Introduction: The case before us is interesting on several aspects. One, the patient is a minor who was treated for 3 days, successfully, before his parents could be contacted. Most importantly, this case is interesting because the causative agent was ultimately found to be a toothpick, identification of which was very difficult because a toothpick does not show on standard diagnostic imaging techniques such as MRI and CT scans. The patient’s family has filed a medical malpractice lawsuit against the hospital.
For malpractice to occur there are 4 conditions that must be met. The plantiff will have to show that Dr. Foreman had a duty to his patient. They need to show that Dr. Foreman breached his duty to that patient. They need to show that his breach of duty caused injury to his patient and lastly, they need to show what damages were incurred as a result of this breach of duty. I will prove why Dr. Foreman is not guilty of committing malpractice. Case Presentation: A 16 yr old male was brought to the ER in respiratory arrest that presented while engaging in sexual activity.
Pt. has no past history of asthma or allergies and no known medical conditions. The pt does have a recent history of a trip that involved sitting in truck for a long period of time during the past few weeks. There are no obvious signs of trauma and in the ER he had a normal EKG and echocardiogram, however a bloody pleural effusion was found during the ER workup. A CBC with differential shows no abnormal blood counts. Tuberculosis was ruled out by a CT scan and ACE level testing of his sputum.
Multiple standard diagnostic imaging studies did not show any obvious abnormalities. The patient’s spleen ruptured and in surgery to remove the spleen, Wegener’s disease was ruled out by microscopic study of a tissue sample of the spleen when it was normal. Signs/symptoms that presented were a cough, pain that changed locations as treatment progressed, complaints of feeling like an anvil is sitting on his chest, a penile bleed and ruptured spleen. Diagnostics: CT scan in ER: no tumors or pneumonia but a bloody pleural effusion was found.
CBC with differential: a standard diagnostic tool. EKG, echocardiogram: normal. Toxicology: no recent drug use was found. ACE (angiotensin converting enzyme) level, sputum testing, MRI & second CT scan: ruled out Tuberculosis, Lymphoma and Sarcoidosis. UA & Urine sediment 2 Venograms: to determine source of a low pressure leak. Negative for a low pressure leak. 1 Arteriogram: to locate a suspected blood clot and treat with tPA. Splenectomy: the tissue was normal. Colonoscopy: toothpick was discovered and removed.
Differential diagnoses discussed included: Wegener’s, deep vein thrombosis, pneumonia, Sarcoidosis, Lymphoma & Tuberculosis, Von Willebrand disease, drug use, heart failure and cirrhosis, DIC (Disseminated Intravascular Coagulation), Leukemia and Autoimmune dysfunction were all differential diagnoses that were considered as symptoms appeared, tested for and ruled out. A lesion was seen on the MRI that was determined to be a granuloma. Bleeding, clotting, & a granuloma are known symptoms of Wegener’s so he was treated with cyclophosphamide which improved the condition in his liver, however symptoms now appeared in his bladder.
FT-28, an experimental drug was discussed by the team as a last resort to alter his immune system. The team suspected that the patient had a condition in which his antibodies were attacking his blood vessels causing the various bleeds he had. Prior to administering the FT-28 to the patient, a new symptom of extreme pain in the abdomen appeared and the patient was rushed to emergency surgery. In surgery, the patient’s spleen as discovered to have ruptured and was removed.
A biopsy was done to confirm Wegener’s with the findings of a ruptured external capsule that was still intact, no signs of a clot or a bleed, normal follicles and normal lymphoid tissue. The determination was that this was normal spleen tissue and no granuloma was present and that the patient did not in fact have Wegener’s. The granuloma seen on the MRI turned out to be scar tissue. While the patient was recovering in the ICU a colonoscopy was done and a toothpick was discovered at this time and removed resolving his symptoms.
Natural History: 0-90% of swallowed objects do not require medical attention but up to 10% of cases end up in death, most likely related to secondary injuries caused by the swallowed agent. 1/3 of patients suffered complications. Epidemiology: In terms of swallowed objects, the tooth pick is most often the swallowed object. Persons at risk of swallowing a toothpick tend to chew on them habitually, have decreased oral sensitivity (possibly due to dentures), eat food rapidly and miss that a toothpick was embedded, or persons that may be inebriated.
