When Watching and Waiting Went Too Far
The following is a hypothetical situation designed to demonstrate a common form of medical error.
Four days in the hospital
A man of 68 was admitted at 11:30 at night with cramping pain and vomiting, 9 years after colon surgery. A CT scan showed a small bowel obstruction and the spot where the intestine narrowed. A tube was placed through his nose to empty his stomach, and he was given fluids. The plan was to rest the bowel and see whether the blockage opened.
On the second day his tube drained 1,900 milliliters and his pulse ran between 105 and 115. The progress note that morning said no acute distress and continue current plan. At 3:00 the next morning a nurse recorded a pulse of 128 and pain that was worse.
The covering doctor was paged at 3:20 and ordered medication for pain. He went to the operating room at 2:00 that afternoon. Two feet of dead bowel were removed, and he never left the intensive care unit.
The short answer
Small bowel obstruction means the intestine is blocked. Most often the cause is scar tissue from an earlier operation, which has kinked or trapped a loop of bowel.
Many of these blockages open on their own with rest, fluids, and a tube through the nose. That is why the first plan in the hospital is usually to wait. The failure in these cases is not the first plan. It is staying with the first plan after it stops working.
The signs the plan has stopped working almost always get written down. A rising pulse. Worsening pain. More fluid coming out of the tube. Then nobody acts on them.
There are two legal questions. Did the care fall below what a careful doctor, nurse, or hospital would have done? And would an operation at the point things turned have changed the outcome?
The rest of this page explains how to tell what happened in your own case. Our guide to severe abdominal pain emergencies covers the other conditions that go wrong this way.
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Article written by Gregory Unatin, Esq. Greg is a managing partner in the law firm of Lupetin & Unatin, a medical malpractice law firm located in Pittsburgh and serving Western Pennsylvania.
Our practice is limited to high-value catastrophic cases because that is where we can do the most for our clients and for patient safety.
What a blockage from scar tissue actually is
Every operation inside the abdomen leaves scar tissue behind. Doctors call it adhesions, meaning bands of scar that stick loops of intestine to each other or to the abdominal wall.
Sometimes a band kinks a loop of bowel, or a loop slips under a band and gets caught. Contents stop moving. The bowel above the block swells with fluid and gas, and that swelling pushes back. This is why the pain comes in waves and why vomiting starts. Many of these blockages then open on their own.
But there is a second path. When a loop is caught tightly, the swelling squeezes the small blood vessels in the wall of the bowel itself. Now the loop is not only blocked, it is being starved. Doctors call this strangulation, meaning the trapped bowel is losing its blood supply. A strangulated loop does not resolve with waiting. It dies.
Why it gets mishandled
Start with the part that is nobody’s fault. The first plan is correct. Resting the bowel, giving fluids, and draining the stomach is what the textbooks say to do, and it works most of the time.
The mistake here is a different kind. It is not mistaking this condition for another disease. It is mistaking a blockage that is getting worse for a blockage that is getting better. Those two look similar from the door of the room.
The physical examination is a poor guide. A trapped loop can be dying while the belly still feels soft. Older patients often have less tenderness than you would expect. An abdomen that has been operated on before feels different anyway. The surgeon who knows that is often not the one there overnight.
The vital signs do change, but they change in ways that always have another explanation. A pulse of 120 gets blamed on pain. Or on being dry (dehydrated). Or on the medication. Each of those is reasonable on its own. What none of them explains is a pulse that climbs every day for three days.
Then the notes take over. A note saying the abdomen is soft and the plan continues again the next morning, and the morning after. Nothing in the chart says the patient is worse, because nobody stepped back far enough to compare Tuesday to Sunday.
Nights and shift changes are where this happens. The person covering at 3:00 in the morning sees one set of numbers, not four days of them.
The tests that should have been repeated
The first scan usually gets ordered and usually gets read correctly. These cases are about whether anyone tested again.
