Could necrotizing fasciitis have been diagnosed sooner?

June 1, 2016

Read about this and two other cases in this "Malpractice Consult" column.

Dawn Collins, JDA 57-year-old Tennessee man presented to an emergency room in 2006 with complaints of severe groin pain. Testing indicated a high white blood cell count, but a magnetic resonance imaging scan was negative for infection.

Read: Mesh cystocele repair leads to perforated bladder 

Two days later, a surgeon was called to consult. She reviewed the medical records, ruled out infection, and left for the weekend.

Four days later, the patient’s condition worsened and he was then diagnosed with necrotizing fasciitis of his groin and penis. The surgeon was called in to perform an operation to excise the area, including removal of skin from the penis and removal of the scrotum with the testicles implanted in the upper thigh. The result of the infection and surgery was described as a horrendous and deforming injury.

Related: How to avoid malpractice suits related to APPs

The man sued the consulting surgeon and alleged she failed to make a timely diagnosis of the infection or perform a biopsy; rather, she relied on the MRI and ignored the clear clinical signs of infection. He argued that if the infection were caught earlier, an effective treatment would have prevented the subsequent injury. He also claimed the surgeon failed to communicate with other medical team members before leaving for the weekend. The man died a year after filing the lawsuit, and his estate pursued the case to trial.

Continue here for the verdict

 

The surgeon contended that her consult and reliance on the MRI and communication were all compliant with the standard of care and that at the time of her consult, the patient did not yet have the infection. A defense judgment was entered.

More malpractice: The malpractice suit: Why expert witness selection is crucial

LEGAL PERSPECTIVE: In medical malpractice cases, the caregivers are held to the “standard of care” expected in the particular situation and are judged as to whether that standard was met. In our legal system, a “reasonable person” standard is used, meaning would a reasonable physician with the same or similar training, in a same or similar situation, have performed similarly as the defendants in the particular lawsuit? In this case, the plaintiff introduced what he called the “gold standard” for diagnosing this particular infection, claiming that the gold standard was to perform a biopsy at the time of consult instead of relying on the MRI findings. The physician prevailed in showing that her care was compliant with the required standard of care.

Allergic reaction to antiseptic solution

A New Jersey man in his 40s was admitted to a hospital for a cystoscopy to examine his bladder lining and urethra. After the procedure, the patient had complaints of inflammation and pain to his penis and was seen by several urologists, but with no treatments performed. As a result, he developed scarring to his penis and complained of tenderness and some functional deficit.

Also see: Patient's bowel perforated during robot-assisted RP

The man sued the urologist, his nurse, and his medical group, claiming that the antiseptic solution on the equipment used for the cystoscopy caused a severe allergic reaction, with severe inflammation and pain to his penis. He alleged the urologist and a nurse who assisted in the procedure negligently failed to provide appropriate medical care and failed to properly clean the equipment prior to the procedure, which resulted in the allergic reaction and injuries.

The defense denied any negligence, contending that any negative reaction the patient experienced to the antiseptic material was one that could not have been anticipated. They argued that the inflammation and related conditions were temporary and had since resolved completely without any scarring. The jury returned a defense verdict.

Next: Failure to diagnose testicular torsion alleged

 

Failure to diagnose testicular torsion alleged

A 14-year-old male from Illinois presented to an emergency room in 2008 with complaints of lower left abdominal pain and was examined and treated by a pediatric ER physician.

A subsequent lawsuit alleged that those involved with his care failed to diagnose left-sided testicular torsion, failed to perform a testicular examination to rule out torsion, and failed to surgically fix the right testicle to prevent a right-sided torsion. As a result, the patient developed a right-sided torsion 6 months later that was treated at a second hospital. There, the medical personnel surgically removed the right testicle, discovered an atrophied left testicle, and surgically fixed the atrophied left testicle to the scrotum in an attempt to salvage hormone production.

Read: Patient sues, alleges delay in testis Ca diagonsis 

The teen, however, is now sterile and requires testosterone replacement therapy for the rest of his life.

The defense maintained that the patient did not suffer from testicular torsion at the time of the first ER visit, that he had none of the classic symptoms such as painful/swollen testicles, and that the physician found no reproducible symptoms when he examined the testicles.

The plaintiff further asserted that presenting complaints for testicular torsion in an adolescent can be limited to lower quadrant pain without testicular pain, so the defense should have investigated further, especially after other diagnostic tests came back normal and the source of the abdominal pain was not found. The jury found in favor of the patient and awarded $351,000.

More on malpractice:

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Partial nephrectomy results in bowel injury, lawsuit

Extracapsular prostate cancer leads patient to sue