Radiologist’s Recommendation Puts Focus on Surgeon’s Judgment

Consultants are not apt to directly tell the referring physician how he or she should treat the patient. But a radiologist’s repeated recommendations to a surgeon for clinical follow-up can come very close.

A 45-year-old teacher and avid skateboarder visited the ER after crashing at a local skate park and landing in dirt. Dr. ER, the emergency room physician, noted a 4 cm laceration to the right suprapatellar region of the left leg. Dr. ER flushed the wound with sterile water and repaired the laceration with subcutaneous and superficial sutures. Dr. OS gave the patient aftercare instructions, advised him to return to the ER if things did not improve or got worse, and directed him follow-up with his primary care physician. Though Dr. ER took a history of a tetanus shot within five years, his chart also recited, twice, “NOT UTD WITH TETANUS SHOT.” The patient claimed that Dr. ER told him that he did not need antibiotics.

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The patient returned to Dr. ER three days later complaining of a diffuse, dull, and severe worsening of left knee pain. The knee was markedly swollen though the wound was healing well. An ultrasound was negative for DVT and an X-ray was “unremarkable,” save for some tissue swelling. The temperature of the crutch-using patient was 98.7. Dr. ER prescribed Naproxen and Norco, but no antibiotics were applied or prescribed.

Three days hence, the patient visited his PCP, who took a history of the skateboarding accident. The patient complained of worsening pain, swelling, tingling, and numbness into his toes. The PCP noted the edema was progressing proximally and that the patient was still using crutches. The PCP counseled the patient extensively on wound care and advised the gentleman to look for potential signs of infection. The PCP told the patient that if tingling and numbness persist, he should remove his compression socks and to go to the ER again if there was no improvement. The PCP recommended an orthopedic consult and recommended a return in a week to remove sutures. No antibiotics were applied or prescribed.

Instead of returning to the PCP the next week, the patient visited Dr. OS, an orthopedic surgeon. Though the patient reported head sweating, Dr. OS’ examination found no sweating and “extremities cool.” Dr. OS found a healing laceration on the anterior surface of the patella, moderate to severe pre-patellar bursitis, and moderate bruising of the anterior knee. X-rays were normal.

Dr. OS assessed some form of internal knee derangement and ordered an MRI. According to the patient, he asked Dr. OS about draining the knee but was told that an aspiration would likely complicate his condition. No antibiotics were applied or prescribed.

When the patient returned two days later, the MRI results were available. Dr. OS incorporated the MRI findings into the “Comments” section of his chart that day, including: “(1) extensive anterior soft tissue edema with loculated 9.8 cm heterogeneous collection superficial to the extensor mechanism consistent with hematoma. Adjacent defect of the vastus medialis myotendinous junction is identified with propagation of collection deep to the muscle belly. Focal laceration/perforating injury is considered. The cutaneous defect is incompletely visualized at the limits of the study. Please correlate with clinical concern for infected collection/superimposed abscess. (2) Joint effusion/hemarthrosis with contained debris and/or blood degradation products as well as dissecting/ruptured popliteal cyst. Again, correlation with clinical concern for infected synovitis is recommended given history of laceration. . . . .”

The radiologist’s recommendations notwithstanding, Dr OS’ assessment included traumatic pre-patellar bursitis. The patient claimed that Dr. OS reported that everything was fine in the MRI. The sutures were removed and Dr. OS advised the patient to modify his activities and to return in two weeks. No antibiotics were applied or prescribed.

On his return to Dr. OS two week later, the patient reported some improvement but was still unable to bear weight on the left leg. His temperature was 99.3. Dr. OS aspirated the knee and sent 22cc of cloudy fluid to the lab. Though the patient’s CBC white blood count was normal with a left shift, the WBC of the aspirate was 120,000. Dr. OS contacted the patient and told him that he needed surgery “tonight.”

On his hospital admission, the patient was diagnosed with septic arthritis and underwent an emergent arthroscopic surgery, converted to an open I&D after findings of extensive infection. Cultures grew coagulase negative staph infection for which the patient received IV antibiotics. A hematologist on his care team opined that the patient’s current anemia was multifactorial but included an untreated four-week infection. Acute renal failure was attributed to IV Vancomycin toxicity.

In the patient’s subsequent lawsuit, he claimed Dr. OS failed to properly diagnose his condition or treat his infection, resulting in a stormy hospitalization and enduring damage to his knee. The dispute was resolved without going to trial. (The patient also sued Dr. ER.)

Discussing all the medical considerations involved in Dr. OS’ care of the patent is beyond the scope of this column. From a litigation standpoint, however, Dr. OS’ failure to document his thinking in light of the two – quite emphatic – recommendations from the radiologist regarding possible infection created a fact pattern that a jury would find compelling for the plaintiff.   
 

Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to gownby@CAPphysicians.com.