It’s 4 a.m. when a 17-year-old awakens at home with severe left shoulder pain that his worried parents call 911. By the time he reaches the emergency room (ER), he has pain all the way to his wrist.
“Any recent injuries?” asks the doctor.
“Yeah, about three days ago, I was lifting about 200 pounds at the gym and noticed that my shoulder was really sore.”
When questioned further, he admits that he’d had a headache, slight fever, a cough with green sputum, and some vomiting the day before.
The doctor examines him and finds everything normal except for limited motion of the left shoulder. X-rays of the chest and shoulder are normal. His white blood count is elevated at 19,000, and the doctor is concerned enough about the headache to do a spinal tap – which is normal. He also orders blood cultures.
After 11 hours in the ER and some intravenous pain medication, the teen feels better, and his left arm is placed in a sling. He is discharged with a diagnosis of shoulder sprain, advised to take ibuprofen for pain, and to see his primary care physician (PCP) the next day for the results of the blood cultures.
The following morning the lab calls the ER with a preliminary report that both cultures are growing the same bacteria, a form of streptococcus. The health unit coordinator (HUC) takes the report and passes it on to the charge nurse, who presents the results to the ER doctor on duty. None of this is documented in the patient’s medical record. Nothing happens.
That afternoon the teen sees his PCP as advised. He is still running a fever. The PCP suspects a deep tissue infection and orders blood cultures, unaware of the results of the cultures 24 hours earlier. He also ordered an MRI of the shoulder to be done the following morning. He, too, sends the boy home.
The patient worsens overnight and returns to the hospital. An MRI shows septic arthritis of the left shoulder. He is admitted and treated but dies after a long battle with the infection. The family files a lawsuit against the emergency physician, the hospital, and the PCP. Over the next two years, the various parties and their attorneys go back and forth with claims and counterclaims.
The teen’s parents asked why the emergency physician focused on the mild headache and cough and even did a spinal tap while almost ignoring their son’s main complaint of shoulder pain so severe that they had called 911. They also asked why there was nothing in the chart about a differential diagnosis or medical decision-making. And why did you do blood cultures and not consider the shoulder as the possible source of the infection? Instead, you focused on our son’s mention of feeling pain in his shoulder at the gym.
The plaintiff’s attorneys point out that the hospital has a very clear policy on managing lab reports of positive blood cultures. It includes a designated “culture nurse” who is supposed to tell the ED physician of positive results, notify the patient’s PCP, fax the results to the PCP, and inform the patient. Neither the HUC, the nurse, nor the doctor could recall who did what. This kid had a serious infection, and you decided not to act on a “preliminary” report from the lab and to wait until the final result is back. If any of you had treated our son earlier, he would be alive today – and we have an infectious disease expert who agrees. Your negligence was a direct cause of our son’s death.
All of the defendants deny any violation of the standard of care or a causal relationship between their actions and the teen’s death. All claim that they acted according to the hospital policy.
“I gave the report to the culture nurse,” says the HUC.
“I told the doctor,” says the nurse,” and he told me to wait for the final results.”
“I never said that,” says the doctor.
And the PCP says, “If I had known about the culture result, I would have admitted him immediately.”
After some two years of litigation, an arbitration settlement was reached for an undisclosed amount against the hospital, nurse, and doctor. The PCP was exonerated.
So what can we learn from this tragedy? How can we reassure the parents that this will not happen to someone else? Here are a few take-home thoughts:
“Pain out of proportion” (POOP) is a red flag.
Address the patient’s chief complaint first. In this case, the other symptoms were only side effects of the main problem.
Pay attention to lab work. In this case, the elevated white blood count and the related blood culture results.
Keep an open mind, broaden your differential and document your medical decision-making (MDM), especially when sending a patient home with pending blood cultures.
Avoid anchoring bias and premature closure based on a patient’s self-diagnosis. This teen’s report of a lifting injury does not comport with his signs and symptoms.
Follow your hospital’s procedures on abnormal lab results.
Don’t automatically write off “preliminary” culture results.
Always rule out sepsis and necrotizing fasciitis in febrile patients with localized pain and an elevated WBC.
If considering a deep tissue infection, a CRP and sedimentation rate are almost always useful.
Charles A. Pilcher is an emergency physician and editor, Medical Malpractice Insights – Learning from Lawsuits.
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