Malpractice Counsel: Necrotizing fasciitis, corneal abrasion

 

A Pain in the Butt

A 75-year-old man presented to the ED complaining of low back pain radiating to his right buttock and leg. There was no history of trauma or overuse. His medical history was significant for hypertension and benign prostatic hypertrophy. Regarding social history, the patient stated that he had quit smoking 20 years prior and only drank alcohol on occasion. He denied any medication allergies.

On physical examination, the patient’s vital signs were: pulse 98 beats/minute; blood pressure, 132/82 mm Hg; respiratory rate, 18 breaths/minute; and temperature, 99.8°F. The head, eyes, ears, nose, and throat examination, and pulmonary, cardiovascular, and abdominal examinations were all normal. On examination of the lower back, the patient exhibited mild tenderness of the right paraspinal lumbar muscles without midline tenderness. He had normal and equal strength of the lower extremities bilaterally. The patient’s buttocks were not examined during this visit.

The emergency physician (EP) felt the patient’s history and physical examination were consistent with a lumbar radiculopathy, and contacted the patient’s primary care physician (PCP) to communicate his impression. Although the PCP was aware that his patient had recently complained of chills, night sweats, and pain radiating from the hip to the anus, he did not communicate this information to the EP. Unfortunately, the patient also did not relate these complaints to the EP. After the EP’s consultation with the PCP, the patient was prescribed an analgesic, referred to an orthopedic surgeon, and discharged home.

Two days later, the patient returned to the same ED via emergency medical services, this time with altered mental status, fever, and hypotension. He was found to have necrotizing fasciitis of the right buttock. The patient received intravenous fluid resuscitation and broad-spectrum antibiotics, and was taken immediately to the operating room. Unfortunately, he did not survive.

The patient’s estate sued the first EP for failure to visualize and palpate the buttocks area and for failure to diagnose an infection of the right buttocks. The plaintiff further argued that the patient would have survived if he had been properly diagnosed and treated at the initial ED visit. The defense argued the patient received a thorough history and physical examination and that the diagnosis of lumbar radiculopathy was consistent with the patient’s clinical presentation. The defense also argued that the patient never reported any complaints or indication of a buttock infection. The case was settled prior to trial for nearly $600,000.

Discussion

This case illustrates two important points: communication and examination of the area of primary complaint. Regarding the first point, the importance of effective communication between healthcare workers cannot be stressed enough. Had the PCP informed the EP of the patient’s additional complaints of chills, night sweats, and pain radiating to the anus, in all likelihood the EP would have reconsidered his initial clinical impression, asked additional questions, and examined the patient more thoroughly. In turn, the chance of making the correct diagnosis would have improved considerably. Unfortunately, this did not happen. Miscommunication or lack of communication between physician-patient and physician-physician are frequent sources of error in medical malpractice cases. In one review by Kachalia et al¹ of 122 closed malpractice claims from four liability insurers involving ED patients, communication factors accounted for 35% of the diagnostic errors made. This emphasizes the importance of good communication skills—not just on the part of the treating physician, nurse, or consultant, but also the patient as well.

The second important point, examining the area of primary complaint, may sound simple, straightforward, and just plain common sense. However, this can be very challenging in the reality of today’s practice of emergency medicine as EPs are often called upon to perform entire histories and physical examinations on patients in hallway beds. Gone are the days when every patient was undressed and placed in a gown in a private area or room. With the emphasis on maintaining patients with relatively minor complaints “vertical” to improve throughput times, the EP is frequently forced to examine such patients fully clothed. This places the EP at high risk for misdiagnosis or a missed diagnosis. In the same study by Kachalia et al,¹ failure to perform an adequate medical history or physical examination accounted for 42% of all diagnostic errors in the ED. Recognizing the challenge of examining the point of complaint is easy—solving the issue, however, will take all of a hospital’s resources.

  

 

Stealing Is Bad for Your Health

A 19-year-old man presented to the ED complaining of left eye pain, foreign body sensation, and tearing. He stated that when he was cleaning his garage approximately 3 hours prior to presentation, a cardboard box had fallen on his head, scattering its contents. Immediately after this occurrence, the patient experienced onset of a foreign body sensation and pain in his left eye. He further noted that he had attempted to irrigate his left eye with tap water, but it did not relieve the pain. After several hours of discomfort, the patient decided to come to the ED. He denied any other injuries or complaints, was in good health, on no medications, and had no known medication allergies. He also denied wearing contacts or corrective lenses.

