HospitalInspections.org

Based on interview and record review, it was determined that the hospital medical staff failed to ensure that the hospital provided quality medical care to one of ten sample patients in the hospital. Patient identifier: 3

Findings include:

Patient 3 presented to the hospital emergency department (ED) on 3/10/10 with complaints of nausea and abdominal pain. Patient 3 had a history of recurrent small bowel obstruction and bowel resection. Patient 3 was treated conservatively in the ED, and when she began feeling better, wanted to go home. Patient 3 was discharged to home and was told if her symptoms worsened to return to the ED.

On 3/11/10 at 10:56 AM, patient 3 returned to the ED with complaints of worsening symptoms including nausea and vomiting. The ED physician ordered laboratory tests and a CT scan to determine if patient 3 had a small bowel obstruction.

The tests were completed and the ED physician reviewed all of the results. Upon review of all the test results, the ED physician determined that patient 3 had a bowel obstruction.

There was no surgical coverage in the ED that day, so the ED physician contacted a physician at the hospital's other campus, but that physician was unable to care for patient 3. The ED physician paged one of the hospital surgeons and reviewed the case with him. The surgeon evaluated patient 3 in the ED at 3:47 PM and arranged to admit patient 3 to the hospital. The surgeon wrote orders for patient 3 to have a nasogastric tube placed, and ordered intravenous fluids to be given. The surgeon talked with patient 3 and her spouse about the course of treatment, and it was determined that patient 3 should have surgery to relieve the obstruction. Patient 3 agreed to the treatment.

The surgeon obtained consent from patient 3 to perform laparoscopic lysis of adhesions and probable open bowel resection.

Patient 3 was taken to surgery on 3/12/10 at 4:40 PM. The surgeon performed a laparoscopic enterolysis. At 8:00 PM patient 3 was returned to the medical/surgical floor.

The following is documentation from patient 3's medical record:

The surgeon documented on 3/14/10 at 3:20 PM, that patient 3 felt rumblings but had not had any flatus or bowel movement. He documented that her pain was better, she had decreased tenderness in her abdomen, but was still distended and bowel sounds were present in all four quadrants. He also documented that she had a slight temperature.

On 3/14/10 at 9:40 PM, patient 3's temperature elevated to 101 degrees, and the nurse obtained an order for Tylenol. Patient 3's pulse was documented as being 118.

On 3/15/10 at 1:00 PM, patient 3 requested her temperature be taken, she felt like she had a temperature and wanted it taken. The temperature was documented as being 99.6.

On 3/15/10 at 4:15 PM, the surgeon ordered a full liquid diet for patient 3, to discontinue the intravenous fluids, and to encourage patient 3 to ambulate as much as possible. He also ordered to have a complete blood count done on 3/16/10.

On 3/15/10 at 5:00 PM, the surgeon documented that patient 3 was better, was passing gas, and had 2 bowel movements, was afebrile and normotensive. He documented that her abdomen was still distended but improved. The surgeon documented to check patient 3's white count in the morning, and if normal and she continued to tolerate full liquids, she could go home.

On 3/16/10 at 12:00 PM, the surgeon documented that patient 3's temperature was 99.6, and her heart rate was 90 to 100's. He documented that she had decreased distension, decreased pain, with positive bowel sounds. He documented that patient 3 reported having a bowel movement the night before. He documented that patient 3 still had cramps but was improving. The surgeon wrote an order for Valium 5 milligrams (MG) at bedtime for insomnia and could repeat in one hour. He also ordered Percocet for pain.

On 3/16/10 at 2:30 PM, patient 3's temperature was documented as being 100, her pulse was 120, and her blood pressure was 150/87.

At 3:30 PM on 3/16/10, a verbal order was obtained for Valium 2.5 MG intervenously (IV) now and to repeat in 40 minutes if still having muscle spasms.

On 3/16/10 at 10:00 PM, patient 3's pulse was documented as being 125.

On 3/17/10 at 8:59 AM, a nurse documented that there was occasional flatus in all quadrants.

On 3/17/10 at 1:30 PM, patient 3's pulse was documented to be 116 and her blood pressure was 158/89.

