A painful result

The story

ET was a 40-year-old married woman and local news reporter when she presented to her local emergency department (ED) complaining of right thigh pain. ET was also a triathlete and worked out vigorously at the gym every afternoon. Her workout that day consisted of squats and other lower-leg exercises, but was otherwise uneventful. After dinner that night, she began to experience anterolateral, burning pain in her right thigh that was unresponsive to ibuprofen. Her ED evaluation was essentially normal and she was discharged with a diagnosis of muscle strain/tear with possible hematoma. ET returned to the ED at 9:30 the next morning. She was walking with difficulty and in severe 10/10 pain. She was tachycardic and her thigh was noted to be mildly swollen and severely tender on palpation. A CT scan of her right thigh was performed.

"Small amount of fluid tracking along lateral aspect of vastus lateralis muscle. Mild decreased attenuation in the distal portion of the muscle itself. Findings may suggest muscle bundle tear and adjacent hematoma. Inflammatory/infectious process cannot be entirely excluded."

Following the CT results, she was rocking and crying in bed from the pain. The ED physician called Dr. Hospitalist, who admitted ET for intravenous pain control.

ET received multiple doses of intravenous hydromorphone overnight and was intermittently sleeping and crying awake because of severe pain. Vitals that morning showed ET to be afebrile, but tachycardic and hypotensive (BP = 85/50 mm Hg). The exam of the thigh was generally unchanged. The impression remained right muscle tear with hypotension as a result of intravenous hydromorphone. Later that morning, a CBC showed a WBC 14.0 K/mcL with 68% bands. Dr. Hospitalist eventually ordered intravenous fluid boluses, intravenous clindamycin, and an anesthesia consult for patient-controlled analgesia. By late afternoon, ET had refractory hypotension and was sent to the ICU for pressor support. Ultrasound found no evidence for DVT [deep vein thrombosis] in her thigh but a CK [creatine kinase] level was more than 2,000 IU/L. A surgical consult was obtained and ET was subsequently transferred via life-flight to the nearest university hospital for fasciotomy and thigh debridement. Within 2 days of the transfer, ET had four surgeries, culminating in a right hip disarticulation for necrotizing fasciitis. She was ultimately hospitalized for 3 months. Today, she is wheelchair bound and divorced because of the effects her illness had on her marital relationship. She is unable to work and has suffered from severe depression because of the loss of her leg.

Complaint

ET and her husband immediately blamed Dr. Hospitalist and the care she received at the community hospital for a delayed diagnosis of necrotizing fasciitis. The husband, a PhD in physiology and nutrition and consultant with the NFL’s Carolina Panthers, was highly critical of the muscle tear diagnosis. He testified that he told the ED physician and Dr. Hospitalist that there was no way that his wife was in so much pain from a muscle tear. In addition, both ET and her husband testified that she suffered no injury at the gym that would account for a muscle tear/rupture in the first place. The complaint alleged that had the ED physician and Dr. Hospitalist made the correct diagnosis, ET would have undergone debridement without the need for amputation. The complaint further alleged that had the debridement occurred in a timely fashion, she would not have suffered from the protracted tertiary hospital stay and all the associated complications and medical bills.

Scientific principles

Necrotizing soft-tissue infections include necrotizing forms of cellulitis, myositis, and fasciitis. These infections are characterized clinically by fulminant tissue destruction, systemic signs of toxicity, and high mortality. Accurate diagnosis and appropriate treatment must include early surgical intervention and antibiotic therapy. It is important to consider necrotizing involvement of the muscle or fascia in the setting of fever, toxicity, soft-tissue involvement with severe pain (particularly if out of proportion to skin findings), crepitus, rapid progression of clinical manifestations, and elevated serum CK level. The diagnosis of necrotizing fasciitis is established surgically, with visualization of fascial planes and muscle tissue in the operating room.

Complaint rebuttal and discussion

The ED physician asserted that, although he was unsure what was going on with ET, he appropriately admitted her to Dr. Hospitalist for further management. ET was hemodynamically stable during her time in the ED, without signs of toxicity or fever. As a result, the ED physician could not be expected to make a diagnosis at that time or even involve surgery as this rare condition was still evolving. This opinion was echoed by multiple ED defense experts and the ED physician involved was subsequently dropped from this case. Dr. Hospitalist asserted that he was admitting ET for pain control and that the CT of the right thigh confirmed the most probable diagnosis was muscle tear with hematoma. Dr. Hospitalist asserted that he had no reason to suspect a rare diagnosis in this otherwise healthy woman. Regardless, Dr. Hospitalist argued that even had he considered necrotizing fasciitis at the time of admission, it was more likely than not going to be too late to prevent ET from losing her leg.

