Failure to obtain timely consults and tests
On August 26 at 8:40 a.m., a 45-year-old man was transported from his home by EMS to Hospital A for severe, sudden onset back pain. The patient’s history included diabetes, hypertension, and obesity.
Failure to obtain timely consults and tests
On August 26 at 8:40 a.m., a 45-year-old man was transported from his home by EMS to Hospital A for severe, sudden onset back pain. The patient’s history included diabetes, hypertension, and obesity.
Presentation and physician action
On August 26 at 8:40 a.m., a 45-year-old man was transported from his home by EMS to Hospital A for severe, sudden onset back pain. The patient’s history included diabetes, hypertension, and obesity.
Emergency Medicine (EM) Physician A saw the patient at 8:50 a.m. and noted significant tachycardia, blood pressure of 200/100 mmHg, and elevated white blood count (WBC). The patient rated his pain as 10/10.
Efforts to lower his blood pressure with IV medication were not successful. A CT scan of the abdomen and pelvis did not reveal any acute findings but did show an enlarged bladder. The patient was given several IV pain medications. Antibiotics were also ordered to address the elevated WBC and possible infection.
At 4 p.m., EM Physician A arranged to transfer the patient to a different facility where he could receive a higher level of care. Around this time, the patient reported that his lower left leg was numb.
The patient was taken to Hospital B at 6 p.m. The trip took about 90 minutes to complete. Upon the patient’s admission to the hospital under Hospitalist A, several tests were ordered, including a neurologic exam, musculoskeletal exam, and pelvic x-ray. The findings were mostly normal. The one exception was a lumbar CT scan that showed mild degenerative changes, which Hospitalist A noted did not explain the patient’s pain level.
Hospitalist A noted that her primary concern was the patient’s malignant hypertensive urgency. She ordered a D-Dimer to rule out aortic dissection and a head CT to rule out acute pathology. Additional notes included that the patient had numbness in both legs; 2+ pulses bilaterally, and bowel and urinary incontinence.
On August 27 at 4:10 a.m., Hospitalist A ordered an MRI of the lumbar spine to rule out acute pathology with an orthopedic evaluation indicated, pending the result of the lumbar MRI. The MRI was ordered as “routine.”
Hospitalist A’s shift ended at 7 a.m. and she was relieved by Hospitalist B.
Hospitalist B saw the patient at 10 a.m., still in the ED waiting for an available inpatient bed. The patient was unable to move his legs. Upon examination, Hospitalist B documented that the patient was suffering from acute to chronic low back pain with bilateral leg numbness/weakness. Hospitalist B rated the patient’s bilaterial leg strength as zero out of five (0/5).
Hospitalist B ordered a neurosurgery consult and upgraded Hospitalist A’s “routine” order for a lumbar MRI to “stat.” The stat MRI was completed almost six and a half hours later at 3:25 p.m.
The lumbar MRI showed disc protrusion and at least mild stenosis at T11/12 and T10/11. The radiologist recommended MRI of the thoracic spine.
At 8 p.m., a nurse placed a call requesting the neurosurgery consult originally ordered by Hospitalist B at 10 a.m. that morning. At 8:45 p.m., Neurosurgeon A examined the patient and documented that he was unable to move or feel his legs, and that his condition had worsened since his arrival at Hospital A. Neurosurgeon A also noted that the previous test results did not explain the patient’s acute paraplegia.
A stat thoracic MRI was ordered, as recommended by the radiologist, and showed disc herniations at multiple levels in the thoracic spine level compressing the spinal cord on the left side.
The next morning, August 28, Neurosurgeon A took the patient to surgery for an emergent thoracic laminectomy at T9-10, T10-11, and T11-12. He documented that he removed an epidural mass consistent with disc material and osteophyte that was compressing the thoracic spinal canal.
The patient remained in Hospital B for three weeks. He had a complete loss of sensory and motor function below T9-10. The patient reported no feeling below the waist and was unable to move his legs. The patient was discharged to a rehabilitation hospital and now uses a wheelchair.
Allegations
A lawsuit was filed against EM Physician A, Hospitalist A, Hospitalist B, Hospital A, and Hospital B alleging numerous delays that resulted in the patient’s permanent paraplegia. Delays included ordering appropriate diagnostic testing and a timely neurosurgery consult.
Legal implications
Expert consultants for both the defense and the plaintiff were critical of the physicians in this case, specifically for failing to recognize the patient’s neurological symptoms and the lack of follow up on ordered imaging tests and a neurosurgery consult. While there was support for Hospitalist B in changing the MRI order from routine to stat to ensure its completion before a neurosurgery consult, the consultants felt that Hospitalists A and B did not fully appreciate the patient’s condition and should have taken more urgent action to get the patient’s MRI completed and the patient seen immediately after by a neurosurgeon.
However, another consultant stated that by the time Hospitalist B saw the patient, he had been reporting leg weakness and numbness for approximately 14 hours and was likely already paraplegic.
The hospital and nursing staff were also criticized for the communication breakdowns that caused delays throughout this patient’s care, from transfer and admission to testing and consults. The events in this case took place during the height of the COVID-19 pandemic, which legal counsel for the hospital pointed to as temporarily affecting the hospital’s operations.
