Short Notes on Appendicitis 2017 - Dr Mark Burgin
23/03/17. Dr. Mark Burgin BM BCh (oxon) MRCGP considers the elements that should be included in a primer for clinical negligence cases involving appendicitis.
Clinical diagnosis remains the mainstay for most patients who present with abdominal pain although blood tests and urine tests are used widely, they may add little to the diagnosis.
Diagnosis of appendicitis has been improved with the use of CT scanning but CTs are not available for instance in General practice and involve radiation, an ultrasound scan can help if the sonographer has high skill.
The Appendix rarely perforates in the first 24 hours of symptoms giving the professionals a window after which the long term consequences are less good making causation relatively easy to prove.
Half of all presentations of appendicitis are straight forward to diagnose with the triad of symptoms tenderness in the right iliac fossa, guarding and rebound, and half are difficult to diagnose (for instance retrocaecal).
Misdiagnosis of Appendicitis may occur without negligence and this fact can be used to challenge causation for instance suggesting that had the examination been performed competently the diagnosis would still have been missed.
There are three issues for the clinical negligence lawyer to consider when presented with delayed diagnosis of appendicitis – severity of the pain, normal abdominal examination and high risk patients.
How severe was the pain?
Pain can be recorded on a scale from one to 10 with 7 to 8 meaning moderate-severe and 9 and 10 meaning severe.
Where the claimant states that the pain was 7 or above at the time of the presentation this is evidence that had the practitioner assessed the pain level they should have been concerned.
Failure to record severity of the pain at the time of the examination would be defended with the ‘my usual practice is only to record pain that is 7 or above’.
This is unconvincing because 6/10 is significantly less onerous to type than asking ‘on a scale from one to ten where ten is the worst pain imaginable how would you score the pain?’
Severe pain is a red flag but even moderate-severe pain the practitioner would need to make the patient safe through further checks (history, examination and investigations).
Failure to ask specifically for all the following: feeling sick (nausea), being sick, loss of appetite, diarrhoea and a high temperature (fever) could not be defended in a patient with severe pain.
Rebound tenderness to rule out peritonitis in mild or moderate pain is associated with a range of opinion with some experts of the opinion that it is not necessary unless the pain was severe.
Abdominal examination normal
With careful examination an area of tenderness can be identified in almost all patients complaining of abdominal pain and particularly those with appendicitis.
The claimant may state that the examination was painful and confirm that the practitioner did not ask them to cough, blow their abdomen out and pull it in or tap on the abdomen with the fingers.
Where a practitioner has recorded SNT (soft, non-tender) the lawyer should be concerned as it suggests a less than thorough examination in addition further examination to localise the pain would be necessary.
There are three ways to address this issue, first requesting evidence that the practitioner has recently undergone refresher training in abdominal examination, secondly asking for a statement of usual practice in abdominal examination and thirdly asking for an estimate of the percent of abdominal pain cases that have normal examinations.
As poor performance in abdominal examination would raise concerns that the practitioner was impaired and putting patients at risk reporting the practitioner to their registration body may be considered.
High risk patients
Children, the elderly, those with medical problems and poor language skills need to be assessed by the most senior doctor available as they are at high risk of misdiagnosis.
There should be protocols in every department where there is training to ensure that less senior staff are properly supervised such as nurse practitioner in primary care.
In a hospital setting a junior doctor may assess a patient and contact their senior so consequent failure by the senior to attend a high-risk patient would raise questions.
The GMC discusses Supervision and states that there should be ‘close personal supervision (for junior doctors, for example)’ and ‘you must be satisfied that the staff you supervise have the necessary knowledge, skills and training to carry out their roles’.
The use of CT scanning in abdominal pain (or laparoscopy) may be mandatory if communication problems cannot be resolved by senior review of the patient.
It may be necessary to request protocols with respect to supervision and training records of the practitioner if the practitioner was not a senior doctor.
The claimant’s statement in respect to the details of the examination and any difficulty in communication may be essential to bringing a case against a professional.
Failure to use CT scanning on its own is not evidence of negligence and misdiagnosis of appendicitis may occur without negligence.
A primer for clinical negligence lawyers in Appendicitis would improve the claimant interview, evidence gathering and the identification of potential cases.
Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.