bleed as she had received almost two liters of IV fluid in the field before ED arrival. The claim further explained that her Hgb of 8 g/dL at 3 a.m. confirmed an ongoing bleed that was being ignored. In summary, the claim alleged negligence on behalf of the ED physician, Dr. GI, and Dr. Hospitalist for failing to appreciate the significance of her bleed, for not placing her in the ICU with invasive monitoring, for not initiating oxygen, for not transfusing Mrs. AP after her labs demonstrated acute blood loss anemia in the face of hypotension, and for failing to emergently perform upper endoscopy to identify and treat her bleeding source.
Scientific principles:
The goal for the initial evaluation of an upper GI bleed is to assess the severity of the bleed, identify potential sources of the bleed, and determine if there are conditions present that may affect subsequent management. All patients with hemodynamic instability or active bleeding should be admitted to an ICU for resuscitation and close observation. Oxygen therapy should also be provided. Whether all patients with suspected acute upper GI bleeding require NGT placement is controversial, in part, because studies have failed to demonstrate a benefit with regard to clinical outcomes. More often, NGT lavage is used when it is unclear if a patient has ongoing bleeding and thus might benefit from an early endoscopy. Early endoscopy (within 24 hours) is recommended for most patients with acute UGI bleeding, though whether early endoscopy affects outcomes and resource utilization is unsettled. Studies have reached variable conclusions when determining whether the application of early endoscopy for risk stratification and treatment reduces resource utilization or affects patient outcomes.
Complaint rebuttal and discussion:
The defendants’ theory of the case was that Mrs. AP suffered an upper GI bleed prior to arrival to the ED that stopped bleeding. While in the ED, her vital signs and general condition improved, and there was no indication for early endoscopy as she was not orthostatic and her hemoglobin was not less than 10 g/dL. Her rebleed, while regrettable, was too big to be resuscitated. ICU care would not have changed the outcome, as Mrs. AP suffered hematemesis and aspiration in the presence of her nurse with immediate physician response.
The medical chart, however, clearly supported the proposition that Mrs. AP was hemodynamically unstable from the start. The plaintiff GI expert opined that had Mrs. AP received early endoscopy with or without sclerotherapy, Mrs. AP would have been further risk stratified to the extent that NGT placement would have been considered and/or therapy would more likely than not have prevented the subsequent large-volume hematemesis and aspiration.
Conclusion:
The scientific principles confirm that Mrs. AP should have been admitted to the ICU with closer monitoring and oxygen therapy. However, the scientific principles also refute the notion that blood transfusion, NGT lavage, or early endoscopy would have made any difference in the outcome. In hindsight, these interventions may have saved Mrs. AP’s life. But taking the facts known to the providers at the time, the case is less clear. At the time of admission, Dr. Hospitalist would have been well served to call Dr. GI to confirm and document the plan of care. According to deposition testimony, Dr. Hospitalist never spoke with Dr. GI. Such a conversation regarding the criteria for early endoscopy would have gone a long way to eliminating Dr. Hospitalist from this case at the outset. Hospitalists do have the right to rely on specialists, but in the middle of the night, we are often on our own and will be held to a "reasonable physician" standard. Dr. Hospitalist had access to the patient and the medical record – Dr. GI did not. A documented discussion with Dr. GI may have provided a better defense for Dr. Hospitalist. Ultimately, despite the issues regarding causation and the prevailing scientific principles, this case was settled on behalf of the plaintiff for an undisclosed amount.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.
The story:
Mrs. AP was a 48-year-old woman who developed painless hematemesis after drinking a glass of milk during dinner. She had a past history of peptic ulcer disease with a bleeding ulcer 3 years ago that required hospitalization. Her past history was otherwise unremarkable and she denied known liver disease or excessive alcohol intake. Her family called for an ambulance as Mrs. AP felt like she was going to pass out. Her systolic blood pressures in the field were 85-90 mm Hg with heart rates above 100 bpm. Intravenous saline was initiated before arrival to the emergency department.
The ED triage nurse recorded a blood pressure of 91/57 mm Hg with a heart rate of 91 bpm. The nurses documented that they cleaned up Mrs. AP, as she had blood on her nose, face, and hands. The ED physician assessed Mrs. AP and noted that she suffered hematemesis followed by presyncope. There was minimal epigastric tenderness on examination. Labs were drawn and Mrs. AP remained on normal saline at 250 cc/hour. A short time later, the nurses document that Mrs. AP had a large brown stool.