Disposition
The case was settled on behalf of the physicians. Outcomes for the cases against the two hospitals are unknown.
About improper performance
Risk management for hospitalists
Disclaimer
Presentation and physician action
On August 26 at 8:40 a.m., a 45-year-old man was transported from his home by EMS to Hospital A for severe, sudden onset back pain. The patient’s history included diabetes, hypertension, and obesity.
Emergency Medicine (EM) Physician A saw the patient at 8:50 a.m. and noted significant tachycardia, blood pressure of 200/100 mmHg, and elevated white blood count (WBC). The patient rated his pain as 10/10.
Efforts to lower his blood pressure with IV medication were not successful. A CT scan of the abdomen and pelvis did not reveal any acute findings but did show an enlarged bladder. The patient was given several IV pain medications. Antibiotics were also ordered to address the elevated WBC and possible infection.
At 4 p.m., EM Physician A arranged to transfer the patient to a different facility where he could receive a higher level of care. Around this time, the patient reported that his lower left leg was numb.
The patient was taken to Hospital B at 6 p.m. The trip took about 90 minutes to complete. Upon the patient’s admission to the hospital under Hospitalist A, several tests were ordered, including a neurologic exam, musculoskeletal exam, and pelvic x-ray. The findings were mostly normal. The one exception was a lumbar CT scan that showed mild degenerative changes, which Hospitalist A noted did not explain the patient’s pain level.
Hospitalist A noted that her primary concern was the patient’s malignant hypertensive urgency. She ordered a D-Dimer to rule out aortic dissection and a head CT to rule out acute pathology. Additional notes included that the patient had numbness in both legs; 2+ pulses bilaterally, and bowel and urinary incontinence.
On August 27 at 4:10 a.m., Hospitalist A ordered an MRI of the lumbar spine to rule out acute pathology with an orthopedic evaluation indicated, pending the result of the lumbar MRI. The MRI was ordered as “routine.”
Hospitalist A’s shift ended at 7 a.m. and she was relieved by Hospitalist B.
Hospitalist B saw the patient at 10 a.m., still in the ED waiting for an available inpatient bed. The patient was unable to move his legs. Upon examination, Hospitalist B documented that the patient was suffering from acute to chronic low back pain with bilateral leg numbness/weakness. Hospitalist B rated the patient’s bilaterial leg strength as zero out of five (0/5).
Hospitalist B ordered a neurosurgery consult and upgraded Hospitalist A’s “routine” order for a lumbar MRI to “stat.” The stat MRI was completed almost six and a half hours later at 3:25 p.m.
The lumbar MRI showed disc protrusion and at least mild stenosis at T11/12 and T10/11. The radiologist recommended MRI of the thoracic spine.
At 8 p.m., a nurse placed a call requesting the neurosurgery consult originally ordered by Hospitalist B at 10 a.m. that morning. At 8:45 p.m., Neurosurgeon A examined the patient and documented that he was unable to move or feel his legs, and that his condition had worsened since his arrival at Hospital A. Neurosurgeon A also noted that the previous test results did not explain the patient’s acute paraplegia.
A stat thoracic MRI was ordered, as recommended by the radiologist, and showed disc herniations at multiple levels in the thoracic spine level compressing the spinal cord on the left side.
The next morning, August 28, Neurosurgeon A took the patient to surgery for an emergent thoracic laminectomy at T9-10, T10-11, and T11-12. He documented that he removed an epidural mass consistent with disc material and osteophyte that was compressing the thoracic spinal canal.
The patient remained in Hospital B for three weeks. He had a complete loss of sensory and motor function below T9-10. The patient reported no feeling below the waist and was unable to move his legs. The patient was discharged to a rehabilitation hospital and now uses a wheelchair.
Allegations
A lawsuit was filed against EM Physician A, Hospitalist A, Hospitalist B, Hospital A, and Hospital B alleging numerous delays that resulted in the patient’s permanent paraplegia. Delays included ordering appropriate diagnostic testing and a timely neurosurgery consult.
Legal implications
Expert consultants for both the defense and the plaintiff were critical of the physicians in this case, specifically for failing to recognize the patient’s neurological symptoms and the lack of follow up on ordered imaging tests and a neurosurgery consult. While there was support for Hospitalist B in changing the MRI order from routine to stat to ensure its completion before a neurosurgery consult, the consultants felt that Hospitalists A and B did not fully appreciate the patient’s condition and should have taken more urgent action to get the patient’s MRI completed and the patient seen immediately after by a neurosurgeon.
However, another consultant stated that by the time Hospitalist B saw the patient, he had been reporting leg weakness and numbness for approximately 14 hours and was likely already paraplegic.
The hospital and nursing staff were also criticized for the communication breakdowns that caused delays throughout this patient’s care, from transfer and admission to testing and consults. The events in this case took place during the height of the COVID-19 pandemic, which legal counsel for the hospital pointed to as temporarily affecting the hospital’s operations.
Disposition
The case was settled on behalf of the physicians. Outcomes for the cases against the two hospitals are unknown.
About improper performance
Risk management for hospitalists
Disclaimer
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