 

On physical examination, the patient’s left eye was closed, and he appeared to be somewhat uncomfortable. His vital signs were all normal. His visual acuity was 20/20 in the right eye and 20/60 in the left eye, which was due to tearing and blurriness from the injury. To facilitate the examination, the EP placed two drops of proparacaine hydrochloride ophthalmic solution 0.5% in both of the patient’s eyes, which provided immediate and near total relief of the left eye pain. On fluorescein and slit-lamp examination, the EP found a small foreign body at approximately the seven o’clock position on the cornea, as well as a surrounding abrasion. The corneal anterior chamber was normal. The EP removed the foreign body, prescribed a topical ophthalmic antibiotic cream. and instructed the patient to return to the ED in 24 hours for a recheck. The EP also instructed the patient to take ibuprofen for any associated pain.

While waiting to be discharged, the patient took the vial of proparacaine that had been left on the counter in the room. He did so without informing anyone and without permission. After the nurse returned to the room and gave the patient his discharge instructions, he was released home. Neither the nurse nor the physician realized the patient had stolen the topical anesthetic.

Four days later, the patient presented back to the same ED with severe pain and decreased vision in his left eye. On examination, he was noted to have a large, deep corneal ulceration. Upon further questioning, the patient admitted to taking the proparacaine drops and using them nearly every waking hour to treat his eye pain. Before the patient was referred to ophthalmology services for emergency evaluation, the EP instructed him stop using the proparacaine drops and explained to him that his symptoms were directly related to his abuse of the medication.

The patient sued the EP for leaving the “miracle” pain-relief medication in the room and thereby facilitating his actions. The plaintiff argued that the immediate and complete pain-relief effects of the medication were too tempting for a nonmedical person to resist, and that the drug should not have been made available to him under any circumstance. The EP argued the patient stole the medication and that any resulting injury was completely the result of the patient’s own actions. The suit was eventually dropped.

Discussion

It is unfortunate that this ever became a malpractice case, since it is clear to any layman that the stealing of medications is inappropriate and illegal; moreover, any damages resulting from that action are completely the responsibility of the transgressor. With that said, a significant amount of time, discomfort, and inconvenience could have been avoided had the nurse or physician simply removed the medication from the room. While I certainly do not think this is required from a medical-legal standpoint, it is a good common-sense practice.

Corneal abrasions and corneal foreign bodies are very uncomfortable, and medications such as nonsteroidal anti-inflammatory drugs or acetaminophen only provide partial pain relief. It is easy to see how a young person, lacking any medical knowledge or the concepts of adverse side effects or toxicity, would be tempted in such a situation. In retrospect, it would probably have been best to have avoided leaving the medication within the patient’s reach in the first place.

With respect to evaluating and treating corneal abrasions, the most commonly used topical ophthalmic anesthetics are proparacaine and tetracaine. When used appropriately and in the hands of trained healthcare workers, these drugs are safe, effective, and exhibit nearly no side effects. However, as this case demonstrates, these drugs can be toxic when abused. The most common toxicities are to the ocular surface and include superficial punctate keratitis, persistent epithelial defects, stromal infiltrates, and corneal edema. More serious injuries can also occur, such as deep corneal infiltrates, ulceration, and eye perforation.¹ The toxic effects associated with these drugs are the reason these medications are never prescribed for home use.

 

A Pain in the Butt

A 75-year-old man presented to the ED complaining of low back pain radiating to his right buttock and leg. There was no history of trauma or overuse. His medical history was significant for hypertension and benign prostatic hypertrophy. Regarding social history, the patient stated that he had quit smoking 20 years prior and only drank alcohol on occasion. He denied any medication allergies.

On physical examination, the patient’s vital signs were: pulse 98 beats/minute; blood pressure, 132/82 mm Hg; respiratory rate, 18 breaths/minute; and temperature, 99.8°F. The head, eyes, ears, nose, and throat examination, and pulmonary, cardiovascular, and abdominal examinations were all normal. On examination of the lower back, the patient exhibited mild tenderness of the right paraspinal lumbar muscles without midline tenderness. He had normal and equal strength of the lower extremities bilaterally. The patient’s buttocks were not examined during this visit.

The emergency physician (EP) felt the patient’s history and physical examination were consistent with a lumbar radiculopathy, and contacted the patient’s primary care physician (PCP) to communicate his impression. Although the PCP was aware that his patient had recently complained of chills, night sweats, and pain radiating from the hip to the anus, he did not communicate this information to the EP. Unfortunately, the patient also did not relate these complaints to the EP. After the EP’s consultation with the PCP, the patient was prescribed an analgesic, referred to an orthopedic surgeon, and discharged home.