Mrs. AP’s lab results returned the following: white blood count 16 K/L, hemoglobin (Hgb) 10 g/dL, and an INR 1.36. Electrolytes were normal except for serum bicarbonate of 15 mmol/L. Mrs. AP’s blood pressures were still running in the 90s/50s mm Hg with IV saline. The ED physician called Dr. GI for admission, but Dr. GI deferred to be primary and asked that the hospitalist on call be contacted. Over the next 2 hours, Mrs. AP remained in the ED. Orthostatics were ordered and were documented to be normal, despite a blood pressure that remained in the low 90s/50s mm Hg. The final blood pressure recording for Mrs. AP in the ED was 101/57 mmHg with a heart rate of 98 bpm. The ED physician specifically documented that he had performed a tilt test that was negative.
A little after midnight, Dr. Hospitalist saw Mrs. AP for the admission history and physical. Dr. Hospitalist noted the last set of vitals in the ED and described Mrs. AP as "hemodynamically stable." Dr. Hospitalist ordered vital signs per routine (Q4 hrs on medical telemetry), Hgb/Hct checks every 4 hours, an intravenous proton pump inhibitor, and continued IV fluid support. His plan of care noted that "GI was consulted and they will see the patient. ... I talked and discussed case and agree with plan."
At 3 a.m., Mrs. AP’s Hgb of 8 g/dL was reported to the nursing floor charge nurse. Her blood pressure and heart rate at that time were 141/62 mm Hg and 82 bpm, respectively. Approximately an hour later, Mrs. AP is complaining of nausea. Shortly after 5 a.m., Mrs. AP suffers a large-volume hematemesis with aspiration in the presence of her nurse. Her oxygen saturation dropped precipitously, and she went into cardiopulmonary arrest. Dr. Hospitalist was on the floor and responded immediately to run the code. Mrs. AP was intubated and a nasogastric tube was placed, which demonstrated a large volume of bright-red blood. Mrs. AP regained her pulse and stabilized briefly. A blood transfusion was initiated, but Mrs. AP lost her pulse again and she was unable to be resuscitated. Mrs. AP was pronounced dead at 6:30 a.m.
The complaint:
Mrs. AP’s husband quickly filed a negligent/wrongful death claim following her death. The negligence claim highlighted that her initial Hgb of 10 g/dL in the ED was already indicative of a significant bleed as she had received almost two liters of IV fluid in the field before ED arrival. The claim further explained that her Hgb of 8 g/dL at 3 a.m. confirmed an ongoing bleed that was being ignored. In summary, the claim alleged negligence on behalf of the ED physician, Dr. GI, and Dr. Hospitalist for failing to appreciate the significance of her bleed, for not placing her in the ICU with invasive monitoring, for not initiating oxygen, for not transfusing Mrs. AP after her labs demonstrated acute blood loss anemia in the face of hypotension, and for failing to emergently perform upper endoscopy to identify and treat her bleeding source.
Scientific principles:
The goal for the initial evaluation of an upper GI bleed is to assess the severity of the bleed, identify potential sources of the bleed, and determine if there are conditions present that may affect subsequent management. All patients with hemodynamic instability or active bleeding should be admitted to an ICU for resuscitation and close observation. Oxygen therapy should also be provided. Whether all patients with suspected acute upper GI bleeding require NGT placement is controversial, in part, because studies have failed to demonstrate a benefit with regard to clinical outcomes. More often, NGT lavage is used when it is unclear if a patient has ongoing bleeding and thus might benefit from an early endoscopy. Early endoscopy (within 24 hours) is recommended for most patients with acute UGI bleeding, though whether early endoscopy affects outcomes and resource utilization is unsettled. Studies have reached variable conclusions when determining whether the application of early endoscopy for risk stratification and treatment reduces resource utilization or affects patient outcomes.
Complaint rebuttal and discussion:
The defendants’ theory of the case was that Mrs. AP suffered an upper GI bleed prior to arrival to the ED that stopped bleeding. While in the ED, her vital signs and general condition improved, and there was no indication for early endoscopy as she was not orthostatic and her hemoglobin was not less than 10 g/dL. Her rebleed, while regrettable, was too big to be resuscitated. ICU care would not have changed the outcome, as Mrs. AP suffered hematemesis and aspiration in the presence of her nurse with immediate physician response.
