Medical Malpractice Insights: We’re Doctors, not Prophets…

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.

This month’s case is another reminder to think of spinal epidural abscess in back pain patients. This diagnosis continues to be missed far too often. Doing the right thing, while not always keeping one from getting sued, will (almost always) keep a jury on your side. We are not responsible for foreseeing the future. We are responsible for keeping an open mind, developing a broad differential, testing appropriately and documenting our findings.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Spinal epidural abscess (SEA) missed but defense prevails.

We’re doctors, not prophets. 

Facts: A 69-year-old male with type 2 diabetes presents to the ED with recurrent low back pain after lifting heavy objects out of his truck. He has no other risk factors for SEA. An x-ray shows only DJD, so he is discharged with pain meds to follow up with his primary physician. He does that, but his pain worsens and returns to the ED 8 days later. Pain is now in the shoulder and back, he is jaundiced and has a rash on one arm and both legs, and jaundice. A complete spinal MRI is done, showing a psoas abscess and lumbar discitis without evidence of SEA. He is admitted and treated with antibiotics. Two days later he develops increased neck pain and left arm deficits. He is transferred to a tertiary hospital, where a repeat MRI shows a cervical epidural abscess. He undergoes spinal decompression surgery but is left with permanent loss of use of his left arm. A lawsuit is filed against the referring hospital and its emergency physicians.

Plaintiff: You didn’t consider that I might have a SEA on my first visit to the ED. You should have checked my ESR or CRP and done an MRI then. Because you waited until my arm became weak, I now can’t use it.

Defense: The evaluation and treatment on your first visit were reasonable. You had no major risk factors for SEA and no fever. We got an x-ray. That was enough at that time. When you came back 8 days later, we looked for SEA on your MRI, and none was present. We treated you appropriately with abx for the psoas abscess. Even if we had done a CRP or ESR on the first or second visit, it would have been elevated on both visits. It only tells us you probably have an infection, and we know you have an abscess in your psoas muscle. We treated you appropriately with antibiotics. There was no indication for an MRI on the first visit, and it would have been negative for SEA anyway, just as it was on the second visit.

Result: Plaintiff attorneys actually pursued this case to trial, where the jury quickly rendered a defense verdict.

Takeaways:

• SEA is rarely diagnosed on first presentation.
• If SEA can’t be ruled out on history and exam alone, an ESR or CRP is evidence that the diagnosis was included in the differential.
• In this case, a psoas abscess was a red herring, but also the likely source of the SEA eventually discovered.
• Antibiotics treatment alone may be tried on small SEA’s without any neurologic symptom, but with very close inpatient monitoring.
• Early surgical decompression before neurologic symptoms arise is the goal, as patient’s functional losses usually remain at the level present at the time of surgery.
• On the first ED visit, symptoms did not warrant an MRI. On the second visit, SEA was considered, an MRI was done, the documentation supportive of the plan, and a full spinal MRI found no SEA.
• SEA is easily ruled out if one thinks about it. A normal CRP or ESR should be sufficient evidence to keep a plaintiff attorney from filing a lawsuit – and finding a plaintiff expert to support the claim.
• We are expected to be physicians, not prophets.

Further Reading:

EP Monthly – Diagnosing SEA

“If the aviation industry managed plane crashes the way we in healthcare manage ours, none of us would dare get on an airplane.”

Physician/Patient Safety Advocate, speaking on the lack of transparency and learning in medical malpractice lawsuits