Medical Malpractice Insights: Positive Blood Culture (ignored), ESR 62 (misinterpreted)

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.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Positive Blood Culture (ignored), ESR 62 (misinterpreted)

Diagnosis of SEA missed despite 10 MD encounters in 10 weeks; patient suffers stroke from septic embolus

Facts:

• An adult diabetic male with a bovine artificial aortic valve and prior CABG presents to the ED with gradually increasing generalized pleuritic chest pain, cough, and fever. ROS is negative for N/V, diaphoresis, or SOB. His exam, CXR, EKG, and chest CT are unremarkable, D-dimer is slightly elevated at 0.7, and troponin is normal. Blood cultures are ordered, but no differential supporting the test is recorded. The patient is treated empirically with levofloxacin for the fever and discharged to follow up with his primary care provider (PCP) in 3 days. A copy of the ED record is sent to the PCP.
• The blood cultures grow viridans (gordonii). The lab informs the on-duty ED physician, but no action is taken. The lab also faxes the report to the patient’s PCP. There it is simply date-stamped and filed in the chart. The patient does not see his PCP as instructed.
• Three weeks later he again presents to the ED with back pain. He is seen by the same ED physician who received the earlier phone report of the positive BC, but no mention is made of that in the record. Possibly suspecting a spinal epidural abscess, an ESR is ordered. Despite the ESR being 62, the patient is treated with prednisone and discharged.
• Over the ensuing week he sees his PCP twice, but the ESR and positive blood cultures are not mentioned. He is treated with more prednisone and Vicodin.
• Five weeks after onset, he presents to the ED (twice actually) with weakness and back pain. This time the elevated ESR is noted, but the positive blood culture is not. He is diagnosed with polymyalgia rheumatica (PMR).
• He sees his PCP 4 more times for his persistent back pain. On his 6th visit, the PCP repeats the ESR. It is now 80. The possibility of endocarditis is raised, and blood cultures are again ordered. The PCP only discovers the prior report when the new results also grow Strep viridans.
• The patient is finally admitted, and an MRI shows osteomyelitis. He is finally given antibiotics.
• Ten weeks after the first visit to the ED, he suffers a stroke from a presumptive septic embolus from subacute bacterial endocarditis (SBE) of his bovine aortic valve and is left with a left hemiparesis.
• A lawsuit is filed against the ED physicians, hospital, and PCP.

Plaintiff: I had a positive blood culture in February. Over the next 2 months I saw my PCP 9 times and was in the ED 3 times, and you paid no attention to this. You even did a sed rate – twice – and didn’t connect the dots. You also treated me with prednisone, a risk factor for infection. I didn’t have PMR but osteomyelitis and SEA. You failed to consider either diagnosis when you had 12 chances to do so. If you’re going to do blood cultures, do something when they come back positive. Because you didn’t, I am now paralyzed from my stroke – and I need a new heart valve.

Defense: No defense arguments are available for this case.

Result: Settlement for undisclosed amount against the ED physicians and the PCP. The hospital paid nothing.

Takeaways:

• Form a differential diagnosis, seek clues to rule out the worst-case scenario (this appears to have been started but never finished), and document accordingly.
• Why order tests if you pay no attention to the results? When you are given a critical result, assure that you have a system in place to acknowledge that and act on the information.
• Document the communication from lab to doctor and from doctor to patient.
• Don’t anchor to a diagnosis, especially when a patient is a bounceback seen on multiple visits.

References:

• Spinal Infections. Medscape eMedicine. Vinas FC. Feb 13, 2018. https://emedicine.medscape.com/article/216650-overview
• Infective Endocarditis. Medscape eMedicine. Brusch JL. Jan 03, 2019. https://emedicine.medscape.com/article/1266702-overview#a4
• Neurological Sequelae of Infectious Endocarditis. Medscape eMedicine. Bowling NN. Sep 06, 2018. https://emedicine.medscape.com/article/1165712-overview
• A similar case originating from a septic hip was presented in the February, 2015, issue of Medical Malpractice Insights – Learning from Lawsuits. https://madmimi.com/s/126e85

“Unreasonable haste is the direct road to error.”

Moliere