The medical chart, however, clearly supported the proposition that Mrs. AP was hemodynamically unstable from the start. The plaintiff GI expert opined that had Mrs. AP received early endoscopy with or without sclerotherapy, Mrs. AP would have been further risk stratified to the extent that NGT placement would have been considered and/or therapy would more likely than not have prevented the subsequent large-volume hematemesis and aspiration.
Conclusion:
The scientific principles confirm that Mrs. AP should have been admitted to the ICU with closer monitoring and oxygen therapy. However, the scientific principles also refute the notion that blood transfusion, NGT lavage, or early endoscopy would have made any difference in the outcome. In hindsight, these interventions may have saved Mrs. AP’s life. But taking the facts known to the providers at the time, the case is less clear. At the time of admission, Dr. Hospitalist would have been well served to call Dr. GI to confirm and document the plan of care. According to deposition testimony, Dr. Hospitalist never spoke with Dr. GI. Such a conversation regarding the criteria for early endoscopy would have gone a long way to eliminating Dr. Hospitalist from this case at the outset. Hospitalists do have the right to rely on specialists, but in the middle of the night, we are often on our own and will be held to a "reasonable physician" standard. Dr. Hospitalist had access to the patient and the medical record – Dr. GI did not. A documented discussion with Dr. GI may have provided a better defense for Dr. Hospitalist. Ultimately, despite the issues regarding causation and the prevailing scientific principles, this case was settled on behalf of the plaintiff for an undisclosed amount.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.
The story:
Mrs. AP was a 48-year-old woman who developed painless hematemesis after drinking a glass of milk during dinner. She had a past history of peptic ulcer disease with a bleeding ulcer 3 years ago that required hospitalization. Her past history was otherwise unremarkable and she denied known liver disease or excessive alcohol intake. Her family called for an ambulance as Mrs. AP felt like she was going to pass out. Her systolic blood pressures in the field were 85-90 mm Hg with heart rates above 100 bpm. Intravenous saline was initiated before arrival to the emergency department.
The ED triage nurse recorded a blood pressure of 91/57 mm Hg with a heart rate of 91 bpm. The nurses documented that they cleaned up Mrs. AP, as she had blood on her nose, face, and hands. The ED physician assessed Mrs. AP and noted that she suffered hematemesis followed by presyncope. There was minimal epigastric tenderness on examination. Labs were drawn and Mrs. AP remained on normal saline at 250 cc/hour. A short time later, the nurses document that Mrs. AP had a large brown stool.
Mrs. AP’s lab results returned the following: white blood count 16 K/L, hemoglobin (Hgb) 10 g/dL, and an INR 1.36. Electrolytes were normal except for serum bicarbonate of 15 mmol/L. Mrs. AP’s blood pressures were still running in the 90s/50s mm Hg with IV saline. The ED physician called Dr. GI for admission, but Dr. GI deferred to be primary and asked that the hospitalist on call be contacted. Over the next 2 hours, Mrs. AP remained in the ED. Orthostatics were ordered and were documented to be normal, despite a blood pressure that remained in the low 90s/50s mm Hg. The final blood pressure recording for Mrs. AP in the ED was 101/57 mmHg with a heart rate of 98 bpm. The ED physician specifically documented that he had performed a tilt test that was negative.
A little after midnight, Dr. Hospitalist saw Mrs. AP for the admission history and physical. Dr. Hospitalist noted the last set of vitals in the ED and described Mrs. AP as "hemodynamically stable." Dr. Hospitalist ordered vital signs per routine (Q4 hrs on medical telemetry), Hgb/Hct checks every 4 hours, an intravenous proton pump inhibitor, and continued IV fluid support. His plan of care noted that "GI was consulted and they will see the patient. ... I talked and discussed case and agree with plan."
