Texas Medical Liability Trust

Failure to conduct an adequate exam and delay in performance

Clinical presentation
A 56-year-old man presented to a new primary care physician, an internal medicine specialist. The patient had a history of hypertension, hyperlipidemia, hypothyroidism and clinical depression. Four years prior to his visit to the internal medicine physician, the patient had been diagnosed with a calcified thoracic HNP. At that time, the treating neurosurgeon told the patient the thoracic disk could result in acute deterioration, including paraplegia and loss of bowel control. He also discussed the risks of surgery to correct the problem. The neurosurgeon urged the patient to seek another opinion, and if he elected to do nothing, to return for a follow up visit in a few months. The patient never returned to the neurosurgeon or sought further treatment for his back.

Physician action
At the time of the first visit with the internal medicine physician, the patient’s medical problems were reviewed. The physician’s records for the patient included the prior CT findings from the neurosurgeon. A routine physical exam was performed and neurological findings were normal. The physician saw the patient routinely over the next 18 months. During these visits, there were no complaints of back pain.

Approximately seven months after his last visit, the patient returned to the internal medicine physician with diffuse low back pain. The neurological exam was normal; there was positive straight leg raising and no change in bladder or bowel function. The patient also had good range of motion. It was noted the patient had a positive calcified disc in his back, as indicated by the previous studies. The physician told the patient to stay off his feet and not to lift anything. He prescribed Naprosyn and told the patient to return in one to two weeks if he was not better.

The patient also sought treatment from a chiropractor for his back pain. The records from the chiropractor were unclear, but it did not appear that any adjustments were performed. The chiropractor did give the patient a prescription and told him to apply ice. Fifteen days after presenting to the internal medicine physician with back pain, the patient returned. He was admitted into the hospital for worsening right low back pain radiating to the right heel, now associated with urinary retention. Ataxia was noted. The internal medicine physician called in an orthopedic surgeon to consult. The surgeon conducted a thorough neurological exam in the presence of the internal medicine physician. All findings were normal. After the exam, the surgeon ordered a lumbar view MRI to be completed ASAP.

The following day, the patient was again seen by the orthopedic surgeon. The patient reported that his back was better and there were no neurological symptoms. The patient was also seen by a urologist, at the request of the internal medicine physician. The IM physician suspected a neurogenic etiology for the urinary retention.

The urologist noted there was no previous, significant history of urological problems, and the patient reported no problems with his urinary bladder despite the acute back pain he experienced four years previously. The examination revealed normal sensation throughout the perineum, a normal bulbocavernosa reflex, tight anal sphincter tone and normal anal wink. The urologist concluded the urinary retention was caused by the acute back pain and accentuated by narcotic medications. In addition, the anticholinergic effects of antidepressants were thought to be playing a role. He felt the patient would recover and intermittent catherization was ordered. The urologist did not believe the bladder dysfunction was neurological in origin.

Early the next morning, the internal medicine physician and the orthopedic surgeon were called to the hospital by the nurses.The nursing entry indicates the patient was experiencing a lack of sensation from the waist down and an inability to move the lower extremities with loss of reflexes. According to the orthopedic surgeon’s note, the patient had severe back spasms at 2 p.m. the previous afternoon. The MRI ordered ASAP by the surgeon the previous morning had not yet been performed. Another MRI was ordered stat, and revealed an extremely large herniated nucleus pulposus at T8-9 level causing severe cord compression.

The patient was transported to another hospital for an emergency thoracotomy with anterior discectomy of T8-9. The procedure was performed without complication. The patient regained partial motor and sensory function in the left leg. He was discharged and transferred to a local rehabilitation hospital. After leaving the rehab hospital, the patient continued physical therapy for approximately two years. At present, the patient can walk with a cane, but suffers permanent loss of bowel and bladder control.

Allegations
The main allegations in this case were:

• failure to conduct a proper and adequate neurological exam (both physicians)

• failure to conduct a rectal and perineal exam (both physicians)

• failure to refer patient to a competent orthopedic surgeon (IM)

• failure to obtain an emergent MRI scan (both physicians)

• delay in performance of surgery (surgeon)

• failure to obtain more experienced and qualified consultants (both physicians)

Legal implications
Overall, TMLT consultants were supportive of the care rendered in this case. When he saw the patient’s condition, the internal medicine physician immediately admitted him to the hospital and called in orthopedic and urology consults. The orthopedic surgeon’s evaluation of the patient was consistent with a patient who had long-standing low back problems from pre-existing conditions that were not emergent in nature.

However, both plaintiff and defense experts were critical of the internal medicine physician’s failure to advise both the orthopedic surgeon and the urologist of the patient’s prior diagnosis of calcified thoracic HNP. It was alleged that the internal medicine physician’s failure to do so led the subsequent consultants to the wrong conclusion. The orthopedic surgeon was also criticized for not ordering a stat thoracic MRI at the time the patient was admitted. The orthopedic surgeon testified that he did not see the need for a stat MRI because the patient had a normal neurological exam. There also was some question as to whether or not a thoracic MRI at the time of admission would have shown a surgical lesion.

Disposition
This case was settled in the low six figures on behalf of the internal medicine physician and in the low six figures on behalf of the orthopedic surgeon.

Risk management considerations
1. Communication between providers - Sharing a patient’s past medical history with subsequent treating physicians and consultants is essential. Relevant past history must be communicated in the medical record and, where appropriate, communicated directly to the consulting physician.

In this case, the internal medicine physician failed to relay relevant past medical history (prior diagnosis of calcified nucleus pulposus) to the orthopedic surgeon which may have affected the surgeon’s assessment of the urgency in obtaining an MRI. However, the orthopedic surgeon cannot completely rely on information given by a referring physician and must perform his own history and physical examination.

2. Inpatient tests - The physician ordering diagnostic testing in a hospital setting should be judicious in acknowledging priority with regard to time for completion and appropriate follow-up of the results. Physicians may dangerously assume that a hospitalized patient will undergo ordered tests in a timely manner due to round the clock monitoring. Test orders must be clear as to their urgency, i.e., routine, STAT, etc. Unless it has a specific meaning in your institution(s), ASAP is too vague a time frame. It may also be necessary for the ordering physician to advise appropriate hospital personnel of the nature of the patient condition and why the test is to be performed. Lastly, the ordering physician must follow-up on the completion of tests ordered.

In this case, there was a question as to whether the delay in performance of the MRI resulted in the patient’s adverse outcome, since it may or may not have shown a surgical lesion at the time of admission. Timely performance of the MRI may have helped to demonstrate the physicians could not have prevented the patient’s paralysis.