Plaintiff experts opined that Dr. Hospitalist should have ordered a CBC and blood cultures on admission as the CT report could not exclude an infectious process. Had a CBC been performed, it was probable that bandemia would have been present and systemic inflammatory response criteria would have been met (bandemia plus tachycardia). In addition, ET was complaining of severe pain out of proportion for exam findings, and this should have put necrotizing soft tissue infection in the differential diagnosis. The combination of systemic inflammatory response plus the severe pain would reasonably have led to a STAT surgical consult the day of admission with earlier debridement and leg-sparing surgery.

Conclusion

An individual hospitalist will admit hundreds of patients a year with routine and common problems. But admission for "pain control" is a red flag for an underlying disorder that has been missed by the ED evaluation. The diagnosis of necrotizing soft tissue infections requires a high level of suspicion. Patients that have new and persistent pain out of proportion to exam findings and in the face of high-dose opiate administration should lead to further investigation. Although ET survived, the outcome was considered catastrophic. A week before trial was to begin this case was settled on behalf of the plaintiff for an undisclosed amount.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reports having no relevant financial conflicts.

The story

ET was a 40-year-old married woman and local news reporter when she presented to her local emergency department (ED) complaining of right thigh pain. ET was also a triathlete and worked out vigorously at the gym every afternoon. Her workout that day consisted of squats and other lower-leg exercises, but was otherwise uneventful. After dinner that night, she began to experience anterolateral, burning pain in her right thigh that was unresponsive to ibuprofen. Her ED evaluation was essentially normal and she was discharged with a diagnosis of muscle strain/tear with possible hematoma. ET returned to the ED at 9:30 the next morning. She was walking with difficulty and in severe 10/10 pain. She was tachycardic and her thigh was noted to be mildly swollen and severely tender on palpation. A CT scan of her right thigh was performed.

"Small amount of fluid tracking along lateral aspect of vastus lateralis muscle. Mild decreased attenuation in the distal portion of the muscle itself. Findings may suggest muscle bundle tear and adjacent hematoma. Inflammatory/infectious process cannot be entirely excluded."

Following the CT results, she was rocking and crying in bed from the pain. The ED physician called Dr. Hospitalist, who admitted ET for intravenous pain control.

ET received multiple doses of intravenous hydromorphone overnight and was intermittently sleeping and crying awake because of severe pain. Vitals that morning showed ET to be afebrile, but tachycardic and hypotensive (BP = 85/50 mm Hg). The exam of the thigh was generally unchanged. The impression remained right muscle tear with hypotension as a result of intravenous hydromorphone. Later that morning, a CBC showed a WBC 14.0 K/mcL with 68% bands. Dr. Hospitalist eventually ordered intravenous fluid boluses, intravenous clindamycin, and an anesthesia consult for patient-controlled analgesia. By late afternoon, ET had refractory hypotension and was sent to the ICU for pressor support. Ultrasound found no evidence for DVT [deep vein thrombosis] in her thigh but a CK [creatine kinase] level was more than 2,000 IU/L. A surgical consult was obtained and ET was subsequently transferred via life-flight to the nearest university hospital for fasciotomy and thigh debridement. Within 2 days of the transfer, ET had four surgeries, culminating in a right hip disarticulation for necrotizing fasciitis. She was ultimately hospitalized for 3 months. Today, she is wheelchair bound and divorced because of the effects her illness had on her marital relationship. She is unable to work and has suffered from severe depression because of the loss of her leg.

Complaint

ET and her husband immediately blamed Dr. Hospitalist and the care she received at the community hospital for a delayed diagnosis of necrotizing fasciitis. The husband, a PhD in physiology and nutrition and consultant with the NFL’s Carolina Panthers, was highly critical of the muscle tear diagnosis. He testified that he told the ED physician and Dr. Hospitalist that there was no way that his wife was in so much pain from a muscle tear. In addition, both ET and her husband testified that she suffered no injury at the gym that would account for a muscle tear/rupture in the first place. The complaint alleged that had the ED physician and Dr. Hospitalist made the correct diagnosis, ET would have undergone debridement without the need for amputation. The complaint further alleged that had the debridement occurred in a timely fashion, she would not have suffered from the protracted tertiary hospital stay and all the associated complications and medical bills.

