Indigestion Leads to Fatal Delay in Pancreatitis Treatment

Case Overview

This case involves an individual in their late 50s with no significant previous medical history who presented with indigestion. During an evaluation, imaging revealed distal narrowing of the common bile duct (CBD), leading to an endoscopic retrograde cholangiopancreatography (ERCP) procedure where a stent was placed. Post-ERCP, the individual experienced severe abdominal pain, nausea, vomiting, and difficulty keeping food down. They presented to a different emergency department after a day, where a CT scan confirmed acute pancreatitis with a lipase level exceeding 50 times the upper limit of normal. Initial treatment included anti-nausea medication and pain relief, but no intravenous fluids were administered, and they were discharged to follow up with their primary care provider in two days. Following persistent symptoms, the individual contacted the facility that performed the ERCP and was advised to return to the original hospital for direct admission. Despite receiving intravenous fluids approximately 12 hours after their arrival at the second hospital, the individual tragically expired due to hemorrhage. Allegations have arisen regarding an 18-hour delay between the diagnosis of pancreatitis and the initiation of intravenous fluids, raising questions of liability regarding the emergency department's management.

Questions to the Emergency Medicine expert and their responses

Please describe your experience evaluating and managing patients for acute pancreatitis.

I am board-certified in emergency medicine and Emergency Medical Services and have over 15 years of academic experience in high-volume Level 1 centers. Currently, I am a tenured professor of Emergency Medicine with over 125 publications, 7 textbook chapters, and international speaking engagements. I manage acute pancreatitis routinely in my practice. I am quite familiar with the pathology and its presentation in the acute phase. I understand the potential complications (necrosis and bleeding) and the need for immediate critical care evaluation.

What protocols should be followed for patients who are diagnosed with acute pancreatitis in the ED? When should hospital admission be considered in these patients?

Hospital policies should be followed for any medical condition. Acute pancreatitis following instrumentation (i.e., ERCP) should almost always be admitted, certainly with the lab's values described.

About the expert

This expert has over a decade of experience in the field of emergency medicine. He received his BA and MS from the University of Virginia and his MD from the University of Virginia Medical School. He completed his residency in emergency medicine at the University of Chicago and his fellowship in emergent cardiac care at the Virginia Commonwealth University Medical Center. Today, this expert is board certified in emergency medicine and emergency medical services and remains a consistent member of multiple associations, including the Society for Academic Emergency Medicine and the National Association of Emergency Medical Services Physicians, among others. Previously, he was the associate director of paramedic training and the director of emergent cardiac care at the VA Commonwealth University Medical Center, as well as the director of the Alabama Resuscitation Center at the University of Alabama Birmingham. This expert later served as an associate professor of surgery at the University of Alabama Birmingham and as an infield track physician at Talladega Superspeedway. Currently, he serves as a physician-scientist of clinical and injury science, as the director of the emergency medical services fellowship, as the director of the therapeutic hypothermia consult service, and as a professor of surgery, emergency medicine, and epidemiology at a university in Alabama. In addition, he is an international flight physician at an international air ambulance airline in Alabama.

E-223847

Specialties:

Emergency Medicine