Medical Malpractice Insights: Diabetic ankle ulcer, fever, and hyperglycemia

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here. Stories of med mal lawsuits can save lives. If you have a story to share click here.

Chuck Pilcher, MD, FACEP

Editor, Medical Malpractice Insights

Editor, Med Mal Insights

Diabetic ankle ulcer, fever, and hyperglycemia

Don’t let your EHR make you look foolish – or worse

Facts: A 55-year-old diabetic male presents to the ED for ankle pain and elevated blood sugar after running out of insulin. He reports a fever the previous night. For the past 5 months he a has been treated in a wound clinic with little change. The ulcer is now “seeping”, and he feels that it is infected. On exam he is afebrile, the malleolus is slightly tender, and the ulcer has only superficial purulence. His glucose is 457 and decreases to 286 with IV NS and low-dose insulin. The wound is cleansed and redressed, and he is discharged feeling “comfortable” 4 hours after arrival. Three days later he presents to another ED. An x-ray reveals osteomyelitis of the ankle with significant collapse of the talus. An amputation of the foot is required. An attorney is consulted. He requests a chart review from an emergency physician and 2 podiatrists to assess the viability of the case.

Plaintiff: The podiatrists believe that an x-ray should have been done and a surgeon contacted on the first ED visit. They claim that the patient should have been admitted, treated with antibiotics and undergone a surgical debridement.

Defense: The EP reviewer had no strong opinion about a deviation from the standard of care by the emergency physician. The patient’s EPIC-generated EHR is clearly “click-tated,” with a long macro differential that includes everything from “skin rash” and “insect bite” to “systemic infection,” “SIRS,” “MRSA” and “Sepsis.” However, he points out that the talar collapse found on his second ED visit indicates long-standing significant osteomyelitis in the ankle joint, present for far longer than 3 days. This makes it impossible to say that earlier treatment would have made the amputation unnecessary. Thus, a lawsuit would be non-viable.

Outcome: The attorney chose not to file a claim or lawsuit. Failure to diagnose osteo on the first ED visit did not predictably or significantly affect the damages that the patient suffered. Even if the first ED physician were to be found negligent, that negligence could not be shown to be a direct cause of the need for amputation. Both elements must be present for a med mal lawsuit to be successful.

Takeaways:

• Read the nurses notes. The patient told the nurse about his fever and expressed concern about his ankle ulcer worsening and now “seeping.” Given that information, an x-ray or even a CT would have been appropriate.
• Confirm – or document why you refute – a nurse’s history. The nurse’s notes were not mentioned by the EP.
• “Click-tating” an EHR may create a nice legal and billing document, but un-edited, excessive and/or unsupported computer-generated entries expose the physician to accusations of lying. Example: Your EHR macro documents that you ruled out ovarian torsion in an 80-year-old male with abdominal pain.
• The differential diagnosis list begs questions (e.g., on what basis did the physician rule out SIRS? Why was an “insect bite” considered when there was no history to support it?). Once again, document your Medical Decision Making (MDM).
• Add some “free text color” to the documentation created by your computer-generated EHR. This shows that a human being was involved in the “medical decision making.”
• Avoid dependence on your charismatic personality to convince a jury that you aren’t a liar. Report what you do. Don’t report what you don’t do.

Further Reading:

emDOCs EM@3AM – Diabetic Foot Infection

emDOCs – Antibiotics for Diabetic Infections