This case involved a patient who complained of severe epigastric pain that was not well characterized. The pain waxed and waned over the course of the past few days but became progressively worse before arriving at the hospital. The patient’s working diagnosis in the ER was Gastritis and the doctors began treatment with Maalox, Oral Lidocaine, Pantoprazole, Hydromorphone, and Ondansetron. The patient was deemed stable and discharged the same night with instructions to avoid stomach irritants such as alcohol, caffeine, or spicy food.

The patient returned to the hospital that same day with increased pain and further CT workup showed a dilated appendix to approximately 12mm at which point the patient was taken for an emergent laparoscopic appendectomy. Medical records indicate that at the time of removal the appendix was nearly gangrenous and burst upon being grasped. The patient suffered post-operative infection/abscess due to the rupture and spillage of infected fecal tissue into the abdominal cavity.

It is believed that it was a departure from the standard of care for the physicians inability to recognize an acute appendicitis and the subsequent discharge of the patient without further clinical workup resulted in debilitating complications.

1. What is the standard operating procedure for ruling out emergent cases such a severe abdominal pain and a possible ruptured appendix?

Located: New York B.A., summa cum laude, Biology, State University of New York at Geneseo M.D., State University of New York at Buffalo Residency, Emergency Medicine,Thomas Jefferson University Hospital Board Certification, Emergency Medicine Certification, Advanced Cardiac Life Support (ACLS) Certification, Pediatric Advanced Life Support (PALS) Diplomat, the American College of Emergency Physicians Fellow, American College of Emergency Physicians Former F*** T**** P******** M******** H******* Former E******** M******* P******** M**** M****** C***** R******** C***** Former E******** M******* P******** R**** a* R***** Current M****** D******* o* U***** C*** C***** a* a m**** m****** c***** i* N** Y*** Current E******** M******* P******** a* a m**** h******* i* N** J***** Current D******* o* C******* C*** i* t** E******** D********* o* a m**** h******* i* N** Y***

This expert has been practicing for nearly a decade. He assists with the management and leadership of the Emergency Department providing emergency medical care to low-high acuity patients at a 38,000/year visit emergency department in a suburban setting. He also has his certification in hyperbaric treatments for wound care patients, and performs quality assurance reviews. He has been published, has significant research experience, and serves in both clinical and administrative roles. He has also won numerous awards, honors, and grants.

Delayed Diagnosis of Gangrenous Appendix Leads to Life-Threatening Infection

This case involves a 9-year-old female patient who presented to the hospital with a ruptured appendix. Additionally, an abscess was identified in her abdomen prior to surgery and an Interventional Radiologist was consulted to drain the abscess; the appendix was removed after the drainage. Several months later, after continual complaints of abdominal pain, the patient had an x-ray taken which revealed a linear object in her abdomen. Shortly after its discovery, the patient experienced increasing pain and rectal bleeding attributed to an embedded guide wire that was not removed during the original drainage procedure.

The wire is usually removed at the time of the drainage procedure. However, sometimes wires do break. If that happens a discussion should occur with the surgeon to possibly remove it at surgery or sometimes it is left in place if it is inaccessible. Retrained wire fragments rarely cause problems but can as it apparently did in this case. The wire being left in the abdomen is quite an unusual circumstance and extremely rare in my experience. It should have been noticed earlier (at the time of drain placement or removal or on subsequent films). Also, I would like to add that it should have been disclosed to the patient/family as soon as possible.

1. Is this a common complication? 2. What measures are taken to prevent such complications?

Location: Massachusetts M.D., Federal University of Sao Paulo M.Sc., Federal University of Sao Paulo Residency, Radiology, Federal University of Sao Paulo Fellowship, Interventional Radiology, Beth Israel Deaconess Medical Center Board Certification: Radiology Member, Society of Interventional Radiology Member, Radiological Society of North America Former C********* B***** H********* C********** Current C********* f** t** m**** s********* c*********** Current S**** R********** a* a m**** u********* m****** c***** Current I********* o* r******** a* a m**** m****** u*********

This expert has over 10 years of experience as an abdominal radiology, and currently practices in a clinical setting. He is a board certified member of the American Board of Radiology with sub-specialty in Interventional Radiology. He has held various academic and administrative leadership positions and is active both as an instructor and staff radiologist a major medical center in the Boston metropolitan area. Finally, he is an editorial reviewer of major medical journals and has been awarded numerous honors for his research and publications.

Guide Wire Left Behind After Abscess Drainage Procedure

This case involves a seven-year-old girl who complained of severe abdominal pain to her second-grade teacher, her school principal, and her school’s nurse. The child was frequently disciplined for disturbing the classroom setting and for complaining of nausea and dizziness. Early in the morning (9:30 AM) the child first complained to her teacher of severe abdominal pain. By 10:00 AM, the child was noted to be laying on the ground in her classroom, crying because the pain became overwhelming. At this time, the school’s principal was asked to speak with the child – and he brought her to the school’s infirmary. The infirmary/school nurse advised the principal that the child was probably “faking” and should be sent back to class immediately. She was then reprimanded by the principal and instructed to sit in her seat for the rest of the day without speaking. The child did this until her appendix likely ruptured and she passed out and became unconscious. An ambulance was called and an emergency surgery was ordered. The child required four subsequent procedures and was discharged after a three-month hospital stay.

