News: A 21-year-old woman visited an emergency department (ED) complaining of tenderness and swelling in her right pinna, the outer structure of her ear. She was given antibiotics and sent home. In the next nine days, she returned to the ED three times for the same problem. During her last visit, she was admitted and tests revealed an infection that was not treated by the prescribed antibiotics. Because of the advanced stage of the infection, the only option was to remove portions her pinna, resulting in a structural deformity.
A jury awarded her $2 million.
Background: On May 19, 1997, the young woman, who had recently had her ears pierced, went to an ED complaining of tenderness and swelling in her right ear. She was examined by an ED physician, who noted the infection and prescribed the antibiotic Keflex.
Because her condition worsened, she returned to the ED on May 25 and was seen by a different physician, who consulted with a plastic surgeon who recommended an incision and drainage of the ear.
Despite making the consult, the ED physician ignored these recommendations and discharged plaintiff, instructing her to use warm soaks and continue the Keflex.
The next day, the young woman returned to the hospital and was seen by a third ED doctor, who aspirated the ear with a needle and sent the fluid to the hospital lab for culture and sensitivity tests. Results were to be returned after 48 hours. He did not ask for a gram-stain test, which may have given relevant information about the infection within an hour. This ED physician changed the patient’s antibiotics, as it seems the Keflex was ineffective. The young woman was told to see a plastic surgeon.
On May 28 the plastic surgeon made an incision in the ear, drained the fluid, and admitted her to a hospital. The culture and sensitivity test results were then available and showed an infection caused by Pseudomonas aeruginosa, a bacteria that the two previous antibiotics did not treat.
The following day, the plastic surgeon removed a substantial portion of the plaintiff’s pinna to treat the infection. After surgery, plaintiff’s ear was structurally deformed. She was given new antibiotics and discharged June 2.
The patient claimed that the second and third ED physicians delayed the correct diagnosis by failing to follow the advice of the consulting plastic surgeon. She also argued that another alternative would have been a gram-strain test, which would have shown the infection earlier and allowed treatment as early as May 25 or 26. She claimed damages of pain and suffering, emotional distress, embarrassment, and humiliation, disfigurement, loss of life pleasures, and possible future medical expenses. Plaintiff also presented evidence showing that later surgery could worsen her condition and was unlikely to improve her structural deformity. While a trial was pending, the plaintiff suffered from a psychiatric disorder due to her deformity.
The charges against the first ED doctor, the consulting plastic surgeon, and the treating plastic surgeon were dismissed. The parties stipulated that any charges against the second and third ED physicians would be molded to be a verdict against the hospital because both doctors were hospital employees.
The jury, upon finding the second ED attending physician to be 70% negligent and third ED doctor to be 30% negligent, awarded the plaintiff $2 million.
What this means to you: What may have been a minor infection became an ordeal resulting in disfigurement. The problems may have been prevented with proper communication between physicians, the ordering of proper tests, and adherence to the recommendations of consultants.
"As we begin review of this scenario, we must keep in mind that it is usual practice for the medical record to be pulled and available to the ER physicians for review so that the medical history and previous visits are known to the treating physician. Risk managers should investigate the process for pulling old records for each patient’s visit to the ER," states Leilani Kicklighter, RN, ARM, MBA, CPHRM, CHt, director, risk management services, of the Miami Jewish Home and Hospital for the Aged, Miami.
"Keflex, a broad spectrum antibiotic, is often proscribed for infections on an outpatient basis. Although discharge instructions are unknown, when six days later the patient returned to the ER and the tenderness and swelling has gotten worse, the consult was an appropriate step. However, ignoring the suggestions that were requested is troublesome. At this point, even though the signs and symptoms had gotten worse, and a surgical [plastic] consultant recommended definitive treatment, the ED physician chose not to follow the consultant’s recommendations, and at this point we do not know if there is any documented support for this decision. In addition, even though the ear was worse than at the visit six days earlier, the antibiotics were not changed, and there is no evidence that the Keflex was continued. A gram stain may have indicated a change in antibiotics but would not have reflected the sensitivity to the antibiotic. Although, it is possible a gram stain may have provoked the doctor to make a change in the antibiotic prescribed," adds Kicklighter.
"The risk manager should refer this case to the peer review. A consultation with a pathologist to review the current standards for indications for grams stains, and the location and set up of the gram-stain area in case there is some aspect that deters the use of the area. It might be worthwhile to refer this case to infection control and the physician director of infection control to determine if there is an opportunity to conduct educational programs to revisit antibiotic use in general and how gram stains can guide use of antibiotics. It is interesting to see that the culture when eventually taken, grew Pseudomonas aeruginosa, which is often associated with moisture. This raises the question of whether this was a contamination at the time of the initial piercing, or contamination later from hair washing or other water use in the area. Which in turn raises the question, should this infection be reported to the area health department if the piercing were done in a business setting? In addition the risk manager should review the medical records from each of this claimant’s visits to the ED to ascertain if there is appropriate documentation and justification for medical decisions," concludes Kicklighter.
Reference
• Jeanine Saunders v. Crozer Chester Medical Center, et al., Philadelphia City (PA) Court of Common Pleas, Case No. 3933.
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