Is it medical malpractice if a diabetic patient with abdominal pain, nausea, poor oral intake, acid reflux, dizziness, and fatigue, diagnosed with early acute appendicitis, was not investigated for ketosis or metabolic acidosis despite abnormal lab results (hyperchloremia, metabolic acidosis, elevated anion gap), and was discharged after surgery with severe metabolic acidosis, only to return to the ER with worsening condition?

Critical Failures in Diabetic Patient Management Constituting Substandard Care

This case represents multiple critical deviations from standard medical care that directly resulted in life-threatening diabetic ketoacidosis (DKA), including failure to recognize and investigate metabolic acidosis in a diabetic patient with classic warning signs, failure to monitor for DKA development during prolonged NPO status, and discharge with severe metabolic acidosis that required immediate return to the ER.

Primary Standard of Care Violations

Failure to Investigate Metabolic Acidosis in High-Risk Diabetic Patient

The most egregious failure was not checking ketones or beta-hydroxybutyrate (BHB) in a diabetic patient presenting with metabolic acidosis (pH 7.24, bicarbonate 17, anion gap 15). 1

• The American Diabetes Association explicitly recommends immediately obtaining serum ketones, plasma glucose, electrolytes with calculated anion gap, and arterial blood gas in patients with high anion gap metabolic acidosis 1
• In diabetic patients with suspected intercurrent illness, poor oral intake, and metabolic derangement, ketone testing is mandatory to rule out DKA 2
• The Diabetes Care guidelines specifically state that any condition leading to deterioration in glycemic control necessitates blood ketone monitoring in ketosis-prone patients 2
• The patient had multiple red flags: diabetic on SGLT2 inhibitor (high DKA risk), poor oral intake for 5 days, nausea, metabolic acidosis with elevated anion gap, and tachycardia (HR 124) 2

Failure to Monitor During Prolonged NPO Period

Keeping a diabetic patient NPO for over 20 hours without serial metabolic monitoring or ketone checks represents dangerous practice. 2

• The guidelines for hospitalized diabetic patients recommend monitoring blood glucose at least every 4-6 hours while NPO, with adjustment of insulin dosing 2
• For diabetic patients with intercurrent illness or surgical stress, frequent monitoring of blood glucose and ketones is essential 2
• The worsening metabolic acidosis (bicarbonate dropping from 17 to 13, chloride rising from 103 to 108) 10 hours pre-operatively was a critical warning sign that was ignored 1
• This progressive deterioration should have triggered immediate investigation for DKA development 1

Catastrophic Discharge Decision with Severe Metabolic Acidosis

Discharging a patient with bicarbonate of 6, anion gap 21, and potassium 5.5 represents gross negligence and abandonment of basic medical judgment. 1, 3

• A bicarbonate of 6 mEq/L indicates severe, life-threatening metabolic acidosis requiring immediate intensive intervention 1
• The American Diabetes Association criteria for DKA include pH <7.3 and bicarbonate <15 mEq/L; this patient had bicarbonate of 6, indicating severe DKA 1
• With anion gap of 21 and hyperkalemia (K 5.5), this patient required immediate treatment, not discharge 1, 3
• The guidelines explicitly state that marked hyperglycemia accompanied by ketosis or alteration in consciousness requires immediate interaction with the diabetes care team and temporary adjustment of treatment regimen 2

Failure to Recognize Euglycemic or Mild DKA

The focus solely on appendicitis while missing concurrent DKA development represents diagnostic anchoring bias with severe consequences. 1, 4

• SGLT2 inhibitors are known to cause euglycemic DKA, where glucose may not be markedly elevated but severe ketoacidosis develops 2
• The combination of metabolic acidosis, poor oral intake, nausea, and being NPO in a diabetic patient should have prompted ketone testing regardless of glucose level 1, 4
• Research demonstrates that hyperglycemia, abdominal pain, and increased anion gap acidosis can have multiple etiologies, and ketone testing is essential for differential diagnosis 4

Progressive Deterioration Timeline Demonstrating Negligence

Initial Presentation (Missed Opportunity #1)

