Educational Articles

Necrotizing Fasciitis Diagnosed as Lumbar Radiculopathy – Death

$585,000 Illinois Settlement

 

The plaintiff’s decedent, an eighty-one year old man, presented to the emergency room with complaints of lower back pain and buttocks pain radiating to his right leg. Upon examination by the ED physician and a physician’s assistant, it was determined that the plaintiff’s symptoms and clinical presentation were consistent with lumbar radiculopathy. The decedent reported having similar symptoms on his left side two weeks prior. The ED physician spoke to the decedent’s primary care physician and informed him of her findings and diagnosis. The primary physician was aware of the decedent’s complaints of chills, night sweats, and pain radiating from the hip to the anus, but did not communicate these complaints to the ED physician, nor did the decedent. The decedent’s buttocks were not examined or visualized before being discharged. The ED physician advised him to follow-up with an orthopedic surgeon and return if he experienced any new symptoms or increased symptoms. Two days later, the decedent was taken to the ED and diagnosed with necrotizing fasciitis of the right buttocks. He died later that day from complications of the infection. The estate of the decedent contends that the physician and physician’s assistant were negligent in failing to visualize and palpate the buttocks area, and failing to diagnose an infection of the right buttocks. The plaintiff’s experts argued that there would have been some evidence of infection, and that the infection would have been treatable. The defense argued that the patient was thoroughly examined and diagnosed with lumbar radiculopathy. Furthermore, the defense contends the patient never reported any complaints of an acute wound or indications of a buttocks infection to any of the ED providers. The estate settled prior to trial for $585,000 with the hospital.

 

This case highlights several factors that could have been improved upon that led to this poor outcome. This case clearly demonstrates why patients should be disrobed and placed in a gown. Often in an effort to expedite care and increase throughput, patients may not be fully disrobed. Disrobing patients allows you to perform a complete exam including a visual inspection of the skin. Examining the skin can lead you to discover other causes for back pain such as shingles, abscesses, cellulitis, and bruising that may lead to suspicions for trauma or abuse. In addition to the physician’s assistant exam, you should do your own history and physical to make sure things are not missed. Lastly, one would hope that the communication with the primary care provider had been more forth coming with the patient’s previous history. Regardless, we often do not have the luxury of a good history from a primary care provider. Additionally, the lack of history from the patient is a common problem. Histories can often be either incomplete or misleading in the elderly or with less educated patients.  They may not understand the ramifications of not providing a full history or understand the importance of other symptoms they experience. It is very important to make sure you think fully about your differential diagnoses and ask appropriate questions. When working with other providers such as students, residents, and advance practice providers or when getting handoffs, make sure you perform your own history and physical. 

Ultimately the take home points are: 1) disrobe the patient to optimize your exam, 2) in the elderly or less educated, think of your differentials and ask probing questions, 3) when working with others and getting handoffs, performing your own history and physical is important, and 4) use all sources of history whenever possible.