The surgeon documented at 4:15 PM on 3/17/10, that patient 3 was still bloated, was not nauseated, but not taking much orally and was uncomfortable. He documented that her temperature was 100, her white cell count was 9, her abdomen was distended, had decreased tenderness, and few bowel sounds. He documented that he suspected a post operative ileus. The surgeon wrote an order for a CT scan to be done in the morning with contrast. He also ordered IV fluids to be restarted, blood work in the morning, dulcolax suppository now and every 6 hours, and to change the diet to clear liquids.

A nurse documented on 3/17/10 at 4:54 PM, that the physician had been in to see the patient and and had called back later and ordered abdominal xrays 2 views, and the patient was informed.

On 3/17/10 at 5:28 PM, a nurse documented that patient 3 was experiencing constant pain in her left quadrant.

The abdominal xrays were done at 6:30 PM on 3/17/10. The results indicated that there were multiple gas-filled loops of large and small bowel. The radiologist documented that the bowel gas pattern was abnormal and suggested an ileus. The radiologist also documented that the xray showed a left pleural effusion.

On 3/17/10 at 7:30 PM, a nurse documented that the physician was notified of the increase in pain and distension and the absence of bowel sounds.

On 3/17/10 at 7:30 PM, a verbal order was obtained for Valium 2.5 MG IV every 6 hours as needed.

Patient 3's pulse and blood pressure on 3/17/10 at 9:00 PM was 132 and 140/80, and her oxygen saturation was documented to be 84% on room air.

On 3/17/10 at 9:40 PM, a nurse documented that another physician (on call physician/surgeon) was notified of patient 3's complaints of, "severe abd (abdominal) pain; absent bowel sounds; firm & (and) distended abd. Tachycardia, elevated BP (blood pressure); desats on room air 84%; pt (patient ) now on 4L/NC (nasal cannula) =92% SPO2; pain meds given."

At 9:40 PM, a verbal order was obtained from that physician for patient 3 to have nothing by mouth, a complete blood count and comprehensive metabolic panel stat (now), a portable chest xray stat, acute abdominal series xray in the morning, Morphine 1 to 5 MG IV every hour as needed for pain, and a nasogastric tube to low intermittent suction if patient 3 wanted it.

At 9:45 PM a nurse documented that patient 3 was informed of the physician orders and patient 3 agreed to the nasogastric tube, which was inserted and connected to low intermittent suction.

The stat blood work and chest xray was completed and showed that patient 3's white blood cell count was 12.8, and that the lung volumes were quite low.

At 11:45 PM, a nurse documented that the physician was notified of the chest xray results, the nasogastric tube output, the complete blood count, and the comprehensive metabolic panel, and patient 3's current vital signs. The nurse documented that the physician's response was to do both xrays, the abdominal series and the CT abdominal scan the next day.

Patient 3's pulse and blood pressure at 10:00 PM was 128 and 157/89.

Patient 3's pulse and blood pressure at 11:30 PM was 122 and 151/100.

Patient 3's pulse and blood pressure on 3/18/10 at 12:30 AM was 120 and 164/76.

Patient 3's pulse and blood pressure at 2:00 AM was 129 and 152/78.

Patient 3's pulse at 5:00 AM was 132 and her oxygen saturation (O2 Sat) was 88 on 4 liters of oxygen.

Patient 3's pulse at 5:25 AM was 132, blood pressure was 158/95 and O2 sat was 90% on 5 liters of oxygen.

The nurses documented that they were frequently monitoring patient 3's pain and were medicating her as needed through the night.

On 3/18/10 at 9:07 AM, a nurse documented that patient 3 was sent to xray.

At 9:27 AM, a nurse documented that patient 3 was not feeling well and was medicated for pain. The tests were pending.

On 3/18/10 at 10:30 AM. a verbal order was written by a nurse for Zosyn 4.5 grams IV every 8 hours, Dilaudid 0.5 mg to 1 mg IV every hour as needed , to discontinue the Morphine and to give nothing by mouth.

At 10:30 AM, the radiologist documented that the CT of the abdomen and pelvis done with contrast revealed that, "Findings were consistent with perforated viscus with large volume of free air and free fluid throughout the abdomen and pelvis as well multiple interloop collections. I discussed these findings with the nurse caring for the patient of examination, nurse contacting the referring surgeon."

At 10:33 AM, a nurse documented, "returned from radiology, informed m.d of rad results (free fluid and air with likely perf bowel.) abx {antibiotic} ordered and pain med changed. will discuss plans with pt."