Two days later, the patient returned to the same ED via emergency medical services, this time with altered mental status, fever, and hypotension. He was found to have necrotizing fasciitis of the right buttock. The patient received intravenous fluid resuscitation and broad-spectrum antibiotics, and was taken immediately to the operating room. Unfortunately, he did not survive.

The patient’s estate sued the first EP for failure to visualize and palpate the buttocks area and for failure to diagnose an infection of the right buttocks. The plaintiff further argued that the patient would have survived if he had been properly diagnosed and treated at the initial ED visit. The defense argued the patient received a thorough history and physical examination and that the diagnosis of lumbar radiculopathy was consistent with the patient’s clinical presentation. The defense also argued that the patient never reported any complaints or indication of a buttock infection. The case was settled prior to trial for nearly $600,000.

Discussion

This case illustrates two important points: communication and examination of the area of primary complaint. Regarding the first point, the importance of effective communication between healthcare workers cannot be stressed enough. Had the PCP informed the EP of the patient’s additional complaints of chills, night sweats, and pain radiating to the anus, in all likelihood the EP would have reconsidered his initial clinical impression, asked additional questions, and examined the patient more thoroughly. In turn, the chance of making the correct diagnosis would have improved considerably. Unfortunately, this did not happen. Miscommunication or lack of communication between physician-patient and physician-physician are frequent sources of error in medical malpractice cases. In one review by Kachalia et al¹ of 122 closed malpractice claims from four liability insurers involving ED patients, communication factors accounted for 35% of the diagnostic errors made. This emphasizes the importance of good communication skills—not just on the part of the treating physician, nurse, or consultant, but also the patient as well.

The second important point, examining the area of primary complaint, may sound simple, straightforward, and just plain common sense. However, this can be very challenging in the reality of today’s practice of emergency medicine as EPs are often called upon to perform entire histories and physical examinations on patients in hallway beds. Gone are the days when every patient was undressed and placed in a gown in a private area or room. With the emphasis on maintaining patients with relatively minor complaints “vertical” to improve throughput times, the EP is frequently forced to examine such patients fully clothed. This places the EP at high risk for misdiagnosis or a missed diagnosis. In the same study by Kachalia et al,¹ failure to perform an adequate medical history or physical examination accounted for 42% of all diagnostic errors in the ED. Recognizing the challenge of examining the point of complaint is easy—solving the issue, however, will take all of a hospital’s resources.

  

 

Stealing Is Bad for Your Health

A 19-year-old man presented to the ED complaining of left eye pain, foreign body sensation, and tearing. He stated that when he was cleaning his garage approximately 3 hours prior to presentation, a cardboard box had fallen on his head, scattering its contents. Immediately after this occurrence, the patient experienced onset of a foreign body sensation and pain in his left eye. He further noted that he had attempted to irrigate his left eye with tap water, but it did not relieve the pain. After several hours of discomfort, the patient decided to come to the ED. He denied any other injuries or complaints, was in good health, on no medications, and had no known medication allergies. He also denied wearing contacts or corrective lenses.

 

On physical examination, the patient’s left eye was closed, and he appeared to be somewhat uncomfortable. His vital signs were all normal. His visual acuity was 20/20 in the right eye and 20/60 in the left eye, which was due to tearing and blurriness from the injury. To facilitate the examination, the EP placed two drops of proparacaine hydrochloride ophthalmic solution 0.5% in both of the patient’s eyes, which provided immediate and near total relief of the left eye pain. On fluorescein and slit-lamp examination, the EP found a small foreign body at approximately the seven o’clock position on the cornea, as well as a surrounding abrasion. The corneal anterior chamber was normal. The EP removed the foreign body, prescribed a topical ophthalmic antibiotic cream. and instructed the patient to return to the ED in 24 hours for a recheck. The EP also instructed the patient to take ibuprofen for any associated pain.

While waiting to be discharged, the patient took the vial of proparacaine that had been left on the counter in the room. He did so without informing anyone and without permission. After the nurse returned to the room and gave the patient his discharge instructions, he was released home. Neither the nurse nor the physician realized the patient had stolen the topical anesthetic.

Four days later, the patient presented back to the same ED with severe pain and decreased vision in his left eye. On examination, he was noted to have a large, deep corneal ulceration. Upon further questioning, the patient admitted to taking the proparacaine drops and using them nearly every waking hour to treat his eye pain. Before the patient was referred to ophthalmology services for emergency evaluation, the EP instructed him stop using the proparacaine drops and explained to him that his symptoms were directly related to his abuse of the medication.

The patient sued the EP for leaving the “miracle” pain-relief medication in the room and thereby facilitating his actions. The plaintiff argued that the immediate and complete pain-relief effects of the medication were too tempting for a nonmedical person to resist, and that the drug should not have been made available to him under any circumstance. The EP argued the patient stole the medication and that any resulting injury was completely the result of the patient’s own actions. The suit was eventually dropped.

