Failure to diagnose bacterial meningitis
A 27-year-old man came to the Emergency Department (ED) reporting persistent headaches that had worsened in the past 48 hours.
Presentation
A 27-year-old man came to the Emergency Department (ED) reporting persistent headaches that had worsened in the past 48 hours. The symptoms started two weeks earlier, soon after the patient had wisdom teeth extracted. The oral surgeon had prescribed cyclobenzaprine, naproxen, tramadol, amoxicillin, and chlorhexidine mouthwash.
Physician action
Emergency Medicine (EM) Physician A evaluated the patient, ordered a non-contrast CT scan of the head and prescribed codeine/paracetamol. The results of the physical and CT exams were normal. The patient was discharged with a diagnosis of “headache.”
The next day, the patient returned to the ED with reports of left-side facial numbness, difficulty swallowing, rapid blood pressure changes, shaking, sweating, fever, abdominal pain, and vomiting. EM Physician B ordered a complete blood count test, metabolic panel, urinalysis, and an x-ray of the neck. The results of the x-ray were normal, and the patient’s white blood cell count was slightly elevated at 11.8.
EM Physician B’s diagnosis included acute cystitis without hematuria, treatment-resistant acute headache, and hypokalemia. The physician ordered potassium chloride 60 mg, acetaminophen 650 mg, cephalexin 500 mg, and ondansetron. The nurse practitioner (NP) discharging the patient added “acetaminophen per protocol” to the patient’s chart and recorded the patient’s temperature at 101.6 before release. The patient was instructed to follow up with his primary care physician and oral surgeon.
Three days later, the patient was found at home unresponsive and in asystole. The EMS transported the patient to the ED with CPR in progress. Resuscitative measures continued upon arrival. The patient never recovered and was pronounced dead.
The autopsy report stated: “I. A. Acute meningitis, bacterial. Brain cultures grew 4+ Beta-hemolytic streptococci, Group F and 4+ Streptococcus anginosus and 3+ anaerobic gram-negative rods (nonviable for identification) 1: probable complication of recent dental surgery. B. Cerebral edema, severe. II. Meningioma at base of pituitary.”
Allegations
A lawsuit was filed against EM Physicians A and B and their group. The allegations were failure to diagnose bacterial meningitis.
Legal implications
Defense consultants expressed mixed support for the care provided in the ED. While they were supportive of EM Physician A’s care, they stated that during the second visit the patient had abnormal vital signs and symptoms of a possible infection that required further investigation. The consultants also stated that the patient’s condition should have prompted contact with the oral surgeon.
Other experts for the defense were more supportive, though they did state that the discharge NP deviated from the standard of care by releasing the patient with fever without EM Physician A’s knowledge.
A consultant for the plaintiff stated that a lumbar puncture was indicated during the patient’s second visit to the ED to rule out infection. This consultant further alleged that had a lumbar puncture been performed, meningitis would have been diagnosed, and the patient’s death could have been avoided.
Disposition
The case was settled on behalf of Emergency Physician B and the group. Emergency Physician A was dismissed.
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Risk management for emergency medicine physicians
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