At 1:58 PM, patient 3's pulse and blood pressure were 122 and 154/96. Her O2 sat was 92% on 5 liters of oxygen.

There is no other documentation in patient 3's medical record by the physician or that the nurses had any communication with the physician until 6:15 PM.

On 3/18/10 at 6:13 PM, a nurse documented, "paged md earlier to inform of bp and pulse with no answer. Called again around 1800 (6:00 PM) with no return call yet, will monitor."

At 7:00 PM a nurse documented, "attempted to call home phone of [md] but the number was disconnected. informed house sup (supervisor) that i have been unable to get a hold of m.d. she stated that she would follow up."

At 8:05 PM a nurse documented, "Assessment done per charting; pt drowsy, awakens with voice. state her pain is at 2/10. increases with cough or movement, still waiting on md to return call. earlier nurse left him a message. will cont to monitor pt."

At 8:15 PM a nurse documented, "[MD] called and stated that he would be in to see pt in about 30 min. discussed bp and pulse and increased drowsyness (sic) over the last few hours. no orders indicated will await his arrival and assessment of patient".

At 8:36 PM a nurse documented, "pain managed with iv meds. abx as ordered, bp still elevated hr (heart rate) still tachy. md is aware reported off to night nurse."

At 9:40 PM, the physician documented in patient 3's medical record, "Pt feels worse today no nausea, but pain has increased/no gas/flatus today...............ABD distended, tender, +rebound - BS (bowel sounds) ext. (extremities) +1 edema .................CT:abd/pelvis multiple ares of fluid/ free air in abdomen consistent with perforated viscus....".

On 3/18/10, a verbal order was written by a nurse to transfer patient 3 to another hospital. The order was not timed.

The physician completed a transfer form on which was documented that the transfer was initiated at 9:30 PM and the receiving hospital had agreed to accept patient 3 and named the physician that had accepted the responsibility for patient 3. Patient 3's spouse signed the consent for transfer.

A nurse documented at 11:25 PM that report was called to a nurse at the receiving hospital. The nurse documented that they were waiting for the ambulance for transport. The nurse documented that the family was aware of the transfer and that the physician had spoken to the spouse and the daughter about the transfer.

At 11:40 PM, a nurse documented that patient 3 was transferred to the receiving hospital.

On the physician discharge summary, the physician/surgeon documented, "Her condition began to decline with worsening abdominal pain. This was not amenable to treatment with IV analgesics....She developed fever. CT scan of her abdomen and pelvis demonstrated significant amount of free fluid and free air in the abdomen raising the concern for potential bowel injury. Unfortunately at this point, surgical services were not available......" The physician then documented that he contacted a physician at another hospital who agreed to accept the patient in transfer, and the patient was transferred for further care.

An interview was held with the hospital Chief Executive Officer (CEO), the Chief Nursing Officer (CNO) and the Risk Manager (RM) on two separate occasions, once on 4/29/10 and again on 5/17/10. During both interviews, the hospital administration stated that the physician who had initially treated patient 3 had medical problems and on the day of the transfer had not been able to perform surgery on patient 3. They also stated that the other surgeons were not available for various reasons. None of the administrative staff could explain why there had been no physician intervention for patient 3 from 10:30 AM on 3/18/10 to 9:40 PM when the physician was in and evaluated patient 3 and transferred her to another hospital.

Based on interview and record review, it was determined that the hospital surgical services were not provided for in such a manner to ensure the health and safety for one of ten sample patients. Patient Identifier: 3

Findings include:

Patient 3 presented to the hospital emergency department (ED) on 3/10/10 with complaints of nausea and abdominal pain. Patient 3 had a history of recurrent small bowel obstruction and bowel resection. Patient 3 was treated conservatively in the ED, and when she began feeling better, wanted to go home. Patient 3 was discharged to home and was told if her symptoms worsened to return to the ED.

On 3/11/10 at 10:56 AM, patient 3 returned to the ED with complaints of worsening symptoms including nausea and vomiting. The ED physician ordered laboratory tests and a CT (computed tomography) scan to determine if patient 3 had a small bowel obstruction.

The tests were completed and the ED physician reviewed all of the results. Upon review of all the test results, the ED physician determined that patient 3 had a bowel obstruction.

