Failure to diagnose epidural abscess

July 3, 2019

Presentation and physician action
A 44-year-old woman with a history of IV drug use was treated at a clinic for a foot infection and back spasms.

A month later, she returned to the clinic and was sent to Hospital A for treatment of a MRSA infection. She was admitted by Emergency Physician A, treated with antibiotics, and discharged from the hospital approximately two weeks later.

The patient returned to the hospital’s ED several weeks later due to continued back pain. She was diagnosed with back strain or sprain and released from the ED. She returned the next day with complaints of abdominal pain. Emergency Physician B ordered a CT scan of the abdomen.

At 6:55 a.m., while being prepped for the CT scan, the patient complained that she could not move her legs.

At 7 a.m., a shift change occurred and Emergency Physician C began caring for the patient. Emergency Physician C was told the patient could not move her legs, but did not re-evaluate the patient. At 9:30 a.m., a nurse noted that the patient was standing on both feet and bearing weight.

At 10 a.m., a radiologist reviewed the CT scan and diagnosed “hepatosplenomegaly.” He also reviewed an x-ray of the spine and did not find anything abnormal. At 10:30 a.m., the patient was discharged. It was noted that the patient was combative and did not want to be discharged due to her reports that she could not move her legs.

Later that day, the patient’s parents brought her back to the ED. Emergency Physician C admitted the patient at approximately 1 p.m. and ordered an MRI of the cervical, thoracic, and lumbosacral spine for paralysis/paraplegia.

After two days in the hospital without the MRI series being performed, Emergency Physician A reordered the MRI of the thoracic and lumbar spine. During this time, the patient reported no improvement in feeling or function.

The next day, the MRI of the lumbar spine was completed. The thoracic MRI was not completed because the patient could not tolerate it. Interpretations of the MRI on the lumbar spine suggested “clumping of the nerve roots at L4 to L5 levels consistent with arachnoiditis.”

After several days, the patient was transferred to Hospital B, a higher-level facility, and evaluated by a neurosurgeon. By this time, the patient had lost function in her legs, developed bladder and bowel incontinence, and lost sphincter control.

The same day as the patient’s transfer, the neurosurgeon discovered a spinal abscess and immediately took the patient to surgery to treat it. The patient remains a paraplegic requiring lifelong care.

 

Allegations
Lawsuits were filed against Hospital A, the ED physicians, and the radiologist. Allegations include failure to timely diagnose the epidural abscess.

The plaintiffs also alleged that the radiologist should have noted abnormal findings on the abdominal CT scan, which would have alerted the ED physicians to order a STAT spinal MRI. The delay in completing the MRI led to the patient’s deterioration and delay in transfer and treatment at Hospital B. It was alleged that if treatment had been timelier, paralysis would have been prevented.

 

Legal implications
Experts for the plaintiff criticized Hospital A for discharging the patient against her will, especially considering her complaints of sudden paralysis. They were also critical of the physicians for not following up on the MRI after several days, or prompting a STAT order given the patient’s condition. One expert felt that the patient’s paralysis warranted a STAT MRI. A resulting diagnosis of spinal abscess would have indicated a medical emergency.

Experts also noted abnormalities on the CT scan that the radiologist did not document, such as inflammation around the spine and a possible soft tissue mass near the thoracic spine. Even though he reviewed the CT scan for abdominal pain, he should have been aware of the back pain since he also reviewed an x-ray of the patient’s spine.

Helpful to the defense was the opinion from the treating neurosurgeon. He believed the patient suffered from an acute infarct, which resulted in her abrupt paralysis prior to the CT scan. Even if the radiologist had noted abnormalities or the MRI completed earlier, once an occlusion occurs it takes only 30 minutes to cause permanent neurological damage.

Expert opinions from all sides agreed that it was likely the patient’s IV drug use led to the MRSA infection, which may have caused her spinal abscess. The patient’s reluctance to discuss her IV drug use may have also contributed to delays in her care.

The case was further complicated by allegations that several hospital staff members were dismissive of the patient, due to her lack of insurance and history of drug abuse.

 

Disposition
The case was settled early on behalf of the radiologists and hospital. The cases against the ED physicians were settled during jury selection. 

 

Risk management considerations
Communication issues were a factor throughout this case.

Emergency Physician C had an obligation to re-evaluate the patient at shift change, especially after being told the patient could not move her legs. Had he re-evaluated the patient, this may have prevented her from being discharged and the delay in diagnosis.

Most harmful to the defense was the fact that the radiologist did not communicate the abnormalities present in the CT scan to the ED physicians. Even though he reviewed the CT scan for complaints of abdominal pain, he should have been aware of complaints of back pain since he also reviewed an x-ray of the patient’s spine. If the ED physicians were given these notes, the MRI could have been completed the same day.

The physicians also failed to complete the MRI tests over several days. This raised ethical questions of whether the hospital elected to not perform the tests because the patient was uninsured. Federal laws prohibit EDs from refusing necessary care to patients for lack of insurance coverage. Protocols should also be in place to ensure tests are completed and reviewed in a timely manner.

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