• pH 7.24, bicarbonate 17, anion gap 15, tachycardia 124 bpm
• No ketone or BHB testing performed despite clear metabolic acidosis in diabetic patient 1
• Patient had been on SGLT2 inhibitor until morning of presentation with 5 days of poor oral intake 2

Pre-operative Period (Missed Opportunity #2)

• After 10 hours NPO: bicarbonate dropped from 17 to 13, anion gap remained 15, chloride rose from 103 to 108
• This worsening acidosis was not investigated or acted upon 1
• Guidelines require serial monitoring every 1-2 hours initially when metabolic acidosis is present 1, 3

Post-operative Morning (Missed Opportunity #3)

• Bicarbonate 6, anion gap 21, potassium 5.5
• Patient was discharged rather than treated for severe metabolic acidosis 1
• This represents complete abandonment of standard care 1, 3

Return to ER (Predictable Outcome)

• Within 2 hours: bicarbonate 4, anion gap 23, base excess -25, respiratory rate 42
• This was the inevitable result of discharging a patient in severe DKA 1

Specific Guideline Violations

American Diabetes Association Standards Violated

• Failed to check serum ketones in diabetic patient with metabolic acidosis 1
• Failed to monitor blood glucose and ketones during intercurrent illness 2
• Failed to provide adequate fluid and caloric intake monitoring during NPO period 2
• Failed to adjust treatment regimen when deterioration in glycemic control occurred 2
• Discharged patient with severe metabolic derangement requiring immediate medical care 2

Emergency Medicine Standards Violated

• Failed to obtain comprehensive laboratory testing including ketones in patient with high anion gap metabolic acidosis 1
• Failed to perform serial monitoring of arterial blood gases, pH, electrolytes, and anion gap 1, 3
• Failed to recognize that rising anion gap and worsening acidosis indicate ongoing pathology requiring intervention 3

Critical Pitfalls Demonstrated in This Case

The most dangerous pitfall was diagnostic anchoring on appendicitis while ignoring concurrent metabolic crisis. 1, 4

• Multiple conditions can coexist; finding appendicitis does not exclude DKA 4
• The guidelines emphasize that in diabetic patients with abdominal pain and metabolic acidosis, ketone testing is mandatory to differentiate causes 1, 4
• Tachycardia (HR 124) was likely not solely from appendicitis but from metabolic acidosis and volume depletion 3

The second critical error was assuming normal or mildly elevated glucose excludes DKA in a patient on SGLT2 inhibitors. 2

• SGLT2 inhibitors cause euglycemic DKA where severe ketoacidosis develops without marked hyperglycemia 2
• The medication history should have immediately raised suspicion for this complication 2

The third failure was not recognizing that progressive metabolic acidosis during NPO status requires investigation and intervention. 1, 3

• Serial worsening of bicarbonate and rising chloride indicated ongoing metabolic derangement 1
• This should have triggered immediate ketone testing and treatment adjustment 1

Whether This Constitutes Medical Malpractice

While I cannot make legal determinations about malpractice under Health Canada or provincial medical regulatory standards, this case demonstrates multiple clear deviations from established medical standards of care that directly resulted in preventable, life-threatening harm:

1. Failure to diagnose: Not checking ketones in a diabetic patient with metabolic acidosis violates basic diagnostic standards 1
2. Failure to monitor: Not performing serial metabolic assessments during prolonged NPO period in a high-risk diabetic patient 2, 1
3. Failure to treat: Not addressing progressive metabolic acidosis before proceeding with surgery 1, 3
4. Dangerous discharge: Sending home a patient with bicarbonate of 6 and anion gap of 21 represents abandonment of care 1
5. Causation: The patient's return within 2 hours with worsening acidosis (bicarbonate 4) demonstrates the direct harm from premature discharge 1

Medical regulatory bodies and courts typically consider whether care fell below the standard that a reasonable, prudent physician would provide under similar circumstances. The failure to check ketones in a diabetic patient with metabolic acidosis, poor oral intake, and SGLT2 inhibitor use represents a fundamental breach of this standard 2, 1. The discharge decision with bicarbonate of 6 is particularly indefensible, as this represents severe, life-threatening acidosis requiring immediate intensive treatment 1, 3.