There was no surgical coverage in the ED that day, so the ED physician contacted a physician at the hospital's main campus, but that physician was unable to care for patient 3. The ED physician paged another of the hospital's surgeons and reviewed the case with him. The surgeon went to the ED and evaluated patient 3 at 3:47 PM. The surgeon arranged to admit patient 3 to the hospital. The surgeon wrote orders for patient 3 to have a nasogastric tube placed, and ordered intravenous fluids to be given. The surgeon talked with patient 3 and her spouse about the course of treatment, and it was determined that patient 3 should have surgery to relieve the obstruction. Patient 3 agreed to the treatment.

The surgeon obtained consent from patient 3 to perform laparoscopic lysis of adhesions and probable open bowel resection.

Patient 3 was taken to surgery on 3/12/10 at 4:40 PM. The surgeon performed a laparoscopic enterolysis. At 8:00 PM, patient 3 was returned to the medical/surgical floor.

The following is documentation from patient 3's medical record:

The surgeon documented on 3/14/10 at 3:20 PM, that patient 3 felt rumblings but had not had any flatus or bowel movement. He documented that her pain was better, she had decreased tenderness in her abdomen, but was still distended and bowel sounds were present in all four quadrants. He also documented that she had a slight temperature.

On 3/14/10 at 9:40 PM, patient 3's temperature elevated to 101 degrees, and the nurse obtained an order for Tylenol. Patient 3's pulse was documented as being 118.

On 3/15/10 at 1:00 PM, patient 3 requested her temperature be taken, she felt like she had a temperature and wanted it taken. The temperature was documented as being 99.6.

On 3/15/10 at 4:15 PM, the surgeon ordered a full liquid diet for patient 3, to discontinue the intravenous fluids, and to encourage patient 3 to ambulate as much as possible. He also ordered to have a complete blood count done on 3/16/10.

On 3/15/10 at 5:00 PM, the surgeon documented that patient 3 was better, was passing gas, and had 2 bowel movements, was afebrile and normotensive. He documented that her abdomen was still distended but improved. The surgeon documented to check patient 3's white count in the morning, and if normal and she continued to tolerate full liquids, she could go home.

On 3/16/10 at 12:00 PM, the surgeon documented that patient 3's temperature was 99.6, and her heart rate was 90 to 100's. He documented that she had decreased distension, decreased pain, with positive bowel sounds. He documented that patient 3 reported having a bowel movement the night before. He documented that patient 3 still had cramps but was improving. The surgeon wrote an order for Valium 5 milligrams (MG) at bedtime for insomnia and could repeat in one hour. He also ordered Percocet for pain.

On 3/16/10 at 2:30 PM, patient 3's temperature was documented as being 100, her pulse was 120, and her blood pressure was 150/87.

At 3:30 PM on 3/16/10, a verbal order was obtained for Valium 2.5 MG intervenously (IV) now and to repeat in 40 minutes if still having muscle spasms.

On 3/16/10 at 10:00 PM, patient 3's pulse was documented as being 125.

On 3/17/10 at 8:59 AM, a nurse documented that there was occasional flatus in all quadrants.

On 3/17/10 at 1:30 PM, patient 3's pulse was documented to be 116 and her blood pressure was 158/89.

The surgeon documented at 4:15 PM on 3/17/10, that patient 3 was still bloated, was not nauseated, but not taking much orally and was uncomfortable. He documented that her temperature was 100, her white cell count was 9, her abdomen was distended, had decreased tenderness, and few bowel sounds. He documented that he suspected a post operative ileus. The surgeon wrote an order for a CT scan to be done in the morning with contrast. He also ordered IV fluids to be restarted, blood work in the morning, dulcolax suppository now and every 6 hours, and to change the diet to clear liquids.

A nurse documented on 3/17/10 at 4:54 PM, that the physician had been in to see the patient and and had called back later and ordered abdominal xrays 2 views, and the patient was informed.

On 3/17/10 at 5:28 PM, a nurse documented that patient 3 was experiencing constant pain in her left quadrant.

The abdominal xrays were done at 6:30 PM on 3/17/10. The results indicated that there were multiple gas-filled loops of large and small bowel. The radiologist documented that the bowel gas pattern was abnormal and suggested an ileus. The radiologist also documented that the xray showed a left pleural effusion.

On 3/17/10 at 7:30 PM, a nurse documented that the physician was notified of the increase in pain and distension and the absence of bowel sounds.