I have worked as a school nurse for eighteen years and have served on various committees which develop guidelines and policies for school nurses. It is absolutely the school nurses responsibility to err on the side of caution. We are trained with this thought in mind. If there is even a slight likelihood that the child isn’t “faking” and actually requires medical assistance, it is imperative that the school nurse calls a local ER, the child’s parents, the pediatrician, and an ambulance. This should never be delayed for the reason illustrated in your case above. This nurse should lose her license and I believe the principal is negligent, too. Any child who presents with complaints of severe abdominal pain (who is laying on the ground, complaining, etc.) deserves immediate medical attention.

1. Is it a departure from the standard of care for a school nurse to fail to offer a more thorough workup of this child / i.e. contact her parents or call an ambulance, to have the child brought to an ER? 2. If a child is clearly in significant pain and discomfort, does the school nurse have an obligation to ensure that proper care and monitoring is ordered?

Location: Georgia Associate's Degree, Early Childhood Education, Point Park College M.S., Early Childhood Education, Mercer University Internship, worked with emotionally disturbed pre-school children, Western Psychiatric Institute Former C**** C*** T****** D***** T******** I**************** P******** C****** Former K*********** a** F**** G**** T****** A****** C*** S****** Former L*** K*********** T****** P********* C*** S***** Current P******** d** c*** c********* a** t******* f***

This expert is the owner and president of a privately owned company that provides on-site training and consultation in the child care industry. She began her career as an early childhood teacher before having a child of her own. After that, she began teaching adult students about child care in the evenings. Ultimately, she started her own training and educating courses, and provided on-site education to various types of facilities, including schools and day care centers. She has been providing training for Early Childhood Education Specialists for over 30 years.

School Nurse Fails to Recognize Appendicitis in a Seven-Year-Old Girl

This case involves a fifteen-year-old female who went to the local emergency room with complaints of abdominal pain. Laboratory studies were ordered and indicated a high white blood cell count. Imaging studies were not ordered and the patient was discharged with a diagnosis of influenza. The patient then went to her family medicine doctor the following day, where once again, a diagnosis of influenza was made. Three days later, the patient visited another doctor who identified a ruptured appendix. The patient was rushed to the hospital where an emergency appendectomy was performed. However, she suffered from numerous complications resulting from the ruptured appendix and may require additional surgeries in the future. Additionally, there was a strong possibility that she was infertile as a result of the delayed surgical intervention.

The delay in surgical intervention may very well have affected this patient's outcome. A chief complaint of abdominal pain in a young individual accompanied by an elevated white blood cell count is symptomatic for serious abdominal infections like appendicitis. The diagnosis of appendicitis should become apparent after a routine history and physical examination administered by the physician. This should reveal previous peri-umbilical pain that then migrates to the right lower abdomen (known as McBurney's point). The patient will also typically indicate a lack of appetite as well as nausea and vomiting throughout the day. The patient may also have a fever. Upon palpation, the patient's abdomen will be extremely tender. Appendicitis could also produce a positive psoas and/or obturator sign. Confirmatory diagnosis could have been made using CT scan with contrast. However, all the physical findings found by a physician stated above could warrant immediate removal of the appendix. Failure to remove an inflamed appendix could lead to widespread infection that spreads to other organs and the body cavity (peritonitis) as well as a tubo-ovarian abscess, which can reduce fertility in females.

1. Should the family medicine doctor have performed specific physical exam maneuvers to rule out the possibility of appendicitis?

Location: Florida B.S., Physics, Vanderbilt University M.D., Vanderbilt School of Medicine Internship, Family Practice, Tripler Army Medical Center Residency, Family Practice, Tripler Army Medical Center M.S., Tropical Medicine & Hygiene, Uniformed Services University of Health Science Board Certification: Family Medicine Fellow, American Academy of Family Physicians Member, American Board of Family Practice Former D******* o* M****** E********* R******** P****** D******* M*** S***** P******** G******** F***** M******* Former S**** F***** P******** a** F***** M******* R******** P****** F***** U*** A*** Current F******* P****** D******* a* m**** m****** u********* Current C******* P******** F***** M******* a* m**** m****** u*********

This expert has been practicing family medicine for almost 30 years. He has won numerous awards and honors, including three last year. He provides many community interests and services in his hometown, and on medical missions to underdeveloped countries. He's written almost 20 books, newspaper articles, and other publications, as well as been a presenter to his peers and students at national and regional presentations. Also, he has published considerably in peer reviewed medical journals on a wide array of topics.

Misdiagnosis of Influenza Leads to a Ruptured Appendix

This case takes place in Delaware and involves a 13-year-old female with no significant past medical history. She presented to her pediatricians office with complaints of severe abdominal pain and discomfort. She was seen by a Nurse Practitioner who prescribed an adult-strength laxative, prior to ruling out appendicitis. The patient returned home and administered the laxative. Several hours later, the patient’s appendix ruptured and she was taken to the hospital. A life-threatening incident, this condition required immediate surgery to remove the appendix and clean her abdominal cavity. In addition to the immediate and acute danger, she has suffered from a host of complications as a result of the ruptured appendix.

