This case involves a 3-year-old girl who presented to the emergency room with intermittent screaming episodes which seemed to be relieved by vomiting. She was administered a laxative and an enema for possible constipation. The physician suspected that the child’s intestine was telescoping on itself and evaluated the child with an abdominal ultrasound. An x-ray demonstrated mildly prominent loops of proximal small bowel with few scattered air-fluid levels. According to the reading, there was a possibility of small bowel obstruction. Based on concern for an abdominal process and the potential need for pediatric surgery consultation, the child was transferred to a higher level facility. After the patient arrived at the transfer facility, an abdominal ultrasound was ordered but was not completed for another 5 hours. The reading was interpreted as appendicitis. The child continued to deteriorate, developing fever, rapid heart rate, hypotension, and abdominal distention. A pediatric surgery consult was finally ordered 7 hours after the child’s arrival and the consult actually occurred 3 hours following the order. A CT was ordered and interpreted the CT that evening. The first interpretation allegedly failed to appreciate the malrotation, obstruction, and impending ischemia however. The following morning, the CT was reviewed again by the pediatric surgery attending. Immediately upon review by the attending, the child was rushed to emergency laparotomy. The child subsequently expired from cardiopulmonary arrest and total small bowel necrosis due to malrotation and volvulus. A radiologist was sought to review the abdominal ultrasounds, x-ray, the abdominal CT, and other diagnostic imaging to determine the reliability of interpretations provided during the clinical encounters at the receiving facility.
Question(s) For Expert Witness
- 1. Please describe your clinical activities as it pertains to reviewing diagnostic imaging for pediatric cases, particularly abdominal pathology.
- 2. Have you been involved in a case such as this, with emergent clinical indications?
Expert Witness Response E-077271
I am a fellowship trained pediatric radiologist with 10 years of experience. Pediatric imaging is my clinical focus and I deal with issues like these on a daily basis. I am on-call every 4th night to cover situations such as this one, and I am called in from home for emergency imaging for suspected volvulus and intussusception. Usually, an upper GI is performed to evaluate for volvulus, but this can also be diagnosed on CT and ultrasound. I also perform ultrasounds to evaluate for intussusception and then reduce these using ultrasound or fluoroscopic guidance with air or liquid reduction. I have a deep understanding of the clinical workup and surgical management of these conditions since the results of these studies I perform/interpret guide the management. Our practice goal is to perform these studies as-soon-as-possible and this usually occurs within 1 hour of the request. Routine requests (weekly) for evaluation of malrotation and volvulus during my 10 years of practice. I have presented lectures to the UCSF radiology residents on this exact topic. I also am asked to give 4-5 lectures per year at national and international conferences for my peers to cover advanced topics in pediatric imaging. These lectures cover pediatric imaging including acute abdominal emergencies in children. I have helped provide expert testimony in a medicolegal case with similar factors as this current case.