The contrast study through the tube. Â A gastrografin challenge study is when contrast is poured down a tube already in the patient’s nose. Hours later an ordinary abdominal film shows whether the contrast reached the colon. If it has, the blockage is opening and waiting is working. If it has not, waiting is not working. The study also helps some blockages open on their own. Its real value is that it turns a judgment call into a piece of paper with a result on it. Â While contrast protocols provide an objective tool to assess resolution of SBO, they are one of several clinical management strategies rather than a mandatory requirement in every SBO case
A repeat scan. A second CT can show what the first could not, because the first was taken too early. A radiologist looks for a loop that no longer takes up the dye normally. Fluid around the intestine, and a loop trapped at both ends, matter too. But while repeat imaging can show progressive changes, a worsening clinical presentation alone often warrants immediate surgical exploration rather than waiting for repeat imaging.
Lactate. Lactate is a blood test that rises when tissue is not getting enough oxygen. It is useful when it is high. A normal lactate does not mean the bowel is healthy, because lactate tends to rise late, after the damage is done. A normal result should not have ended the conversation.
An examination recorded every day, by the same standard. Serial examinations mean exams are repeated and compared. When a patient is not improving, the answer is to look again rather than to write the same note. Â A documented daily abdominal examination is expected. Copying and pasting the exam findings from the day before does not cut it.
The clock
Once a loop is trapped tightly, the injury runs on its own schedule.
Pressure builds inside the trapped loop. The small vessels in its wall get squeezed shut. Without blood, the wall of the intestine begins to die. Then it leaks. Intestinal contents spill into the abdomen and cause peritonitis, which is infection of the lining of the belly. Blood pressure falls and organs begin to fail.
Nobody can pin the survival of a trapped loop to a specific number of hours. What is not in dispute is earlier surgery is more likely to lead to living bowel, and later surgery finds dead bowel. A surgeon divides the band of scar or frees the trapped loop, looks at the bowel, and takes out what cannot be saved. How much comes out depends almost entirely on when the operation happens.
In this case, the plan should have changed when the pain, the pulse, and the tube output all worsened, and surgery then would have saved the bowel.
Who is at highest risk
- Any prior abdominal or pelvic surgery, and more so after several operations.
- A previous episode of obstruction, meaning the scar tissue has caused trouble before.
- Older age, because tenderness and fever are often muted and the trend is the only signal.
- Any reason the patient could not report worsening pain, including dementia, sedation, a breathing tube, or a language barrier.
- Frailty, because these patients tolerate a late operation far worse than an early one.
Each of these should raise the level of watchfulness rather than lower it. Our guide to severe abdominal pain covers the broader risk factors across these emergencies.
What to look for in the records
These are things you can check, or ask a lawyer to check.
- The daily progress notes, and whether an abdominal examination was recorded each day or the same sentence was copied forward.
- The complete vital sign record for the whole admission, read as a trend.
- The tube output volumes for each day, and whether they were going up.
- Whether a contrast study through the tube was ever ordered, and if not, whether anyone wrote down why.
- Whether any repeat scan was done, and what it says next to the first one.
- Every lactate value with its time, and what was done after each result.
- The nursing notes, for pain, vomiting, urine output, swelling of the belly, and refusal to eat.
- The paging record: who was called, at what time, and how long an answer took.
- Consultation requests to surgery, with the time placed and the time answered.
- The overnight coverage and handoff documentation, which shows what the covering doctor was told.
- The operative report, which describes what was found and how much bowel was dead.
The central question – did failing to change course, change the outcome?
Waiting to see if an obstruction relieves with non-operative intervention is the standard of care. Most obstructions from scar tissue really do open without an operation. Surgery inside an abdomen full of scar tissue is difficult and risky. It can injure the intestine and creates more scar tissue for later. A surgeon who operates on every one of these patients on day one will hurt people who would have recovered anyway. A defense expert will say the team followed the accepted plan, and that hindsight makes a hard call look obvious. Sometimes that is right.
