This case involves a middle-aged female patient with chronic kidney disease who presented to the ER with complaints of abdominal pain and lower extremity weakness. A physical exam revealed diminished peripheral pulses indicating vascular compromise in the legs. A CT scan revealed an abdominal aortic aneurysm but vascular surgery determined the patient did not meet the criteria for emergent surgery. The patient’s blood was then closely monitored and her volume of red blood cells and hemoglobin levels began to steadily decline. As her blood pressure continued to drop, an MRI was ordered but was never performed. There was a concern that the patient had a bowel perforation and so she was transferred to a better-equipped facility for surgical intervention. At the second hospital, a STAT CT was ordered but was not performed for several hours. The CT revealed a ruptured common iliac artery aneurysm and suffered from massive internal bleeding. An expert in cardiovascular surgery was sought to opine on the standard of care for patients presenting to the ER with these conditions.
Question(s) For Expert Witness
- 1. Do you routinely treat patients like the one described in this case?
- 2. Have you lectured/published on the management of such patients?
Expert Witness Response E-006875
Having lectured and consulted clinically on cases similar to this, it seems the crux of this case is whether the patient is a candidate for surgery. If the initial facility was not prepared to take care of her, then they should have transferred her to a tertiary facility as soon as possible. Only there could that determination be made. In addition, from a clinical standpoint, it makes little sense to transfer a patient with a perforation to surgery after she was predetermined to not be an operative candidate. Furthermore, another area of concerned should be centered around the delay in the CT scan at the second facility and if that delayed repair, assuming she was a candidate.