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
56-year-old man came to a new primary care physician, an
internal medicine specialist. The patient had a history of
hypertension, hyperlipidemia, hypothyroidism and clinical
depression. Four years before this visit, the patient had
been diagnosed with a calcified thoracic HNP. At that time,
the treating neurosurgeon told the patient the thoracic disk
could result in acute deterioration, including paraplegia
and loss of bowel control. He also discussed the risks of
surgery to correct the problem. The neurosurgeon urged the
patient to seek another opinion, and if he elected to do
nothing, to return for a follow-up visit in a few months.
The patient never returned to the neurosurgeon or sought
further treatment for his back.
Physician
action
During
the visit with the internal medicine physician, the
patient’s medical history was reviewed. The physician’s
records for the patient included the prior CT findings from
the neurosurgeon. A routine physical exam was performed and
neurological findings were normal. The physician saw the
patient routinely over the next 18 months. During these
visits, there were no complaints of back pain.
Approximately seven months after his last visit, the patient
returned to the internal medicine physician with diffuse low
back pain. The neurological exam was normal; there was
positive straight leg raising and no change in bladder or
bowel function. The patient also had good range of motion.
It was noted that the patient had a positive calcified disc
in his back, as indicated by the previous studies. The
physician told the patient to stay off his feet and not to
lift anything. He prescribed Naprosyn, and told the patient
to return in one to two weeks if he was not better.
The
patient also sought treatment from a chiropractor for his
back pain. The records from the chiropractor were unclear,
but it did not appear that any adjustments were performed.
The chiropractor did give the patient a prescription and
told him to apply ice.
Fifteen
days after coming to the internal medicine physician with
back pain, the patient returned. He was admitted to the
hospital for worsening right low back pain radiating to the
right heel, now associated with urinary retention. Ataxia
was noted. The internal medicine physician called in an
orthopedic surgeon to consult. The surgeon conducted a
thorough neurological exam in the presence of the internal
medicine physician. All findings were normal. After the
exam, the surgeon ordered a lumbar view MRI to be completed
ASAP.
The
following day, the patient was again seen by the orthopedic
surgeon. The patient reported that his back was better and
there were no neurological symptoms. The patient was also
seen by a urologist, at the request of the internal medicine
physician. The IM physician suspected a neurogenic etiology
for the urinary retention.
The
urologist noted there was no previous, significant history
of urological problems, and the patient reported no problems
with his urinary bladder despite the acute back pain he
experienced four years previously. The examination revealed
normal sensation throughout the perineum, a normal
bulbocavernosa reflex, tight anal sphincter tone, and normal
anal wink. The urologist concluded the urinary retention was
caused by the acute back pain and accentuated by narcotic
medications. In addition, the anticholinergic effects of
antidepressants were thought to be playing a role. He felt
the patient would recover and intermittent catheterization
was ordered. The urologist did not believe the bladder
dysfunction was neurological in origin.
Early the
next morning, the internal medicine physician and the
orthopedic surgeon were called to the hospital by the
nurses. The nursing entry indicates the patient was
experiencing a lack of sensation from the waist down, and an
inability to move the lower extremities with loss of
reflexes. According to the orthopedic surgeon’s note, the
patient had severe back spasms at 2 p.m. the previous
afternoon. The MRI ordered ASAP by the surgeon the previous
morning had not yet been performed. Another MRI was ordered
stat, and revealed an extremely large herniated nucleus
pulposus at T8-9 level causing severe cord compression.
The
patient was transported to another hospital for an emergency
thoracotomy with anterior discectomy of T8-9. The procedure
was performed without complication. The patient regained
partial motor and sensory function in the left leg. He was
discharged and transferred to a local rehabilitation
hospital. After leaving the rehab hospital, the patient
continued physical therapy for approximately two years. At
present, the patient can walk with a cane, but suffers
permanent loss of bowel and bladder control.
Allegations
The main
allegations in this case were:
• failure
to conduct a proper and adequate neurological exam (both
physicians);
• failure
to conduct a rectal and perineal exam (both physicians);
• failure
to refer patient to a competent orthopedic surgeon (IM);
• failure
to obtain an emergent MRI scan (both physicians);
• delay
in performance of surgery (surgeon); and
• failure
to obtain more experienced and qualified consultants (both
physicians)
Legal
implications
Overall,
TMLT consultants were supportive of the care given in this
case. When he saw the patient’s condition, the internal
medicine physician immediately admitted him to the hospital
and called in orthopedic and urology consults. The
orthopedic surgeon’s evaluation was consistent with a
patient who had long-standing low back problems from
pre-existing conditions that were not emergent in nature.
However, both plaintiff and defense experts were critical of
the internal medicine physician’s failure to advise both the
orthopedic surgeon and the urologist of the patient’s prior
diagnosis of calcified thoracic HNP. It was alleged that the
internal medicine physician’s failure to do so led the
subsequent consultants to the wrong conclusion.
The
orthopedic surgeon was also criticized for not ordering a
stat thoracic MRI at the time the patient was admitted. The
orthopedic surgeon testified that he did not see the need
for a stat MRI because the patient had a normal neurological
exam. There also was some question as to whether or not a
thoracic MRI at the time of admission would have shown a
surgical lesion.
Disposition
This case
was settled on behalf of the internal medicine physician and
the orthopedic surgeon.
Risk
management considerations
1.
Communication between providers — sharing a patient’s past
medical history with subsequent treating physicians and
consultants is essential. Relevant history must be
communicated in the medical record and, where appropriate,
communicated directly to the consulting physician.
In this
case, the internal medicine physician failed to relay
relevant medical history (prior diagnosis of calcified
nucleus pulposus) to the orthopedic surgeon that may have
affected his assessment of the urgency in obtaining an MRI.
However, the orthopedic surgeon cannot completely rely on
information given by a referring physician and must perform
his own history and physical examination.
2.
Inpatient tests — the physician ordering diagnostic testing
in a hospital setting should be judicious in acknowledging
priority with regard to time for completion and appropriate
follow up of the results. Physicians may dangerously assume
that a hospitalized patient will undergo ordered tests in a
timely manner due to round-the-clock monitoring. Test orders
must be clear as to their urgency, i.e., routine, STAT, etc.
Unless it has a specific meaning in your institution(s),
ASAP is too vague a time frame. It may also be necessary for
the ordering physician to advise appropriate hospital
personnel of the nature of the patient condition and why the
test is to be performed. Lastly, the ordering physician must
follow up on the completion of tests ordered.
In this
case, there was a question as to whether the delay in
performance of the MRI resulted in the patient’s adverse
outcome, since it may or may not have shown a surgical
lesion at the time of admission. Timely performance of the
MRI may have helped to demonstrate the physicians could not
have prevented the patient’s paralysis.
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