Discussion

It is unfortunate that this ever became a malpractice case, since it is clear to any layman that the stealing of medications is inappropriate and illegal; moreover, any damages resulting from that action are completely the responsibility of the transgressor. With that said, a significant amount of time, discomfort, and inconvenience could have been avoided had the nurse or physician simply removed the medication from the room. While I certainly do not think this is required from a medical-legal standpoint, it is a good common-sense practice.

Corneal abrasions and corneal foreign bodies are very uncomfortable, and medications such as nonsteroidal anti-inflammatory drugs or acetaminophen only provide partial pain relief. It is easy to see how a young person, lacking any medical knowledge or the concepts of adverse side effects or toxicity, would be tempted in such a situation. In retrospect, it would probably have been best to have avoided leaving the medication within the patient’s reach in the first place.

With respect to evaluating and treating corneal abrasions, the most commonly used topical ophthalmic anesthetics are proparacaine and tetracaine. When used appropriately and in the hands of trained healthcare workers, these drugs are safe, effective, and exhibit nearly no side effects. However, as this case demonstrates, these drugs can be toxic when abused. The most common toxicities are to the ocular surface and include superficial punctate keratitis, persistent epithelial defects, stromal infiltrates, and corneal edema. More serious injuries can also occur, such as deep corneal infiltrates, ulceration, and eye perforation.¹ The toxic effects associated with these drugs are the reason these medications are never prescribed for home use.

 

A Pain in the Butt

A 75-year-old man presented to the ED complaining of low back pain radiating to his right buttock and leg. There was no history of trauma or overuse. His medical history was significant for hypertension and benign prostatic hypertrophy. Regarding social history, the patient stated that he had quit smoking 20 years prior and only drank alcohol on occasion. He denied any medication allergies.

On physical examination, the patient’s vital signs were: pulse 98 beats/minute; blood pressure, 132/82 mm Hg; respiratory rate, 18 breaths/minute; and temperature, 99.8°F. The head, eyes, ears, nose, and throat examination, and pulmonary, cardiovascular, and abdominal examinations were all normal. On examination of the lower back, the patient exhibited mild tenderness of the right paraspinal lumbar muscles without midline tenderness. He had normal and equal strength of the lower extremities bilaterally. The patient’s buttocks were not examined during this visit.

The emergency physician (EP) felt the patient’s history and physical examination were consistent with a lumbar radiculopathy, and contacted the patient’s primary care physician (PCP) to communicate his impression. Although the PCP was aware that his patient had recently complained of chills, night sweats, and pain radiating from the hip to the anus, he did not communicate this information to the EP. Unfortunately, the patient also did not relate these complaints to the EP. After the EP’s consultation with the PCP, the patient was prescribed an analgesic, referred to an orthopedic surgeon, and discharged home.

Two days later, the patient returned to the same ED via emergency medical services, this time with altered mental status, fever, and hypotension. He was found to have necrotizing fasciitis of the right buttock. The patient received intravenous fluid resuscitation and broad-spectrum antibiotics, and was taken immediately to the operating room. Unfortunately, he did not survive.

The patient’s estate sued the first EP for failure to visualize and palpate the buttocks area and for failure to diagnose an infection of the right buttocks. The plaintiff further argued that the patient would have survived if he had been properly diagnosed and treated at the initial ED visit. The defense argued the patient received a thorough history and physical examination and that the diagnosis of lumbar radiculopathy was consistent with the patient’s clinical presentation. The defense also argued that the patient never reported any complaints or indication of a buttock infection. The case was settled prior to trial for nearly $600,000.

Discussion

This case illustrates two important points: communication and examination of the area of primary complaint. Regarding the first point, the importance of effective communication between healthcare workers cannot be stressed enough. Had the PCP informed the EP of the patient’s additional complaints of chills, night sweats, and pain radiating to the anus, in all likelihood the EP would have reconsidered his initial clinical impression, asked additional questions, and examined the patient more thoroughly. In turn, the chance of making the correct diagnosis would have improved considerably. Unfortunately, this did not happen. Miscommunication or lack of communication between physician-patient and physician-physician are frequent sources of error in medical malpractice cases. In one review by Kachalia et al¹ of 122 closed malpractice claims from four liability insurers involving ED patients, communication factors accounted for 35% of the diagnostic errors made. This emphasizes the importance of good communication skills—not just on the part of the treating physician, nurse, or consultant, but also the patient as well.