On 3/17/10 at 7:30 PM, a verbal order was obtained for Valium 2.5 MG IV every 6 hours as needed.

Patient 3's pulse and blood pressure on 3/17/10 at 9:00 PM was 132 and 140/80, and her oxygen saturation was documented to be 84% on room air.

On 3/17/10 at 9:40 PM, a nurse documented that another physician (on call physician/surgeon) was notified of patient 3's complaints of, "severe abd (abdominal) pain; absent bowel sounds; firm & (and) distended abd.(abdomen) Tachycardia, elevated BP (blood pressure); desats on room air 84%; pt (patient ) now on 4L/NC (nasal cannula) =92% SPO2; pain meds given."

At 9:40 PM, a verbal order was obtained from that physician for patient 3 to have nothing by mouth, a complete blood count and comprehensive metabolic panel stat (now), a portable chest xray stat, acute abdominal series xray in the morning, Morphine 1 to 5 MG IV every hour as needed for pain, and a nasogastric tube to low intermittent suction it patient 3 wanted it.

At 9:45 PM a nurse documented that patient 3 was informed of the physician orders and patient 3 agreed to the nasogastric tube, which was inserted and connected to low intermittent suction.

The stat blood work and chest xray was completed and showed that patient 3's white blood cell count was 12.8, and that the lung volumes were quite low.

At 11:45 PM, a nurse documented that the physician was notified of the chest xray results, the nasogastric tube output, the complete blood count, and the comprehensive metabolic panel, and patient 3's current vital signs. The nurse documented that the physician's response was to do both xrays, the abdominal series and the CT abdominal scan the next day.

Patient 3's pulse and blood pressure at 10:00 PM was 128 and 157/89.

Patient 3's pulse and blood pressure at 11:30 PM was 122 and 151/100.

Patient 3's pulse and blood pressure on 3/18/10 at 12:30 AM was 120 and 164/76.

Patient 3's pulse and blood pressure at 2:00 AM was 129 and 152/78.

Patient 3's pulse at 5:00 AM was 132 and her oxygen saturation (O2 Sat) was 88 on 4 liters of oxygen.

Patient 3's pulse at 5:25 AM was 132, blood pressure was 158/95 and O2 sat was 90% on 5 liters of oxygen.

The nurses documented that they were frequently monitoring patient 3's pain and were medicating her as needed through the night.

On 3/18/10 at 9:07 AM, a nurse documented that patient 3 was sent to xray.

At 9:27 AM, a nurse documented that patient 3 was not feeling well and was medicated for pain. The tests were pending.

On 3/18/10 at 10:30 AM. a verbal order was written by a nurse for Zosyn 4.5 grams IV every 8 hours, Dilaudid 0.5 mg to 1 mg IV every hour as needed , to discontinue the Morphine and to give nothing by mouth.

At 10:30 AM, the radiologist documented that the CT of the abdomen and pelvis done with contrast revealed that, "Findings were consistent with perforated viscus with large volume of free air and free fluid throughout the abdomen and pelvis as well multiple interloop collections. I discussed these findings with the nurse caring for the patient of examination, nurse contacting the referring surgeon."

At 10:33 AM, a nurse documented, "returned from radiology, informed m.d of rad results (free fluid and air with likely perf bowel.) abx {antibiotic} ordered and pain med changed. will discuss plans with pt."

At 1:58 PM, patient 3's pulse and blood pressure were 122 and 154/96. Her O2 sat was 92% on 5 liters of oxygen.

There is no other documentation in patient 3's medical record by a physician or that the nurses had any communication with a physician until 6:15 PM.

On 3/18/10 at 6:13 PM, a nurse documented, "paged md earlier to inform of bp and pulse with no answer. Called again around 1800 (6:00 PM) with no return call yet, will monitor."

At 7:00 PM a nurse documented, "attempted to call home phone of [md] but the number was disconnected. informed house sup (supervisor) that i have been unable to get a hold of m.d. she stated that she would follow up."

At 8:05 PM a nurse documented, "Assessment done per charting; pt drowsy, awakens with voice. state her pain is at 2/10. increases with cough or movement, still waiting on md to return call. earlier nurse left him a message. will cont to monitor pt."

At 8:15 PM a nurse documented, "[MD] called and stated that he would be in to see pt in about 30 min. discussed bp and pulse and increased drowsyness (sic) over the last few hours. no orders indicated will await his arrival and assessment of patient".

