Medical Malpractice Insights: A Rare Presentation – Groin pain? Nec fasc? Diabetes? Appendicitis?

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Chuck Pilcher, MD, FACEP

Editor, Medical Malpractice Insights

Editor, Med Mal Insights

A Rare Presentation – Groin pain? Nec fasc? Diabetes? Appendicitis?

Can a lawsuit prove negligence and causation? Who should be sued? Why? And for what?

FACTS:

Clinic Visit 1: A 48-year-old female insulin-dependent diabetic presents to an NP at her primary care clinic on a Sunday with intermittent nausea/vomiting. It began 5 days earlier after eating chicken nuggets from Wendy’s. She also reports fever, sweating and right anterior thigh/groin pain that worsens with walking. She is concerned about food poisoning and says the groin/thigh pain feels like a prior episode of sciatica. Insulin is listed as one of her meds, but her diabetes is not otherwise addressed. Temp is 98.7 and pulse 121. Exam is normal except for tenderness as documented in the diagram. There is no mention of an abdominal exam. She is given 60 mg IM ketorolac for thigh pain. X-ray and lab are considered but not available in the clinic on Sunday. She is diagnosed with “groin pain” and advised to return the next day for US or x-ray if not improved or to go to the ED if worse. She is discharged with diclofenac for thigh pain. No anti-nausea med is apparently needed.

Clinic Visit 2: The next afternoon she returns to the clinic and tells the same NP that the shot helped but the thigh pain has returned. She requests an x-ray. Temp is normal and HR is 105. No further history is recorded and exam is unremarkable except for R anterior hip tenderness and a limp when she walks. Again, no abdominal exam is recorded. An x-ray of her R hip is normal. She is discharged with no change in treatment

Emergency Department: Three days later she presents to the ED with worse R leg pain and dyspnea. She is again seen by an NP. ROS is now positive for nausea. She denies fever and vomiting; abdominal pain is again not mentioned. On exam she is described as “ill, tachycardic, tachypneic and dry” with a soft, non-tender abdomen. Her R anterior thigh, knee and posterior calf are tender, swollen and ecchymotic. Lab shows WBC of 26,000, 59% polys plus 26% bands, and more immature cells. Glucose is 490, CO2 8, and pH 7.26 with 3+ urinary ketones. EKG shows atrial fibrillation with a rate of 169. The 3-line ED physician note says only that he had “face to face time with this patient,” “she appears acutely ill” and has “tachycardia” and “intact radial pulse.” She admitted to the ICU for “DKA.”

Hospital Inpatient: R thigh is indurated and blistered but abdomen is all but ignored. On the 2nd hospital day, she becomes obtunded and is intubated. A head CT is obtained for unclear reasons; it is normal. The abdomen is finally addressed and a CT of the abdomen/pelvis is done. It reveals a 7.5 cm abscess in the R thigh and retro-cecal appendicitis with retro-peritoneal perforation. A retrospective note now addresses that “symptoms started w/ nausea and abdominal pain.” An I & D of the thigh produces foul-smelling pus. Sepsis is diagnosed and antibiotics started for the first time. The retroperitoneal abscess is treated with a temporary percutaneous drain. She only gets worse, and by the 4th hospital day she is unresponsive. She is finally taken to surgery, an appendectomy is done and her thigh explored, revealing large areas of necrotic tissue. High level amputation is considered, but she dies of sepsis and multiorgan failure on hospital day 7. An attorney is consulted and the records reviewed by a medical expert to determine if a med mal lawsuit has merit.

1. CLINIC/ARNP ARGUMENTS:

PLAINTIFF:

• You didn’t address her diabetes; no glucose was ever checked.
• Her tachycardia of 121 and 105 were ignored.
• No explanation for the thigh pain or the N/V was ever given.
• She never had a documented abdominal exam.
• Appendicitis was never considered.
• My pain increased when walking. You never considered that as potential lower abdominal rebound tenderness.
• All the focus was on her thigh problem despite N/V for 5 days.
• She was seen only by an ARNP, not a physician.
• She returned for a second visit and all you did was get a useless hip x-ray.
• You never took her condition seriously.

