Failure to diagnose Fournier’s gangrene
A 50-year-old man came to the emergency department (ED) at a medical center reporting swollen testicles. His discomfort began that morning with posterior, right testicular tenderness. The patient denied any dysuria or urinary urgency/frequency.
Failure to diagnose Fournier’s gangrene
A 50-year-old man came to the emergency department (ED) at a medical center reporting swollen testicles. His discomfort began that morning with posterior, right testicular tenderness. The patient denied any dysuria or urinary urgency/frequency.
Presentation
A 50-year-old man came to the emergency department (ED) at a medical center reporting swollen testicles. His discomfort began that morning with posterior, right testicular tenderness.
His vitals were recorded as temperature: 98.9; heart rate: 133 bpm; respiratory rate: 20; blood pressure: 186/102 mmHg; and oxygen saturation: 95 percent. He weighed 267 pounds and was noted as being “morbidly obese.” The patient denied any dysuria or urinary urgency/frequency.
Physician action
Emergency medicine (EM) Physician A examined the patient around 10:30 a.m., and noted tenderness with increased rigidity to the posterior epididymis which was worse on the right. There was no testicular swelling or erythema. The patient was diagnosed with epididymitis and told to follow up with a urologist in two to four days.
The patient was given educational materials on epididymitis and prescriptions for sulfamethoxazole/trimethoprim and tramadol. He was instructed to return to the ED if symptoms worsened.
Three days later, the patient was found unresponsive by a family member and transported by EMS to a different ED. The patient was tachycardiac and hypotensive on arrival and required intubation.
Lab work revealed significant hypernatremia, acute kidney injury, significant leukocytosis, and a glucose level of 1200. He was in severe septic shock and diabetic ketoacidosis. The patient’s hemoglobin A1C was 12.7%, which suggested untreated diabetes.
Physical exam of the patient’s scrotum revealed a large central area of necrosis surrounded by erythema, warmth, edema, and crepitus. X-ray and CT scan results revealed extensive subcutaneous gas involving the right scrotal sac, base of penis, mons pubis, and into the right groin and right ventral abdominal wall. The findings were consistent with Fournier’s gangrene.
That day, the patient underwent emergency debridement of the scrotum. During the procedure, a necrotic area measuring 8 x 10 cm was noted to involve the anterior and dependent aspects of the scrotum. The right inguinal area was also examined and did not reveal evidence of a necrotizing process.
The patient was transferred to the critical care unit where he remained intubated and sedated. He was followed by specialists in urology, general surgery, infectious disease, critical care, and nephrology. His prognosis was poor.
Three days after surgery, the patient’s code status was changed to DNR; however, his family elected to continue all other aspects of medical management. On his first day in the critical care unit, the patient’s blood cultures grew enterococcus and, five days later, his blood cultures grew yeast.
Over the next several days, hemodialysis was initiated for advanced renal failure related to the patient’s septic shock. Bedside debridement was performed by a urologist. A tracheostomy tube and gastrostomy tube were also placed.
Approximately two weeks after surgery, the patient was transferred to the stepdown unit but remained intubated.
Five days later, the patient’s family agreed to hospice care for the patient. He was taken off the ventilator and hemodialysis was discontinued. The patient died the next day.
Allegations
A lawsuit was filed against EM Physician A and Hospital A for failure to timely diagnose and treat Fournier’s gangrene. Allegations included failure to order urinalysis, urine culture, STI testing, diagnostic imaging (ultrasound) to rule out testicular torsion or abscess, blood glucose levels, and CBC. It was further alleged that these failures breached the standard of care and led to the patient’s death.
Legal implications
Expert consultants for both the plaintiff and defense noted EM Physician A’s failure to recognize and address the patient’s abnormal vital signs including elevated heart rate. Another consultant pointed out that it was unclear how EM Physician A came to the diagnosis of epididymitis, as the physician’s decision making was not documented.
Multiple consultants specifically pointed out that a urinalysis was necessary to support the epididymitis diagnosis or ensure its appropriate treatment. This failure to obtain lab work to confirm the diagnosis of epididymitis was considered below the standard of care.
EM Physician A also failed to include differential diagnoses in the patient record. This gave the appearance that other potential causes of the patient’s pain and symptoms were not considered. The incomplete record also reflected that EM Physician A failed to recognize that the patient met the criteria for systemic inflammatory response syndrome (SIRS). Had the potential for SIRS been observed, further testing and admission to the hospital would have been indicated.