The laxative should have never been prescribed, and there are a number of reasons why. There are steps that should have been taken to ensure that this patient warranted a laxative - which clearly weren't taken - and since appendicitis wasn't ruled out, it was a dangerous decision to prescribe this young woman a laxative. The laxative obviously aggravated the appendix and caused it to rupture far sooner than it would have otherwise.

1. Do you have any specific knowledge on the effects of prescribing an adult-strength laxative to a pediatric patient with acute appendicitis? 2. Is it likely that this prescription aggravated the girl’s condition? 3. Have you ever treated a child with acute appendicitis / or a child who has suffered from a ruptured appendix?

Location: WV & OH B.A., Duquesne University M.D., West Virginia University Residency, Pediatrics, The Medical University of South Carolina Board Certified, American Board of Pediatrics Current P*********** p****** p******* Current C******* o* P********* m**** m****** c***** Current M****** D******* f** R***** B*** C***** f** A********* P********** M*******

Northeast

Delaware

This board certified expert has been practicing for over 15 years. He received his medical degree from the West Virginia University School of Medicine prior to completing residency training in pediatrics at the Medical University of South Carolina. He has been named 'Pediatrician of the Year' three times by a large, regional newspaper, and he maintains a busy private practice as a pediatrician. He is also the Chairman of Pediatrics at a major medical center.

Delayed Diagnosis of Appendicitis Results in Ruptured Appendix

This case involves a 4-month-old girl who presented to the ER with multiple symptoms, including a visibly distended abdomen. An ultrasound was performed, however it was noted that the testing did not visualize the appendix. Because of this, and the young age of the child, the surgeon ruled out appendicitis and considered other explanations for the patient’s condition, which continued to deteriorate over the course of the next few days. Eventually, the patient died in the hospital, with the cause of death identified as a ruptured appendix. It was alleged that the patient should have been diagnosed with and treated for appendicitis shortly after her arrival at the hospital.

Appendicitis is uncommon in children under 6 months of age, but it should always be considered as part of the differential diagnosis. An abdominal ultrasound should be interpreted with caution. Acute appendicitis can only be excluded on ultrasound examination if it is clearly visualized, and normal in appearance (normal diameter, compressible, with no sonographic evidence of inflammation). I have extensive experience in both the diagnosis and treatment of patients with both simple uncomplicated appendicitis and complex cases. I perform approximately 100 appendectomies every year, and have done so since 2006. I am a pediatric surgeon champion for the American College of Surgeons national surgical quality improvement program (NSQIP), and our institution has been participating in the appendectomy pilot study which has established best practices for pediatric appendicitis.

1. Do you have extensive experience treating patients who present with signs of appendicitis? 2. Are you familiar with the sign and symptoms that are present when appendicitis is the issues?

Location: Connecticut BS, Biology, Trinity College MD, University of Connecticut School of Medicine MPH, University of Michigan School of Public Health Residency, General Surgery, University of North Carolina Hospitals Fellowship, Extracorporeal Life Support, University of Michigan Health System Fellowship, Pediatric Surgery, Arkansas Children's Hospital Board Certified: General Surgery, Pediatric Surgery Certified: Advanced Trauma Life Support Instructor, Advanced Trauma Operative Management Instructor Fellow, American College of Surgeons Fellow, American Academy of Pediatrics Member, American Pediatric Surgical Association Member, Eastern Association for the Surgery of Trauma Member, International Pediatric Endosurgery Group Member, Nathan A. Womack Surgical Society 25+ Publications in the Pediatric Surgery field Current A******** S****** L****** C********** H******* Current A******** P******** o* S****** a** P********* T** N******** U********* M****** C*****

This double board certified general surgeon/pediatric surgeon earned a BS in Biology from Trinity College, an MD from the University of Connecticut School of Medicine, and a MPH from the University of Michigan School of Public Health. Additionally, he completed residency training in General Surgery at University of North Carolina Hospitals and fellowship training in pediatric surgery at Arkansas Children's Hospital. He is a fellow in both the American College of Surgeons and the American Academy of Pediatrics. He has authored more than 25 publications in his field, and is currently an attending surgeon at a children's hospital, in addition to his role as assistant professor of surgery and pediatrics at a major university medical center in the northeast.

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Ruptured Appendix Expert Witness Case Studies

Delayed Diagnosis of Gangrenous Appendix Leads to Life-Threatening Infection

Guide Wire Left Behind After Abscess Drainage Procedure

School Nurse Fails to Recognize Appendicitis in a Seven-Year-Old Girl

Misdiagnosis of Influenza Leads to a Ruptured Appendix

Delayed Diagnosis of Appendicitis Results in Ruptured Appendix

Fatal Appendicitis Could Have Been Detected Earlier: Pediatric Surgery Expert

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