The
ultimate goal in presenting these cases is to help
physicians practice safe medicine. An attempt has been made
to make the material more difficult to identify. If you
recognize your own claim, please be assured it is presented
solely to emphasize the issues of the case.
Presentation
A 53-year-old man came to the emergency department (ED) on
a Saturday with a complaint of severe low back pain for five
days, reporting he had no sensation or movement in his legs
or feet. His oral temperature was elevated at 100.4 degrees.
Further history revealed five prior back surgeries performed
by an orthopaedic surgeon in a large metropolitan area.
Physician
action
The ED physician called an orthopedic surgeon (the
defendant in this case) for consultation. Initial
examination of the lower extremities showed no weakness,
intact sensory function, motor strength 5/5 in all muscle
groups, and normal rectal sphincter tone. Reflexes were
symmetrical and straight leg raising was negative. He also
documented in the admission note that the patient did move
his legs and feet, and had some peripheral nerve function.
Because of the probability of infection, a blood draw was
ordered for culture and sensitivity studies. Pain medication
and antibiotic therapies were initiated.
The next day the patient reported he could not move his
legs. A CT scan of the lumbar spine ruled out any evidence
of an acute canal block, but did show severe stenosis at
L3–4 and L4–5. Chronic postoperative changes, including
degenerative changes and scar tissue, were noted with
indication that a spinal fusion had been performed. All
metal was absent from the back, but screw tracts in the
pedicles were evident.
A myelogram was attempted but aborted, as the radiologist
did not obtain any CSF return. Entrance was made at L3–4
with a 22-gauge needle and the radiologist tried up to the
level of L1–2 with still no CSF. This would indicate severe
scarring and changes within the spinal canal that might be
contributing factors to the patient’s pain. Lab blood
studies showed a high white count consistent with an
infection. The IVP and chest x-ray were negative. An
abdominal x-ray showed a probable paralytic-type ileus. An
MRI was ordered, but the orthopedic surgeon was told the
procedure was not available at this hospital on the weekend.
Upon re-examination, the patient had good rectal sphincter
tone. The physician suspected possible cauda equina
syndrome. The possibility of transferring the patient to
another facility was discussed at a family conference. The
conclusion was made that the treatment would be the same as
he was already receiving. The defendant told the family that
he made multiple attempts to contact the patient’s original
orthopedic surgeon with no response. However, there was no
documentation to support this. In fact, the call logs for
the original orthopedic surgeon did not show any calls from
the defendant.
On Monday, the original orthopedic surgeon was contacted
and the patient was transferred by ground ambulance to his
care. Medical records indicated that during the patient’s
weekend stay, the patient did improve with the return of
some sensation and some active movements of the feet and
legs. The next day, blood culture results from a specimen
taken at the time of admission showed a positive infection
for Staphylococcus aureus.
When the original treating surgeon examined the patient,
there was no anal/perineal sensation. He had flaccid
paralysis of the lower extremity. There was no sensation.
The surgeon’s impression was the patient had cauda equina
syndrome and surgery was scheduled.
A detailed operative report described a central
decompression laminectomy from T-8 to L-5 and drainage of an
epidural abscess. Gross pus was encountered at L-5 and
upward to T-8 upon entering the spine. All areas suspected
of purulent material were cleaned. A left subclavian Hickman
catheter was placed for prolonged antibiotic therapy. The
patient was ultimately discharged to a rehabilitation
facility where he received IV antibiotic therapy for six
weeks. The patient is currently paralyzed from the waist
down with bowel and bladder incontinence.
Allegations
The plaintiffs alleged that the defendant failed to timely
diagnose cauda equina syndrome and transfer the patient for
emergency treatment. They further alleged that the patient
should have been transferred to a facility for an MRI that
would have resulted in an earlier diagnosis of the spinal
epidural abscess. Also named in the suit was the hospital at
which the patient came for emergency treatment.
Legal
implications
No experts reviewing this case, either orthopedic surgeon
or neurosurgeon, were supportive of the defendant’s
treatment.
The plaintiffs deposed the patient’s first treating surgeon
who was very critical of the defendant’s management of this
patient. He maintained that his orthopedic group always had
physicians available on call when the primary treating
physician was not available. It was also determined by
checking the telephone records at the hospital that the
defendant had not been accurate in describing his efforts to
reach the previous treating surgeon in order to expedite a
timely transfer and treatment intervention.
Although the defendant wanted to perform an MRI of the
lumbar spine and could not do so since this was not an
option at the current treating facility, it was discovered
that the physician had knowledge that an MRI was available
at another hospital in the area. The defendant also
indicated there were no technicians on call over the
weekend, but this was disputed by personnel from that
facility.
The doctor made a judgment that the patient’s condition was
not emergent enough to transfer him to a major orthopedic
and neurosurgery center in that area, although this was a
viable option.
Disposition
Given these issues, the decision was made to resolve the
suit. This was a case with significant damages as the
plaintiff had permanent paraplegia. The potential for a
large, adverse jury verdict was a concern. A settlement was
made on behalf of the defendant physician. The hospital also
settled for an undisclosed amount.
Risk
management considerations
Clearly hindsight is always an unfair advantage in
reviewing any closed claim. It should be noted that the
tests ordered by the defendant were appropriate, given the
symptoms of the patient. Risk challenges are heightened for
the on-call consultant facing a new patient with a complex
medical history. Also, a physician practicing in a smaller
locale may confront limitations at the hospital ED that are
critical for an accurate and timely diagnosis. Knowledge of
available 24-hour services at facilities, both locally and
via transport, will assist on-call physicians when facing
difficult situations, as illustrated in this case. When
faced with differential diagnoses that include potentially
serious conditions, definitive steps to obtain needed
diagnostic tests and care may need to be expedited.
The attempts to reach the patient’s first surgeon should
have been documented in the medical record. Whether
delegated to hospital staff or the responsibility of the
physician, those calls cannot be verified unless they are
noted in the medical record. Accurate and timely
documentation of medical decision-making, as well as
attempts to obtain a thorough patient history, will increase
the likelihood of a better outcome.
The
information and opinions in this article should not be used
or referred to as primary legal sources nor construed as
establishing medical standards of care for the purposes of
litigation, including expert testimony. The standard of care
is dependent upon the particular facts and circumstances of
each individual case and no generalization can be made that
would apply to all cases. The information presented should
be used as a resource, selected and adapted with the advice
of your attorney. It is distributed with the understanding
that neither Texas Medical Liability Trust nor Texas Medical
Insurance Company is engaged in rendering legal services. ©
2007 TMLT
