This case involves the care of a 10-month-old infant who was admitted to the hospital for lethargy and a distended abdomen. The working diagnosis after interpretation of imaging studies was thought to be acute appendicitis. The child was taken in for emergent surgery and the procedure was conducted without complication but the surgical report indicated that the appendix was ambiguous for actual inflammation. Several complications arose while the patient was in the intensive care unit; the patient experienced severe third spacing of fluid and went into hypovolemic shock. It was suspected that the child had a postoperative infection.

From the case summary that you shared with me, it seems as if the patient may have been mismanaged postoperatively given that the surgery went without complication. But what is most troubling to me is the third spacing of fluids. This may be an ominous sign of a surgery that went longer than expected or one that was not properly replaced with IV fluids. Cases like this need close monitoring of the patients fluid status throughout the procedure and afterwards in a critical care setting. If the patient did have an insidious infection this would complicate the problem even further. I would have to review more detailed information in order to provide an assertive opinion.

1. What are some of the signs that indicate mismanaged care post-operatively?

Location: California B.S., , Biology, Lima Peru Medical School M.D., Lima Peru Medical School Residency, Pediatrics, Loyola University Medical Center Fellowship, Anesthesia and Critical Care, Johns Hopkins University Fellowship, Pediatric Intensive Care, Johns Hopkins University Board Certification, Pediatrics Active Medical Licenses: CA, MD, IL Former P******** A******** P******** o* P********* U******** Former D******* P******** I******** C*** U*** F******* V***** R******* H******* C* Current D******* P******** I******** C*** U*** M**** C********* M****** C***** Current M****** C********** P******** E******** P****** C********** H******* C*

This expert is a board certified Pediatrician with additional fellowship training in pediatric intensive care and anesthesia critical care. He was trained at Loyola University Medical Center during residency and Johns Hopkins University for his Fellowship. He has extensive experience in dealing with the complicated pediatric patient that requires critical care post operatively. He was the Director of a pediatric intensive care unit at a Major Medical Center in California. He currently is the Chief Medical Coordinator for a Pediatric Medical Consulting Program at a Children's Hospital in California.

Childhood Appendectomy Causes Severe Third Spacing of Fluid and Shock

This case takes place in Minnesota and involves the death of an elderly female who passed away from Clostridium difficile colitis and sepsis. The plaintiff was admitted to the hospital for shortness of breath, congestive heart failure and bilateral lower extremity cellulitis. On admission the plaintiff’s assessment included diabetes, hypertension, chronic renal failure, peripheral vascular disease and congestive heart failure. During her hospitalization, a cardiac consultation and work up were performed and the plaintiff was ruled out for myocardial infarction. The plaintiff was discharged a week later to a rehab and skilled nursing center. A nursing note reflected that the plaintiff’s temperature had spiked at 102 with complaints of 2 loose stools. The plaintiff was given Tylenol for discomfort and Imodium twice a day as needed for diarrhea. Progress notes indicate that the patient continued to have loose stool and had been medicated with Imodium throughout the night. Her temperature increased to 103 and she was transferred to another hospital with stool results positive for Clostridium difficile. Her admission diagnosis included acute renal failure, dehydration and hypovolemia, secondary to Clostridium difficile colitis. She was aggressively volume resuscitated and was started on appropriate broad spectrum antibiotics for suspected sepsis. As prep for surgery was underway, the plaintiff went into cardiac arrest. Resuscitation efforts were unsuccessful and the plaintiff was pronounced dead due to sepsis and Clostridium Difficile colitis.

I see this infection on a weekly basis. Clostridium difficile has to be the leading diagnosis on anyone with diarrhea and fever on antibiotics. Imodium is contraindicated in this condition and can make the situation much worse. The patient should have been started on empiric therapy pending stool test results.

What is the standard work up and treatment for these patients?

Location: New York B.S., Farleigh Dickinson University M.D., New Jersey Medical School Internship, St. Luke's-Roosevelt Hospital Center Residency, St. Luke's-Roosevelt Hospital Center Fellowship, Infectious Diseases, New York University/Bellevue Medical Center Board Certification: Internal Medicine Board Certification: Infectious Diseases Fellow, American Medical Association Member, American Academy of HIV Medicine Member, Infectious Diseases Society of America Former D******** A*** a** I********* D****** C***** B******* H******* Current S************** A*** C******* T***** U*** N** M****** C***** Current C******* A******** P******** i* M******* T********** u********* Current A******** P******** I********* D******* N** M****** C*****

Midwest

Minnesota

This board-certified infectious diseases expert has been practicing for over 25 years. He is a member of numerous professional societies and has performed many research activities in the field of infectious diseases. He is also extensively published and has held several clinical and administrative appointments. He currently serves as an Associate Professor of Infectious diseases at a top-ranking NYC Medical Center and an attending physician of Infectious Diseases at a major NYC medical center.