At 8:36 PM a nurse documented, "pain managed with iv meds. abx as ordered, bp still elevated hr (heart rate) still tachy. md is aware reported off to night nurse."

At 9:40 PM, the physician documented in patient 3's medical record, "Pt feels worse today no nausea, but pain has increased/no gas/flatus today...............ABD distended, tender, +rebound - BS (bowel sounds) ext. (extremities) +1 edema .................CT:abd/pelvis multiple areas of fluid/ free air in abdomen consistent with perforated viscus....".

On 3/18/10, a verbal order was written by a nurse to transfer patient 3 to another hospital. The order was not timed.

The physician completed a transfer form on which was documented that the transfer was initiated at 9:30 PM and the receiving hospital had agreed to accept patient 3 and named the physician that had accepted the responsibility for patient 3. Patient 3's spouse signed the consent for transfer.

A nurse documented at 11:25 PM that report was called to a nurse at the receiving hospital. The nurse documented that they were waiting for the ambulance for transport. The nurse documented that the family was aware of the transfer and that the physician had spoken to the spouse and the daughter about the transfer.

At 11:40 PM, a nurse documented that patient 3 was transferred to the receiving hospital.

On the physician discharge summary, the physician/surgeon documented, "Her condition began to decline with worsening abdominal pain. This was not amenable to treatment with IV analgesics....She developed fever. CT scan of her abdomen and pelvis demonstrated significant amount of free fluid and free air in the abdomen raising the concern for potential bowel injury. Unfortunately at this point, surgical services were not available......" The physician then documented that he contacted a physician at another hospital who agreed to accept the patient in transfer, and the patient was transferred for further care.

An interview was held with the hospital Chief Executive Officer (CEO), on 4/29/10. The CEO stated that the surgeon that had performed the surgery on patient 3, had recently returned to work after having been off for 6 weeks due to a neck injury that had required surgery. The CEO stated that the surgeon had been cleared to return to work by his surgeon. The CEO stated that the surgeon had reported the incident that occurred on 3/18/10 with patient 3 to him. The CEO stated that the surgeon had indicated that he had had a lot of pain that day and had taken medication, and determined that he should not perform surgery on patient 3.

Interviews were held with the CEO, the Chief Nursing Officer (CNO) and the Risk Manager (RM) on two separate occasions, once on 4/29/10 and again on 5/17/10. During both interviews, the hospital administration stated that the physician who had initially treated patient 3 had medical problems, and on the day of the transfer, had not been able to perform surgery on patient 3. They also stated that the other surgeons were not available for various reasons. None of the administrative staff could explain why there had been no physician intervention for patient 3 from 10:30 AM to 9:40 PM on 3/18/10, when the physician was in and evaluated patient 3 and transferred her to another hospital.

The receiving hospital surgeon documented on the operative report the following:

"The patient is a 43-year-old female who underwent a laparoscopic lysis of adhesions approximately 1 week ago at [hospital] for a recurrent small bowel obstruction. She has had several small bowel obstructions in the past requiring a laparotomy on 2 separate occasions. She was doing well until 3 days ago when she developed increasing abdominal pain, distention, and tachycardia. She underwent a CT scan of the abdomen and pelvis which showed a large amount of fluid within the abdomen with free intraperitoneal air suggesting a possible small bowel injury. The surgeon who did her initial operation 1 week ago at [hospital] could not operate on her due to a recent neck surgery, and his partners refused to help. She was, therefore, transferred to [hospital] for further management. She will now undergo an emergent exploratory laparotomy for probable small bowel perforation."

"Upon entering the abdomen, a massive amount of succus was encountered under pressure. A geyser of succus shot up through the incision when the peritoneum was entered. A total of 2 liters of small bowel succus was aspirated from the abdominal cavity. An inflammatory rind was present covering the majority of the loops of small bowel indicating a element of chronicity...The perforation was not readily visible due to the inflammatory rind covering the majority of the small bowel. After a complete abdominal exploration, a 5-mm hole was present in the small bowel on the left side of the abdomen adjacent to one of the previous laparoscopic trocar sites. It could not be determined in which part of the small bowel the perforation was located since a major portion of the small bowel remained adhesed together. Frank peritonitis was present. Succus was present in every quadrant of the abdominal cavity."