by Olga Maystruk, Designer and Brand Strategist, and
Karen Werth, Senior Risk Management Representative
Presentation and physician action
An eight-year-old girl was brought to the emergency department (ED) of a large hospital with a groin injury from a bicycle accident. Examination revealed a 4.5 cm inguinal laceration with excessive vaginal bleeding and a possible split of the hymen. The patient also vomited once while in the ED.
A head CT and pelvic ultrasound were performed and found to be normal. The attending ED physician administered a local anesthetic with epinephrine, prepped the wound, and closed it with a single layer of eight sutures. The physician’s note stated: “Explored for foreign body, but nothing was found.”
While in the ED, the patient was also seen by a pediatric gynecologist. While the patient could not tolerate an extensive vaginal examination, the pediatric gynecologist noted that vaginal bleeding was minimal and had possibly clotted through natural processes. The patient was then discharged home with instructions to her mother to return the patient to the ED if she had worsening symptoms or was using one pad per hour.
Two days later, the patient had a temperature of 103 degrees and reported foul-smelling wound discharge. The mother took the patient to see her pediatrician, Pediatrician A, who diagnosed the patient with cellulitis. Pediatrician A prescribed both oral and topical antibiotics (mupirocin and clindamycin), and acetaminophen with codeine. The patient’s mother was told to contact Pediatrician A if the patient’s condition worsened.
While at home, the patient’s condition worsened, but the mother did not contact Pediatrician A.
Two days after the visit with Pediatrician A, the patient was taken to a different ED with urinary incontinence, worsening of the wound appearance and discharge, and a temperature of 104 degrees. A CT scan of the abdomen/pelvis showed a fascial defect between the child's rectus abdominis and external oblique muscle.
The patient was taken emergently to the operating room, where a pediatric surgeon found extensive necrotizing fasciitis and soft tissue infection of the left groin and abdominal wall into the extra peritoneal space. Additionally, a 3x7 cm piece of cloth possibly from the patient’s clothing during the bicycle accident, was discovered embedded deep in the wound between the rectus abdominal muscle and external oblique muscle.
Four days after surgery, the patient underwent a CT cystogram which showed an extraperitoneal bladder leak, an injury likely from the bicycle accident.
The next day, the child was returned to surgery for bladder repair, wound debridement, and wound VAC placement. The patient returned for VAC replacement and wound debridement six more times every three days.
During a follow-up visit with the pediatric surgeon three months later, it was noted that the patient was recovering well and reported no pain. She was negative for fever, chills, dysuria, urinary frequency, or incontinence. The wound appeared to be healed and all the surrounding tissue was negative for erythema.
Six months later, the patient was taken to a psychiatrist who evaluated the patient and noted symptoms of PTSD, anxiety, depressive reaction, and organic depression all due to the infection.
The patient also received an assessment from a physical medicine and rehabilitation physician. The report stated the patient needed monthly physical therapy and psychiatry visits, bi-monthly visits with a psychotherapist, two-to-four visits annually with a rehabilitation specialist, and an abdominal MRI every three-to-five years.
Allegations
A lawsuit was filed against Pediatrician A alleging failure to explore the wound and detect the foreign body, and failure to follow up.
Legal implications
Two of the three expert consultants for the defense stated that Pediatrician A acted within the standard of care. One consultant noted that at the time of the visit there was no evidence of a significant infection; therefore, the physician’s outpatient management was correct. However, given the next set of events two days later, it was difficult to judge the severity of infection based on the records. This consultant believed the primary issue in this case to be the incorrect closure of the initial laceration, leaving a foreign body inside. The mother’s failure to act immediately and follow the physician’s orders were also seen as factors in this case.
The other consultant for the defense was more critical of Pediatrician A and felt he did not meet the standard of care. This consultant stated that since fever and foul odor are indicators of a severe wound infection, a reasonable treatment would have been to refer the patient to the ED, admit the patient to the hospital, start IV antibiotics, and consult general surgery. This consultant felt that had Pediatrician A met the standard of care the patient's infection would have been less severe, but surgery and a prolonged hospitalization would have still been likely or required.
A consultant for the plaintiff noted that while Pediatrician A’s antibiotic orders were appropriate, failing to schedule a 24-hour follow-up appointment was below the standard of care.
Disposition
This case was settled on behalf of Pediatrician A.
Risk management considerations
Although the primary issue was the incorrect closure of the laceration with a retained foreign body, communication breakdowns between the patient’s mother and the different providers in this case may have contributed to the severity of the outcome.
During the ED visit, instructions were given to the mother to return to the ED if the patient’s symptoms worsened; however, the mother instead contacted Pediatrician A. After the visit with Pediatrician A, the mother was given instructions to contact Pediatrician A if symptoms worsened. In this instance, the mother returned to the ED.
Studies have shown that patients often do not correctly remember medical treatment or follow-up information given by health care providers, with 40 to 80 percent of medical information forgotten immediately. Reasons for inaccurate patient recall can vary from physicians using unfamiliar medical terminology to stressful circumstances, such as a poor prognosis or highly emotional scenarios. When the patient is a child in distress, a parent or guardian may find it difficult to understand or concentrate on follow-up instructions, which can lead to a delay in care. (1)
To ensure directions for care and follow-up are understood, it is recommended that a provider’s spoken instructions be supported with written, detailed instructions to the patient or the patient’s caregiver. In this case, printed or written instructions to contact Pediatrician A’s office if the patient had worsening symptoms or fever, chills, bleeding, etc., may have resulted in the mother obtaining earlier instructions to seek emergent care or obtain a referral to general surgery. Document the specifics of patient education in the medical record, including follow-up instructions or handouts given. In Texas, documentation of patient/family education and specific instructions for follow up are considered standard elements of an “adequate medical record”. (2)
Pediatrician A’s lack of follow up was also a weakness in this case. It is a good risk management practice to schedule follow-up visits at the time of the visit before patients leave the office. For example, follow-up visits can be scheduled during the checkout process. Doing so ensures patients will be seen and properly followed.
If a patient’s condition is complicated or life-threatening, the physician may want to consider scheduling follow-up appointments soon after the initial visit, for example, in 24 hours.
Another weakness in this case was documentation. One expert described the documentation as “scant” regarding the description of the wound. In addition, portions of the note were handwritten and difficult to read. Clear, comprehensive, and proper documentation can help to facilitate quality care and be a crucial benefit when defending a medical liability claim.
Sources
- Kessels RPC. Patients’ memory for patient information. Journal of the Royal Society of Medicine. May 2003. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC539473/. Accessed August 31, 2021.
- Texas Medical Board. Texas Medical Board Rules Chapter 165 Medical Records. Rule 165.1(6)(C)(D). Available at https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=165&rl=1. Accessed September 2, 2021.
Olga Maystruk can be reached at olga-maystruk@tmlt.org.
Karen Werth can be reached at karen-werth@tmlt.org.