Etiology/Pathogenesis: A swallowed toothpick can cause multiple internal injuries that ead to infection and peritonitis depending on location of the injury. Wooden toothpicks are often missed because the diagnostic imaging studies do not pick them up as they are not radiopaque. Therapy/Response: Detection is difficult in standard diagnostic studies because they often fail to pick up the image. Symptoms are not clear because they are dependent on part of body that is affected and may mimic many other conditions.
Diagnostic tests that are recommended include: blood work, CT with contrast, MRI, X-ray, gastroscopy, endoscopy, colonoscopy depending on symptoms presenting. There are no characteristic lab findings. Conclusion: To prove medical malpractice has occurred, the plaintiff needs to prove that Dr. Foreman had a duty to treat his patient, that he breached that duty, that the patient was injured as a result of that breach of duty, and what the damages were to the patient. Dr. Foreman and the medical team had a duty to treat this patient despite not having medical consent from his parents due to his condition.
When this client presented in the ER in respiratory arrest, it was unclear what was immediately causing the patient’s symptoms. He was treated symptomatically as they ppeared, assuming implied consent since the patient’s parents could not be located over a span of 3 days and because his condition was deteriorating. The premise of implied consent is that if the patient or guardian of that patient were able to give consent to a treatment, they would do so. The law protects Dr. Foreman in this instance because his patient’s parents were in fact unable to be located.
The team ran multiple tests that ruled out conditions as symptoms appeared. It is known from the patient’s internal injuries that the toothpick was traveling through the Gl tract. Two CT scans and an MRI had not picked up any foreign objects, is blood counts were normal leading the treatment team to believe that the patient had an autoimmune disease. There was discussion with the patient’s family regarding an experimental drug, FT28, after other options appeared to be ruled out. The family did not give approval for this drug to be given.
It is true that when the experimental drug was not allowed by the client’s parents, Dr. Foreman did try to persuade the patient to take this medication, however, it ultimately was never given because of the new symptom of pain that appeared, which was treated immediately by an emergency surgery to remove a ruptured spleen. During the surgery, a biopsy was examined and Dr. Foreman was able to rule out Wegener’s with appearance of normal spleen tissue. The decision was made to perform a colonoscopy, at which point the toothpick was discovered and removed, saving the patient’s life.
This particular cause of injury is extremely difficult to pinpoint and treat immediately. While most swallowed foreign objects are passed through the body without harm, the shape and pointed ends of the toothpick increase the odds of it being stuck in the body and causing harm. As was presented earlier, a toothpick will not show on an X-ray or other conventional iagnostic imaging studies because it is invisible to imaging techniques that rely on the density of an object to pick it up. The toothpick becomes the same density as the tissues around it due to water absorption of the wood it is made of.
As a result, ? treatment of the condition is symptomatic and often involves many tests. Approximately 10% of patients who ingest a toothpick die before it is discovered. A 42 yr old patient in the UK had an intact toothpick lodged in his heart for 1 yr before it was discovered. He was diagnosed with pneumonia and then told he had a heart infection. Several ultrasounds did not reveal the toothpick, and when a surgeon did find it, they believed it was an object left behind from a prior surgery.
A 37 yr old male in Italy suffered severe lower abdominal pain and after an endoscopy was done, it was discovered a toothpick had caused injury to several Gl tract organs. Author Sherwood Anderson died as a result of internal injuries sustained when he accidentally ingested a toothpick in 1941 while on a cruise. There has been prior cases of swallowed toothpicks that have been mistaken for Crohn’s disease, pneumonia & cancer to name a few. This patient’s case was no different in the quest to discover the cause of his ailments.
In conclusion, the criteria for malpractice have not been met. Dr. Foreman did meet his duty to treat his patient. While he was dangerously close to breaching that duty when he attempted to persuade the patient to take the experimental drug, it did not happen. None of the patient’s injuries were a direct result of Dr. Foreman’s treatment. The toothpick was perforating organs as it travelled through the gastrointestinal tract. Dr. Foreman’s patient lived because he was willing to run whatever test necessary to save his life.