The second important point, examining the area of primary complaint, may sound simple, straightforward, and just plain common sense. However, this can be very challenging in the reality of today’s practice of emergency medicine as EPs are often called upon to perform entire histories and physical examinations on patients in hallway beds. Gone are the days when every patient was undressed and placed in a gown in a private area or room. With the emphasis on maintaining patients with relatively minor complaints “vertical” to improve throughput times, the EP is frequently forced to examine such patients fully clothed. This places the EP at high risk for misdiagnosis or a missed diagnosis. In the same study by Kachalia et al,¹ failure to perform an adequate medical history or physical examination accounted for 42% of all diagnostic errors in the ED. Recognizing the challenge of examining the point of complaint is easy—solving the issue, however, will take all of a hospital’s resources.

  

 

Stealing Is Bad for Your Health

A 19-year-old man presented to the ED complaining of left eye pain, foreign body sensation, and tearing. He stated that when he was cleaning his garage approximately 3 hours prior to presentation, a cardboard box had fallen on his head, scattering its contents. Immediately after this occurrence, the patient experienced onset of a foreign body sensation and pain in his left eye. He further noted that he had attempted to irrigate his left eye with tap water, but it did not relieve the pain. After several hours of discomfort, the patient decided to come to the ED. He denied any other injuries or complaints, was in good health, on no medications, and had no known medication allergies. He also denied wearing contacts or corrective lenses.

 

On physical examination, the patient’s left eye was closed, and he appeared to be somewhat uncomfortable. His vital signs were all normal. His visual acuity was 20/20 in the right eye and 20/60 in the left eye, which was due to tearing and blurriness from the injury. To facilitate the examination, the EP placed two drops of proparacaine hydrochloride ophthalmic solution 0.5% in both of the patient’s eyes, which provided immediate and near total relief of the left eye pain. On fluorescein and slit-lamp examination, the EP found a small foreign body at approximately the seven o’clock position on the cornea, as well as a surrounding abrasion. The corneal anterior chamber was normal. The EP removed the foreign body, prescribed a topical ophthalmic antibiotic cream. and instructed the patient to return to the ED in 24 hours for a recheck. The EP also instructed the patient to take ibuprofen for any associated pain.

While waiting to be discharged, the patient took the vial of proparacaine that had been left on the counter in the room. He did so without informing anyone and without permission. After the nurse returned to the room and gave the patient his discharge instructions, he was released home. Neither the nurse nor the physician realized the patient had stolen the topical anesthetic.

Four days later, the patient presented back to the same ED with severe pain and decreased vision in his left eye. On examination, he was noted to have a large, deep corneal ulceration. Upon further questioning, the patient admitted to taking the proparacaine drops and using them nearly every waking hour to treat his eye pain. Before the patient was referred to ophthalmology services for emergency evaluation, the EP instructed him stop using the proparacaine drops and explained to him that his symptoms were directly related to his abuse of the medication.

The patient sued the EP for leaving the “miracle” pain-relief medication in the room and thereby facilitating his actions. The plaintiff argued that the immediate and complete pain-relief effects of the medication were too tempting for a nonmedical person to resist, and that the drug should not have been made available to him under any circumstance. The EP argued the patient stole the medication and that any resulting injury was completely the result of the patient’s own actions. The suit was eventually dropped.

Discussion

It is unfortunate that this ever became a malpractice case, since it is clear to any layman that the stealing of medications is inappropriate and illegal; moreover, any damages resulting from that action are completely the responsibility of the transgressor. With that said, a significant amount of time, discomfort, and inconvenience could have been avoided had the nurse or physician simply removed the medication from the room. While I certainly do not think this is required from a medical-legal standpoint, it is a good common-sense practice.

Corneal abrasions and corneal foreign bodies are very uncomfortable, and medications such as nonsteroidal anti-inflammatory drugs or acetaminophen only provide partial pain relief. It is easy to see how a young person, lacking any medical knowledge or the concepts of adverse side effects or toxicity, would be tempted in such a situation. In retrospect, it would probably have been best to have avoided leaving the medication within the patient’s reach in the first place.

With respect to evaluating and treating corneal abrasions, the most commonly used topical ophthalmic anesthetics are proparacaine and tetracaine. When used appropriately and in the hands of trained healthcare workers, these drugs are safe, effective, and exhibit nearly no side effects. However, as this case demonstrates, these drugs can be toxic when abused. The most common toxicities are to the ocular surface and include superficial punctate keratitis, persistent epithelial defects, stromal infiltrates, and corneal edema. More serious injuries can also occur, such as deep corneal infiltrates, ulceration, and eye perforation.¹ The toxic effects associated with these drugs are the reason these medications are never prescribed for home use.