General Surgery

Case summary

An 84-year-old man presented to a local hospital three days after tripping and falling over his walking stick, sustaining significant skin tears to his left arm. His comorbidities included chronic obstructive pulmonary disease (COPD), hypertension, hypercholesterolaemia, osteoarthritis and having undergone a right hip and knee replacement. He was transferred to a private hospital under the care of a plastic surgeon, where a bilateral debridement and skin graft was performed for the wound. Over the ensuing days he developed coffee-ground vomiting and a drop in haemoglobin was noted. Endoscopy revealed a large duodenal ulcer, which was not actively bleeding.

The patient had been on long-term proton pump inhibitors before admission. Intravenous pantoprazole was recommenced and he was admitted to the intensive care unit (ICU), where progress was steady. However, it became apparent that despite numerous blood transfusions the ulcer was bleeding again. Surgical intervention was sought. A laparotomy was performed with ulcer resection, cholecystectomy, bypass and ventral hernia repair. Slow progress was made to the point where the patient was discharged from ICU. The plastic and reconstructive surgery team debrided an infected wound. Sepsis became an ongoing issue, with an infected peripherally inserted central catheter line thought to be the most likely cause. An aspiration event also occurred. Following discussion with the family given the unlikely prospect of recovery, palliative care measures were instituted. The patient passed away some six weeks after admission.

Discussion

Concerns have been raised regarding communication between the various disciplines involved in the care of this patient. It was noted in the audit report that there may have been a failure to recognise that the patient had a poor level of health at the time of admission.

Review of the earliest blood results included in the report demonstrate an iron deficiency anaemia and severe hypoalbuminaemia. These results should have prompted a review by a physician, perhaps before the initial plastic surgery, which could have been delayed. The plastic surgery was performed within hours of the patient’s arrival and could easily have been delayed for a comprehensive medical assessment. A review may have also picked up the fact that the patient should have been on a proton pump inhibitor.

There was a period of 10 days between the endoscopy and the eventual surgery, with many units of transfusion in between. Earlier surgical consultation by the gastroenterology team of a potential impending problem may have helped. It is surprising that there is no policy regarding ‘x number of units transfused warrants surgical consultation’. The surgery itself was extensive. There were no direct surgical complications.

The patient improved to the point where he was on the ward and receiving treatment from various allied health teams. Dietician review occurred relatively late in the admission, as their input was not sought at an earlier stage. It could be argued that total parenteral nutrition should have been instituted earlier and continued for much longer.

Each of the numerous health professionals performed their respective tasks well; however, the notes suggest there was never a sense of who was in control of the overall situation.

Handwritten notes were illegible in many entries and there were few examples of speciality identification, in contrast to the allied health team. Many larger hospitals have designated physicians precisely for this type of patient, which aids immensely in coordination of care. Improved communication and coordination and better initial assessment may have changed the course of this admission.

Clinical lessons

Elderly potentially frail patients are better off being medically assessed before non-urgent surgery. A physician/geriatrician would be in a good position to coordinate treatment, calling in appropriate surgical teams as needed.