The two central questions remain: Did the care fall below what a careful doctor, nurse, or hospital would have done in the same situation? And would an operation at the point things turned have changed the outcome?
The argument here is not that surgery was needed on day one. It is narrower. It is that this chart already held the findings that called for a change of plan, at an hour you can point to. The plan did not change. The medical evidence must show that reassessing would have led to the operating room.
How people die from this, and what happens to those who survive
Most people admitted with a blockage from scar tissue get better without an operation and go home.
When it goes the other way, it often goes one of three ways. The most common is a leak from the dead loop, causing peritonitis and then septic shock, where blood pressure stops responding and organs fail. The second is aspiration, meaning vomit going into the lungs, which happens more often in patients who are weak, sedated, or lying flat. The third is death in the days after a very large resection, when a frail patient cannot recover from losing that much intestine.
Among those who survive, the injuries that permanently change a life are these, most common first.
- A permanent ostomy, meaning the bowel empties through an opening in the skin into a bag. It is permanent when too much bowel was removed to reconnect.
- A large hernia in the abdominal wall, which follows when the belly is left open for a time. It often needs a major reconstruction later.
- Short bowel syndrome, meaning so little intestine is left that the person cannot absorb enough food and lives on nutrition through a vein. This one is uncommon, and it is the hardest to live with.
Some patients also face repeated obstructions and further operations in the years that follow.
How we prove a case like this
A handful of records decide this condition.
The daily progress notes show whether anyone examined the abdomen each day, or whether the same wording was carried forward. The complete vital sign record is what turns three ordinary looking days into a trend. The nursing notes and the paging record show what was observed and what was reported. The consultation requests and the handoff documentation, with times, show who knew what and when. The operative report tells us what was found, which is how we know what an earlier operation would have found.
These cases usually need general surgery, hospital medicine or internal medicine, a nursing standard of care expert, and radiology.
Pennsylvania also requires a licensed professional to certify that the care fell below the accepted standard before a case can move forward. This article walks through the full investigation process.
Two other conditions on our site injure the bowel the same way. One is a twisted intestine, or a hernia with intestine trapped in it, strangled by a different mechanism. The other is loss of blood supply to the intestine, which ends in the same dead bowel.
Frequently Asked Questions
It is a fair question. Being in a hospital bed is not the same as being treated. The law asks whether the care met the standard, not whether the patient was in the building. In these cases the negligence is usually a failure to reassess and a failure to escalate, and both happen inside hospitals. A chart with worsening numbers and an unchanged plan reads very differently from one that shows a response.
Often it is true, and often it is beside the point. The question is who should have picked up the phone, and when. That can be the medical team managing the admission, the nurse who recorded the numbers, or the covering doctor overnight. We read the paging record and the consultation times to see where the hours went.
No. The records that matter here are the ones hospitals do not hand over easily, including nursing notes, vital sign flowsheets, and paging logs. We request the complete chart ourselves. If you already have paperwork, bring it, but do not wait on it.
No. An initial conversation is free, and so is our review of the case. We work on a contingency basis, which means a fee only if we recover money for you.
In Pennsylvania, a medical malpractice lawsuit must be filed in a proper court within two years of the date of death or in the absence of death, the date when the patient knew or should have known they suffered an injury which may have been related to health care. The practical point is that these cases depend on nurses and residents remembering one specific night, and hospital staff move on. Waiting costs you something even when no deadline is close.
What to do now
Gather what you have: discharge paperwork, any operative report, the death certificate if there is one, the hospital name and the dates. Then write down what you saw, day by day, while it is fresh. Which day he seemed worse. What you told the nurse, and at what time. What you were told when you asked about surgery. Families notice a change before a chart does, and what you remember can be evidence. Then call us, or start with our guide to severe abdominal pain emergencies if you want to understand the medicine first.