Failure to diagnose spinal epidural abscess

Presentation
A 45-year-old woman with leg weakness called EMS to her home. The patient was transported to a hospital ED with “new weakness and altered sensation to bilateral lower extremities.” The patient had a history of insulin-dependent diabetes and chronic back pain. The triage nurse noted the patient had bilateral leg weakness and an inability to lift or bend her legs. The patient reported she had recently been seen at another hospital on two occasions for a urinary tract infection and back pain.
 

Physician action
ED Physician A examined the patient and noted parasthesia, hyperglycemia, and hypokalemia. The patient’s metabolic values indicated an Hgb. A1C of 15.9, blood glucose of 599, and a potassium level of 3.3. Physician A attributed the leg weakness and parasthesia to the patient’s hyperglycemia and low potassium. No neurological exam was noted, and Physician A’s handwritten notes were illegible. Physician A prescribed insulin, potassium, and ketorolac tromethamine upon discharge. The patient told the nursing staff that she felt she should not be discharged and that she was unable to bear weight or to walk.

ED Physician B encountered the patient in tears as she was exiting the hospital. Physician B observed that the patient was able to bear weight and move her legs, and ordered an MRI of the patient’s lumbar spine. The MRI was “negative” with the exception of bilateral hydronephrosis and urinary bladder distention. Physician B ordered a Foley catheter to relieve the patient’s bladder distention and instructed the patient to follow up at a nearby hospital clinic. The patient was instructed to see a urologist for removal of the Foley and management of her bladder dysfunction.

A few hours after the patient’s discharge, the patient arrived at another hospital and was unable to urinate or stand. She was admitted from the ED. The admitting physician consulted a neurologist who assumed the patient had previously undergone a full MRI series of her spine. Two days later, the patient showed signs of neurological deficits in her legs and incontinence of the bladder and bowel.

It was then discovered that the previous MRI imaged only the patient’s lumbar spine. An MRI of her entire spine was ordered, and it revealed a large spinal epidural abscess (SEA) at the T4-7 level.

Five days later, after the patient’s SEA diagnosis, the treating physicians initiated a transfer to another hospital with neurosurgery capabilities for urgent decompression of the patient’s SEA. The surgery did not restore the neurologic function of the patient’s legs. The patient is now permanently paraplegic requiring at least 8 hours of daily custodial care.
 

Allegations
A lawsuit was filed against ED physicians A and B. In addition, suit was also filed against the physicians who treated the patient’s urinary tract infection and back pain at the first hospital; eight subsequent treating physicians, including five practice groups (employers of the codefendant physicians); and two of the involved hospitals.

The plaintiff claimed her repeated complaints of back pain and inability to feel her legs or to walk were disregarded by her physicians. Their lack of attention resulted in a delayed diagnosis of SEA and permanent bilateral paraplegia. The allegations against ED physicians A and B, who discharged her on the same day, included gross negligence. (In ED medical malpractice cases, a “willful and wanton” negligence standard is applied until the patient is stabilized.)
 

Legal implications
The lack of documentation in the orders of Physicians A and B was the primary concern regarding the standard of care issues in this case. No neurological exam was documented; the patient’s inability to walk was not explained; and the medical records gave the impression the patient may have been rushed out of the ED without being appropriately diagnosed.

Although standard of care experts were found to support these ED physicians, the majority of reviewing consultants and medical experts from multiple specialties were critical of the care provided. Specifically, they felt the patient was inappropriately discharged twice without a firm diagnosis for leg weakness and inability to walk.

A subsequent treating neurosurgeon also testified that the patient’s history of uncontrolled diabetes made her a higher risk for SEA. In addition, had the ED physicians admitted the patient, a correct diagnosis and prompt treatment may have helped the patient recover without neurological deficits. 

The other treating physicians who did not diagnose the patient’s condition or order surgical intervention emergently — despite progressing neurologic deficits — were similarly criticized.
 

Disposition
The case was settled on behalf of ED Physicians A and B. The co-defendants also settled their cases prior to trial. 


Risk management considerations
ED Physicians A and B did not have sufficient documentation to successfully defend their care. A more complete work up may have averted the patient’s outcome. The patient gave a clear history of back pain, leg weakness, and inability to walk. But the documentation did not show a firm diagnosis or that a neurology consultation was ordered, which may have given the impression the physicians did not listen to the patient’s complaints.

Good documentation shows a physician’s orders and thought processes. In this case and given the patient’s presentation, if the physicians had documented their diagnostic reasoning, it would have strengthened their defense. The lack of documentation to support findings is a common allegation in medical malpractice claims and is correctable with appropriate attention.

 

 

These closed claim studies are based on an actual malpractice claims from TMLT. These cases illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. These studies have been modified to protect the privacy of the physicians and patients.

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