Medical Malpractice Insights: Neurologist discharged with spinal epidural abscess

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Chuck Pilcher, MD, FACEP

Editor, Medical Malpractice Insights

Assure that your hospital uses opportunities to learn from a bad patient experience

Facts: A semi-retired vacationing neurologist with a prior history of a “spine infection” develops neck pain a few hours after a 15 mile bike ride. He attributes the pain to neck extension during the ride, but 2 days later he notes numbness and tingling in both arms and goes to the ED. He informs the staff that he is a neurologist and is concerned about possible cord and/or nerve root compression. He requests an MRI and blood tests to evaluate for a repeat spine infection. A “spine consultant” examines him, checks reflexes (without a reflex hammer – which he claims he doesn’t own), checks Babinski’s only when prompted (and then incorrectly), and checks sensation only with his index finger. He does not check gait, coordination, or motor dexterity. The cervical MRI reveals spinal cord arthritis, cord compression, and a mass behind the spinal canal that is read as a blood clot. WBC and inflammatory markers are elevated, but the patient is not informed. He is discharged to follow up with a spine surgeon within two weeks. On returning home 2 days later with ongoing symptoms, he reviews his visit on a patient portal and notes the lab abnormalities. He goes to his usual hospital, is admitted, and undergoes surgical drainage/decompression of a cervical spinal epidural abscess (SEA). Upon his recovery he attempts to turn his experience into a teaching opportunity for the involved hospital and emergency department. Here are the arguments the physician hoped to share with hospital and ED staff:

Emergency Physician and “Spine Consultant”:

• My symptoms warranted an MRI and lab work. I shouldn’t have had to ask for those tests.
• You should have told me about my lab abnormalities and possible spinal “blood clot.” Then you should have admitted me.
• Your average patient has a major disadvantage. Had I not understood the gravity of my own situation, I could be a quadriplegic now.

“Spine Consultant”:

• A check of Babinski’s is routine neurology, and you didn’t even do it right.
• Failing to use a reflex hammer to check reflexes is like failing to use a stethoscope to check the lungs.

Hospital:

• You have a Communications and Resolution Program (CRP) at your hospital. Why wouldn’t you use it?
• Your spine service’s claim that the consultant “conducted the examination to the best of his ability” needs to be challenged.
• You ignored my offer to review my care as a teachable moment for the ED and spine service staff and students.
• You refused to apologize or acknowledge that my care could have been better, even though I sent multiple letters explaining that I only wanted to teach, not sue.

Result:

• The patient recovered after surgery and a long course of antibiotics.
• The hospital missed a golden opportunity to learn – and never miss another SEA again.
• After 10 months of the neurologist attempting to help the hospital get better, the CRP director acknowledged, “Hospitals don’t seem to know what to do with the opportunity you present… A forum for these kinds of discussions – constructive, insightful patient feedback – doesn’t”

Takeaways:

• Hospitals and doctors remain resistant to admitting error, mainly from fear of malpractice lawsuits.
• Patient complaints are teaching moments that may be the “canary in the coal mine.” They should be valued, not excused, ignored or dismissed.
• Patients want to know that “this won’t happen to someone else.” Acceptance and normalization of mistakes assures that they will be repeated.
• Having a CRP and using it regularly assures that patients feel heard and valued, that lessons are learned and that processes are changed.
• Apologies do not increase the cost or incidence of med mal lawsuits and may in fact reduce them.
• Rather than announcing oneself as a physician on ED arrival, assuming the role of a patient may result in better interactions with caregivers.

References/Further Reading:

1. https://www.emdocs.net/emdocs-podcast-episode-63-spinal-epidural-abscess/
2. https://www.emdocs.net/spinal-epidural-abscess-challenges-to-diagnosis-and-how-to-improve/
3. Effects Of A Communication-And-Resolution Program On Hospitals’ Malpractice Claims And Costs. Kachalia A et al. Health Affairs, Vol. 37, No. 11, Nov 2018.
4. Perspective: Don’t bend the rules for VIP’s. Pilcher CA. Blogpost, January, 2017.