Misdiagnosis of C. Difficile and Sepsis Results in Patients Death

This case takes place in New Jersey and involves an elderly female patient with atrial fibrillation who was admitted to a skilled nursing facility. Diagnoses on admission were diabetes, Parkinson’s disease, and hypertension. Due to the patient’s atrial fibrillation, Coumadin was administered and an order for clotting tests and intensive observation was given as well. However, while the screening protocols were ordered by the attending physician, the order was not properly carried over by the nurse on duty, and as a result the patient was not properly tested. No notes mentioning the need for testing were written by the nurse on the routine treatment log for the dates in question, and that lack of testing apparently continued for the next few weeks. As a result, the patient overdosed on Coumadin, causing a gastrointestinal bleed that resulted in hypovolemic shock and death.

It remains critical in the management of anticoagulation to closely monitor the blood tests, regardless of other mitigating factors (ie, environment of skilled nursing facility with dependence on RN for transcribing "Telephonic" orders). When errors occur on telephonic orders in the venue of a skilled nursing facility, liability is shared between the provider ordering the tests and the RN/LPN taking and transcribing the telephonic orders. Oversight is required, usually in the form of countersignature of telephonic orders within 24 hours of the order being given verbally, to ensure the execution of verbatim verbal orders. Having said this, the summary implies the lack of adequate and timely oversight of the telephonic orders such that the INR not being obtained with "forgotten" and a review of the patient's medications (especially Coumadin) was not performed on a regular basis for the weeks that passed until it was suddenly noted the patient had complications as a result of unmonitored administration of Coumadin. I have had over a thousand patients administered Coumadin for atrial fibrillation yet not one has had unmonitored treatment. None have had the complication of shock from Gastrointestinal bleeding as a result of weeks of Coumadin without monitoring. Clearly, the standard of care was not met in the proper administration of a potent blood thinner (Coumadin) and the patient's outcome would have been different had closer monitoring occurred. This is unusual in its nature as there appears to be clear disregard for the need for closer attention to the patient's medications and monitoring.

1. Do you routinely treat patients like the one described in this case? 2. Have you ever had a patient develop this outcome? 3. Based on this brief summary of the case, do you believe this patient might have had a better outcome had the care rendered been different?

Location: NJ BS, University of Wisconsin, Milwaukee MD, Medical College of Wisconsin, Milwaukee Residency, Internal Medicine, Loyola University Medical Center Board Certification: Internal Medicine Certification: American Physician Wound Care Certification Certification: NYU Advanced Certification in the Management of Complex Wounds Member, American Medical Association Member, American College of Physicians Member, American Society of lnternal Medicine Award, America's Top Doctor - 2006, 2008 & 2009, Research Council for American Healthcare Award, AMA Physician Recognition Award Former H********** a** C********* I******** f***** p******* Former A******** D********** o* M******* a** E******** M******* a** C******* I********* o* M******* B************ H******* Former A******** i* D********** o* I******* M******* a** U***** C*** Current I******* M******* P******************** a*** h******* Current I******* M******* P******************** a*** m****** c*****

Northeast

New Jersey

This highly qualified and board certified Internal Medicine physician has over 18 years experience working in private practice. He is a member of the American Medical Association, the American College of Physicians and the American Society of Internal medicine. He has won multiple awards throughout his career including America's Top Doctor for three consecutive years. He is currently a physician at his own private practice as well as an attending internal medicine physician/hospitalist at several area hospitals.

Patient is Killed by Coumadin Overdose

This case involves a 75-year-old female patient with a medical history of atrial fibrillation who was admitted to a skilled nursing facility for long-term care. In addition to her atrial fibrillation, the patient was also suffering from a number of other conditions when she was first admitted to the facility, including diabetes, Parkinson’s disease, and an upper respiratory infection that had persisted for some weeks. As a consequence of her atrial fibrillation, the patient had been on Coumadin for an extended period of time. During her stay at the nursing home, the patient’s INR was never tested, due to the fact that the patient’s nurse never properly carried out the treating physician’s orders to do so. As a result, the patient suffered a massive gastrointestinal hemorrhage, which eventually caused her to enter hypovolemic shock. The patient eventually died as a result of her bleeding.

I have been in various nursing administration positions from Head Nurse through Director of Nursing both in skill nursing facilities and acute care hospitals. I have had many patients on Coumadin. Monitoring and titrating this drug is very important in order to ensure that the correct dose is given each day. PT/INR values tend to fluctuate each day therefore it is of extreme importance to have the blood draw as ordered. Nursing notes are to be reflective of the patient situation. All changes, progress, lack of progress and status quo must be documented. The notes are a vital communication to the team that cares for the patient. I have worked in clinical practice for many years, taught in in-service education, and in academic education. During all of this time, patient safety and positive outcomes for the patient and family have been my main concern and focus. I have taught this concept to hundreds of nurses and still teach it today.

This highly qualified nurse has been practicing for over 40 years. She has a BS in Nursing from Lehman College and an MA, Med and EdD in Nursing Administration from Columbia University. She has authored publications in the Journal of Nursing Administration, Nursing Clinics of North America, Clinical Nurse Specialist, and the Quality Review Bulletin. Previously, she was an Associate Director of Nursing at Bellevue Hospital Center. She now serves as an adjunct lecturer at a New York City medical college and a Staff Development Coordinator at a medical center in the Bronx.