At 3 a.m., Mrs. AP’s Hgb of 8 g/dL was reported to the nursing floor charge nurse. Her blood pressure and heart rate at that time were 141/62 mm Hg and 82 bpm, respectively. Approximately an hour later, Mrs. AP is complaining of nausea. Shortly after 5 a.m., Mrs. AP suffers a large-volume hematemesis with aspiration in the presence of her nurse. Her oxygen saturation dropped precipitously, and she went into cardiopulmonary arrest. Dr. Hospitalist was on the floor and responded immediately to run the code. Mrs. AP was intubated and a nasogastric tube was placed, which demonstrated a large volume of bright-red blood. Mrs. AP regained her pulse and stabilized briefly. A blood transfusion was initiated, but Mrs. AP lost her pulse again and she was unable to be resuscitated. Mrs. AP was pronounced dead at 6:30 a.m.
The complaint:
Mrs. AP’s husband quickly filed a negligent/wrongful death claim following her death. The negligence claim highlighted that her initial Hgb of 10 g/dL in the ED was already indicative of a significant bleed as she had received almost two liters of IV fluid in the field before ED arrival. The claim further explained that her Hgb of 8 g/dL at 3 a.m. confirmed an ongoing bleed that was being ignored. In summary, the claim alleged negligence on behalf of the ED physician, Dr. GI, and Dr. Hospitalist for failing to appreciate the significance of her bleed, for not placing her in the ICU with invasive monitoring, for not initiating oxygen, for not transfusing Mrs. AP after her labs demonstrated acute blood loss anemia in the face of hypotension, and for failing to emergently perform upper endoscopy to identify and treat her bleeding source.
Scientific principles:
The goal for the initial evaluation of an upper GI bleed is to assess the severity of the bleed, identify potential sources of the bleed, and determine if there are conditions present that may affect subsequent management. All patients with hemodynamic instability or active bleeding should be admitted to an ICU for resuscitation and close observation. Oxygen therapy should also be provided. Whether all patients with suspected acute upper GI bleeding require NGT placement is controversial, in part, because studies have failed to demonstrate a benefit with regard to clinical outcomes. More often, NGT lavage is used when it is unclear if a patient has ongoing bleeding and thus might benefit from an early endoscopy. Early endoscopy (within 24 hours) is recommended for most patients with acute UGI bleeding, though whether early endoscopy affects outcomes and resource utilization is unsettled. Studies have reached variable conclusions when determining whether the application of early endoscopy for risk stratification and treatment reduces resource utilization or affects patient outcomes.
Complaint rebuttal and discussion:
The defendants’ theory of the case was that Mrs. AP suffered an upper GI bleed prior to arrival to the ED that stopped bleeding. While in the ED, her vital signs and general condition improved, and there was no indication for early endoscopy as she was not orthostatic and her hemoglobin was not less than 10 g/dL. Her rebleed, while regrettable, was too big to be resuscitated. ICU care would not have changed the outcome, as Mrs. AP suffered hematemesis and aspiration in the presence of her nurse with immediate physician response.
The medical chart, however, clearly supported the proposition that Mrs. AP was hemodynamically unstable from the start. The plaintiff GI expert opined that had Mrs. AP received early endoscopy with or without sclerotherapy, Mrs. AP would have been further risk stratified to the extent that NGT placement would have been considered and/or therapy would more likely than not have prevented the subsequent large-volume hematemesis and aspiration.
Conclusion:
The scientific principles confirm that Mrs. AP should have been admitted to the ICU with closer monitoring and oxygen therapy. However, the scientific principles also refute the notion that blood transfusion, NGT lavage, or early endoscopy would have made any difference in the outcome. In hindsight, these interventions may have saved Mrs. AP’s life. But taking the facts known to the providers at the time, the case is less clear. At the time of admission, Dr. Hospitalist would have been well served to call Dr. GI to confirm and document the plan of care. According to deposition testimony, Dr. Hospitalist never spoke with Dr. GI. Such a conversation regarding the criteria for early endoscopy would have gone a long way to eliminating Dr. Hospitalist from this case at the outset. Hospitalists do have the right to rely on specialists, but in the middle of the night, we are often on our own and will be held to a "reasonable physician" standard. Dr. Hospitalist had access to the patient and the medical record – Dr. GI did not. A documented discussion with Dr. GI may have provided a better defense for Dr. Hospitalist. Ultimately, despite the issues regarding causation and the prevailing scientific principles, this case was settled on behalf of the plaintiff for an undisclosed amount.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.