Scientific principles

Necrotizing soft-tissue infections include necrotizing forms of cellulitis, myositis, and fasciitis. These infections are characterized clinically by fulminant tissue destruction, systemic signs of toxicity, and high mortality. Accurate diagnosis and appropriate treatment must include early surgical intervention and antibiotic therapy. It is important to consider necrotizing involvement of the muscle or fascia in the setting of fever, toxicity, soft-tissue involvement with severe pain (particularly if out of proportion to skin findings), crepitus, rapid progression of clinical manifestations, and elevated serum CK level. The diagnosis of necrotizing fasciitis is established surgically, with visualization of fascial planes and muscle tissue in the operating room.

Complaint rebuttal and discussion

The ED physician asserted that, although he was unsure what was going on with ET, he appropriately admitted her to Dr. Hospitalist for further management. ET was hemodynamically stable during her time in the ED, without signs of toxicity or fever. As a result, the ED physician could not be expected to make a diagnosis at that time or even involve surgery as this rare condition was still evolving. This opinion was echoed by multiple ED defense experts and the ED physician involved was subsequently dropped from this case. Dr. Hospitalist asserted that he was admitting ET for pain control and that the CT of the right thigh confirmed the most probable diagnosis was muscle tear with hematoma. Dr. Hospitalist asserted that he had no reason to suspect a rare diagnosis in this otherwise healthy woman. Regardless, Dr. Hospitalist argued that even had he considered necrotizing fasciitis at the time of admission, it was more likely than not going to be too late to prevent ET from losing her leg.

Plaintiff experts opined that Dr. Hospitalist should have ordered a CBC and blood cultures on admission as the CT report could not exclude an infectious process. Had a CBC been performed, it was probable that bandemia would have been present and systemic inflammatory response criteria would have been met (bandemia plus tachycardia). In addition, ET was complaining of severe pain out of proportion for exam findings, and this should have put necrotizing soft tissue infection in the differential diagnosis. The combination of systemic inflammatory response plus the severe pain would reasonably have led to a STAT surgical consult the day of admission with earlier debridement and leg-sparing surgery.

Conclusion

An individual hospitalist will admit hundreds of patients a year with routine and common problems. But admission for "pain control" is a red flag for an underlying disorder that has been missed by the ED evaluation. The diagnosis of necrotizing soft tissue infections requires a high level of suspicion. Patients that have new and persistent pain out of proportion to exam findings and in the face of high-dose opiate administration should lead to further investigation. Although ET survived, the outcome was considered catastrophic. A week before trial was to begin this case was settled on behalf of the plaintiff for an undisclosed amount.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reports having no relevant financial conflicts.

The story

ET was a 40-year-old married woman and local news reporter when she presented to her local emergency department (ED) complaining of right thigh pain. ET was also a triathlete and worked out vigorously at the gym every afternoon. Her workout that day consisted of squats and other lower-leg exercises, but was otherwise uneventful. After dinner that night, she began to experience anterolateral, burning pain in her right thigh that was unresponsive to ibuprofen. Her ED evaluation was essentially normal and she was discharged with a diagnosis of muscle strain/tear with possible hematoma. ET returned to the ED at 9:30 the next morning. She was walking with difficulty and in severe 10/10 pain. She was tachycardic and her thigh was noted to be mildly swollen and severely tender on palpation. A CT scan of her right thigh was performed.

"Small amount of fluid tracking along lateral aspect of vastus lateralis muscle. Mild decreased attenuation in the distal portion of the muscle itself. Findings may suggest muscle bundle tear and adjacent hematoma. Inflammatory/infectious process cannot be entirely excluded."

Following the CT results, she was rocking and crying in bed from the pain. The ED physician called Dr. Hospitalist, who admitted ET for intravenous pain control.