1. Do you serve as an administrator at a skilled nursing facility like the one described in this case? 2. Have you ever had a patient develop this outcome? 3. Can you opine on the importance of accurate nursing notes?

Location: NY BS, Nursing, Lehman College MA, Nursing Administration, Columbia University MEd, Nursing Administration, Columbia University EdD, Nurse Executive Role, Columbia University ANCC Advanced Certifications: Gerentological Nursing, Nursing Administration Member, American Nurses Association Former D******* o* N****** F******* N********** N****** H*** Former C**** N****** H*** C*** U*** P****** D********* o* N****** C****** o* M**** S**** V****** Former S****** A******** t* t** M****** C***** D*************** P****** D********* o* N****** C****** o* M**** S**** V****** Former A******** D******* o* N****** B******* H******* C***** Current S**** D********** C********** a m**** m****** c***** i* t** B**** Current A****** I********* o* N****** a m****** c****** i* t** B****

Nursing Home Resident Dies Following Coumadin Overdose

This case involves a middle-aged male patient who passed away shortly after undergoing a cardiac catheterization procedure. A week before the incident in question, the patient presented to the emergency room with complaints of chest pain and shortness of breath. A chest X-ray as well as an EKG revealed multiple troubling findings, and the patient was admitted to the hospital. The patient was taking Coumadin at the time for deep vein thrombosis. He discontinued Coumadin for the procedure, bridging with another medication until the procedure was complete. He underwent cardiac catheterization and was diagnosed with moderate coronary artery disease, however the procedure was largely uneventful and the patient was recommended for discharge home. A few hours before the patient was set to leave the hospital, however, his blood pressure suddenly plummeted. Treating physicians suspected hypovolemic shock, which was confirmed by a CT scan that revealed an internal hemorrhage. The patient was taken off of his anticoagulant medication and given a number of different blood products, however no surgical intervention was undertaken. The patient’s condition continued to deteriorate until he was eventually diagnosed with multiorgan failure and treatment was discontinued. It was alleged that the cardiac catheterization procedure was mishandled, and eventually led to the patient’s death

I regularly treat patients who are similar to the case described, and I perform cardiac catheterization a minimum of three days a week. My yearly procedure count is between 700-750 cases including cardiac, cerebral, and peripheral cases. I believe this patient may have had a better outcome if the care was rendered differently. If the cardiac catheterization was performed via radial access, then the retroperitoneal bleed could not have possibly been caused by the cardiac catheterization. Furthermore, the morning after catheterization, the patient's blood count showed a significant drop from 36% to 31%. If it is determined that the catheterization did not cause the bleed, then there is still the issue of the physician not picking up on the significant blood loss. I would like to learn more, ie. the access site used to perform cardiac catheterization and, if femoral, was a closure device used or not.

1. Do you routinely treat patients similar to the one described in the case and perform cardiac catheterization? If so how often? 2. Have you ever had a patient develop the outcome described in the case? If so, please explain.

Location: TN B.S., American University of Beirut M.D., American University of Beirut Residency, Internal Medicine, Cleveland Clinic Foundation Fellowship, Cardiovascular Diseases, University of Texas Health Science Center Fellowship, Interventional Cardiology, Vanderbilt University Board-certification, Internal Medicine Board-certification, Interventional Cardiology Board-certification, Nuclear Cardiology Certification, Meaningful Use Stage 1, Centers for Medicare & Medicaid Service 30+ publications in peer-reviewed journals Current D******* o* C************* C************** L********* a** A******** I************* C*********** a* m**** u******************** h******* Current A******** P******** o* M******* a* h*********** m**** u*********

This highly qualified and board-certified Interventional Cardiologist received his M.D. from the American University of Beirut. He went on to complete residency in Internal Medicine at the Cleveland Clinic Foundation, a fellowship in Interventional Cardiology at Vanderbilt University, and a Fellowship in Cardiovascular Diseases at the University Texas Health Science Center. He is certified in Internal Medicine and Interventional Cardiology by the American Board of Internal Medicine and in Nuclear Cardiology by the American Board of Nuclear Cardiology. This expert has authored 30+ publications in peer-reviewed publications in the field. Currently, he is an Assistant Professor of Medicine at a high-ranking major university as well as the Director of Cardiovascular Catheterization Laboratory and Attending Interventional Cardiologist at major university affiliated hospital.

Hypovolemic Shock Expert Witnesses

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Hypovolemic Shock Expert Witness Case Studies

Childhood Appendectomy Causes Severe Third Spacing of Fluid and Shock

Misdiagnosis of C. Difficile and Sepsis Results in Patients Death

Patient is Killed by Coumadin Overdose

Nursing Home Resident Dies Following Coumadin Overdose

Patient Suffers Fatal Hemorrhage While on Coumadin

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