Patient Dies From Shock Due to Missed Intestinal Bleed

This case involves a thirty-seven-year-old female patient who presented to the hospital with complaints of severe upper-right quadrant pain, vomiting, and dark blood in her stool. A week prior to her admission, the patient had an abdominal ultrasound at her PCP that was read as normal and did not show any acute illness. Four days before her admission, however, the patient experienced coffee-ground emesis and the inability to tolerate anything by mouth. The patient’s medical history was significant for hepatocellular carcinoma with status post chemo-radiation. The patient experienced a severely hypotensive episode a few hours after her admission. Subsequently, the hospital staff placed a twenty gauge IV, but the access was lost when a nurse tried to infuse a bolus of fluids. Over the next twenty minutes, the nursing staff tried to regain peripheral access but did not have any success. The patient became unarousable shortly after and a code was called. Femoral IV access was finally obtained but the patient remained in a state of pulseless electrical activity for sixteen minutes until the time of death was called. The cause of death was cardiac arrest secondary to a large gastrointestinal bleed.

Question(s) For Expert Witness

1. What diagnostic tests should have been done to detect this bleed at an earlier stage?

Expert Witness Response E-005297

A complete blood count (CBC) is necessary to assess the level of blood loss in a patient with upper gastrointestinal bleeding. When possible, having the patient's previous results is useful to gauge this loss. CBC should be checked frequently (q4-6h), every four to six hours, during the first day. Based on the patient's initial hemoglobin level and clinical assessment of shock, a type and screen or type and crossmatch should be ordered. The patient should be cross-matched for two to six units, based on the rate of active bleeding. Also, the hemoglobin level should be monitored serially in order to follow the trend. An unstable hemoglobin level may signify ongoing hemorrhage requiring further intervention.