DEFENSE:

• Her pain and tenderness were only in the groin and thigh. There was no evidence of infection.
• She had no persistent vomiting, was not dehydrated and had no fever.
• She reported no home blood glucose elevations. I don’t check blood glucose on every diabetic with musculoskeletal pain complaints.
• Of course I examined the abdomen. It was benign. I just failed to document it. Her groin/thigh was so tender that I drew a picture of it.
• If she had appendicitis, she would have had abdominal pain. I had no reason to consider it. We don’t even know when the appendicitis began.
• There is no connection between her thigh pain and her appendicitis.
• Her D/C instructions were cautious and appropriate.
• On her second visit she was no worse. There was no evidence of thigh abscess or appendicitis. Even the hospital didn’t find either until the 2nd hospital day.
• She needed no nausea meds, indicating no significant intra-abdominal problem.
• Groin or hip pain when walking is far more often due to musculoskeletal problem or hernia.
• Antibiotics were not given for at least 24 hours after hospital admission.
• The chart reflects a reasonable thought process of judgement calls, not negligence.
• Her death is not my fault.

2. EMERGENCY PHYSICIAN & ARNP ARGUMENTS:

PLAINTIFF:

• She was seriously ill. An emergency physician should have seen her, not an ARNP.
• The EP was never really involved in her care; the only evidence of contact with the pt. is a note saying that her radial pulse was normal.
• The cause of the DKA was never addressed.
• Infection is the most common cause of DKA and a source was not sought.
• You should have done blood cultures and started her on antibiotics.

DEFENSE:

• A dx of diabetic ketoacidosis was appropriate on admission.
• An ARNP is able to care for DKA.
• The EP documented seeing the patient and agreed with the ARNP’s plan.
• There was no reason to suspect infection, so no need for antibiotics in the ED.

3. HOSPITAL TEAM ARGUMENTS:

PLAINTIFF:

• Treated only for DKA.
• Initial focus only on thigh problem.
• Delay in diagnosis of abscess of thigh.
• Delay in diagnosis of retrocecal appendix perforation with retroperitoneal abscess.
• Delay in administration of antibiotics.

DEFENSE:

• She had a complex problem and we did our best to solve it.
• Our care was appropriate, timely and within the standard of care.

4. ALL DEFENDANTS’ ARGUMENTS:

• Appendicitis rarely if ever presents with nothing more than thigh or groin pain.
• Her appendicitis was not diagnosed until the second hospital day and was ruptured. We don’t know when it ruptured. You had symptoms for 5 days before you were first seen, so the rupture could have happened earlier.
• A thigh abscess is rarely if ever associated with appendicitis.
• The patient had 3 major problems: DKA, groin infection of unknown cause and ruptured appendix. Each were important. Who was negligent? When? And in what way?
• The leg/groin/thigh area had a “necrotizing infection.” How the appendicitis infected the groin is unclear. Is it possible that the two were un-related?
• A delay in antibiotics administration was unfortunate but no one can say on a “more probable than not” basis that earlier treatment would have changed the outcome.
• At what point did which defendant actually fall below the standard of care for a reasonably prudent physician with similar training and experience in a similar situation?
• And if there were negligence, what is your proof that her death was directly attributable to that negligence.

Result: The attorney was advised of the complexity of the case and the extremely rare presentation of appendicitis. To pursue the case would require expert testimony from multiple specialties: Emergency Medicine, Nurse Practitioner, Urgent Care/Family Medicine, Endocrinology, General Surgery, Infectious Disease, Radiology, Nursing and Hospital Medicine. The defense would most certainly present testimony from these specialists. Given the above arguments pro and con, the attorney determined that the case would be too complex, time consuming and expensive to pursue within the risk tolerance of the law firm. No case was filed.

Takeaways: There are more questions than answers in this case, but:

• This is a common outcome. Even if there could be negligence and causation, the cost and time to prove that in court may come down to an economic decision. This is especially a problem for patients with less severe injuries even when negligence and causation are obvious.
• If you take a history or examine a body part, document it.
• Groin pain, nausea and/or vomiting deserve an abdominal exam.
• Peritonitis can cause a limp or pain that increases with walking. A “heel bounce test” or any of several similar tests can check for this. If positive, pursue the possible causes. Yes, it could be a hip/leg problem but it could also be peritonitis.
• A type 1 diabetic with N/V for 5 days, even intermittently, deserves a blood glucose check.
• While the temp was normal, a pulse of 121 and 105 should be addressed and repeated.
• Greg Henry, one of emergency medicine’s best known and best loved mentors teaches “It is more likely that a common condition will present in an uncommon fashion than that a rare condition will present with classical symptoms.” In this case he is absolutely right.

Recommendation: Take 26 minutes to watch “A World of Hurt: How Medical Malpractice Harms Everyone.  Emergency Physician Gita Pensa MD is featured in this documentary. Her side gig is “Physician Defendant Support and Coaching.” The mission of Medical Malpractice Insights – Learning from Lawsuits is to help every reader escape the need for her counsel – but she’s there to help.

Resources:

• NSTI Pearls Part I
• NSTI Pearls Part II
• Fournier’s Gangrene