Disposition
This case was settled on behalf of EM Physician A. Hospital A also settled this case with the plaintiff.
Risk management for emergency medicine physicians
About diagnostic errors
Disclaimer
Presentation
A 50-year-old man came to the emergency department (ED) at a medical center reporting swollen testicles. His discomfort began that morning with posterior, right testicular tenderness.
His vitals were recorded as temperature: 98.9; heart rate: 133 bpm; respiratory rate: 20; blood pressure: 186/102 mmHg; and oxygen saturation: 95 percent. He weighed 267 pounds and was noted as being “morbidly obese.” The patient denied any dysuria or urinary urgency/frequency.
Physician action
Emergency medicine (EM) Physician A examined the patient around 10:30 a.m., and noted tenderness with increased rigidity to the posterior epididymis which was worse on the right. There was no testicular swelling or erythema. The patient was diagnosed with epididymitis and told to follow up with a urologist in two to four days.
The patient was given educational materials on epididymitis and prescriptions for sulfamethoxazole/trimethoprim and tramadol. He was instructed to return to the ED if symptoms worsened.
Three days later, the patient was found unresponsive by a family member and transported by EMS to a different ED. The patient was tachycardiac and hypotensive on arrival and required intubation.
Lab work revealed significant hypernatremia, acute kidney injury, significant leukocytosis, and a glucose level of 1200. He was in severe septic shock and diabetic ketoacidosis. The patient’s hemoglobin A1C was 12.7%, which suggested untreated diabetes.
Physical exam of the patient’s scrotum revealed a large central area of necrosis surrounded by erythema, warmth, edema, and crepitus. X-ray and CT scan results revealed extensive subcutaneous gas involving the right scrotal sac, base of penis, mons pubis, and into the right groin and right ventral abdominal wall. The findings were consistent with Fournier’s gangrene.
That day, the patient underwent emergency debridement of the scrotum. During the procedure, a necrotic area measuring 8 x 10 cm was noted to involve the anterior and dependent aspects of the scrotum. The right inguinal area was also examined and did not reveal evidence of a necrotizing process.
The patient was transferred to the critical care unit where he remained intubated and sedated. He was followed by specialists in urology, general surgery, infectious disease, critical care, and nephrology. His prognosis was poor.
Three days after surgery, the patient’s code status was changed to DNR; however, his family elected to continue all other aspects of medical management. On his first day in the critical care unit, the patient’s blood cultures grew enterococcus and, five days later, his blood cultures grew yeast.
Over the next several days, hemodialysis was initiated for advanced renal failure related to the patient’s septic shock. Bedside debridement was performed by a urologist. A tracheostomy tube and gastrostomy tube were also placed.
Approximately two weeks after surgery, the patient was transferred to the stepdown unit but remained intubated.
Five days later, the patient’s family agreed to hospice care for the patient. He was taken off the ventilator and hemodialysis was discontinued. The patient died the next day.
Allegations
A lawsuit was filed against EM Physician A and Hospital A for failure to timely diagnose and treat Fournier’s gangrene. Allegations included failure to order urinalysis, urine culture, STI testing, diagnostic imaging (ultrasound) to rule out testicular torsion or abscess, blood glucose levels, and CBC. It was further alleged that these failures breached the standard of care and led to the patient’s death.
Legal implications
Expert consultants for both the plaintiff and defense noted EM Physician A’s failure to recognize and address the patient’s abnormal vital signs including elevated heart rate. Another consultant pointed out that it was unclear how EM Physician A came to the diagnosis of epididymitis, as the physician’s decision making was not documented.
Multiple consultants specifically pointed out that a urinalysis was necessary to support the epididymitis diagnosis or ensure its appropriate treatment. This failure to obtain lab work to confirm the diagnosis of epididymitis was considered below the standard of care.
EM Physician A also failed to include differential diagnoses in the patient record. This gave the appearance that other potential causes of the patient’s pain and symptoms were not considered. The incomplete record also reflected that EM Physician A failed to recognize that the patient met the criteria for systemic inflammatory response syndrome (SIRS). Had the potential for SIRS been observed, further testing and admission to the hospital would have been indicated.
Disposition
This case was settled on behalf of EM Physician A. Hospital A also settled this case with the plaintiff.
Risk management for emergency medicine physicians
About diagnostic errors
Disclaimer
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