ET received multiple doses of intravenous hydromorphone overnight and was intermittently sleeping and crying awake because of severe pain. Vitals that morning showed ET to be afebrile, but tachycardic and hypotensive (BP = 85/50 mm Hg). The exam of the thigh was generally unchanged. The impression remained right muscle tear with hypotension as a result of intravenous hydromorphone. Later that morning, a CBC showed a WBC 14.0 K/mcL with 68% bands. Dr. Hospitalist eventually ordered intravenous fluid boluses, intravenous clindamycin, and an anesthesia consult for patient-controlled analgesia. By late afternoon, ET had refractory hypotension and was sent to the ICU for pressor support. Ultrasound found no evidence for DVT [deep vein thrombosis] in her thigh but a CK [creatine kinase] level was more than 2,000 IU/L. A surgical consult was obtained and ET was subsequently transferred via life-flight to the nearest university hospital for fasciotomy and thigh debridement. Within 2 days of the transfer, ET had four surgeries, culminating in a right hip disarticulation for necrotizing fasciitis. She was ultimately hospitalized for 3 months. Today, she is wheelchair bound and divorced because of the effects her illness had on her marital relationship. She is unable to work and has suffered from severe depression because of the loss of her leg.

Complaint

ET and her husband immediately blamed Dr. Hospitalist and the care she received at the community hospital for a delayed diagnosis of necrotizing fasciitis. The husband, a PhD in physiology and nutrition and consultant with the NFL’s Carolina Panthers, was highly critical of the muscle tear diagnosis. He testified that he told the ED physician and Dr. Hospitalist that there was no way that his wife was in so much pain from a muscle tear. In addition, both ET and her husband testified that she suffered no injury at the gym that would account for a muscle tear/rupture in the first place. The complaint alleged that had the ED physician and Dr. Hospitalist made the correct diagnosis, ET would have undergone debridement without the need for amputation. The complaint further alleged that had the debridement occurred in a timely fashion, she would not have suffered from the protracted tertiary hospital stay and all the associated complications and medical bills.

Scientific principles

Necrotizing soft-tissue infections include necrotizing forms of cellulitis, myositis, and fasciitis. These infections are characterized clinically by fulminant tissue destruction, systemic signs of toxicity, and high mortality. Accurate diagnosis and appropriate treatment must include early surgical intervention and antibiotic therapy. It is important to consider necrotizing involvement of the muscle or fascia in the setting of fever, toxicity, soft-tissue involvement with severe pain (particularly if out of proportion to skin findings), crepitus, rapid progression of clinical manifestations, and elevated serum CK level. The diagnosis of necrotizing fasciitis is established surgically, with visualization of fascial planes and muscle tissue in the operating room.

Complaint rebuttal and discussion

The ED physician asserted that, although he was unsure what was going on with ET, he appropriately admitted her to Dr. Hospitalist for further management. ET was hemodynamically stable during her time in the ED, without signs of toxicity or fever. As a result, the ED physician could not be expected to make a diagnosis at that time or even involve surgery as this rare condition was still evolving. This opinion was echoed by multiple ED defense experts and the ED physician involved was subsequently dropped from this case. Dr. Hospitalist asserted that he was admitting ET for pain control and that the CT of the right thigh confirmed the most probable diagnosis was muscle tear with hematoma. Dr. Hospitalist asserted that he had no reason to suspect a rare diagnosis in this otherwise healthy woman. Regardless, Dr. Hospitalist argued that even had he considered necrotizing fasciitis at the time of admission, it was more likely than not going to be too late to prevent ET from losing her leg.

Plaintiff experts opined that Dr. Hospitalist should have ordered a CBC and blood cultures on admission as the CT report could not exclude an infectious process. Had a CBC been performed, it was probable that bandemia would have been present and systemic inflammatory response criteria would have been met (bandemia plus tachycardia). In addition, ET was complaining of severe pain out of proportion for exam findings, and this should have put necrotizing soft tissue infection in the differential diagnosis. The combination of systemic inflammatory response plus the severe pain would reasonably have led to a STAT surgical consult the day of admission with earlier debridement and leg-sparing surgery.

Conclusion

An individual hospitalist will admit hundreds of patients a year with routine and common problems. But admission for "pain control" is a red flag for an underlying disorder that has been missed by the ED evaluation. The diagnosis of necrotizing soft tissue infections requires a high level of suspicion. Patients that have new and persistent pain out of proportion to exam findings and in the face of high-dose opiate administration should lead to further investigation. Although ET survived, the outcome was considered catastrophic. A week before trial was to begin this case was settled on behalf of the plaintiff for an undisclosed amount.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reports having no relevant financial conflicts.