Heightened Awareness to Reduce Missed Diagnosis of Infections
Dr. Eric Zacharias
By Dr. Eric Zacharias
CASE STUDY
A 45-year-old woman was trail running when she tripped on a rock and fell, scraping her knee and straining the back of her calf and hamstring. Three days later, she noted a sudden worsening of her leg pain and presented to her physician’s office with complaints of “leg pain and muscle pull.” At the appointment, she complained of diffuse, severe pain in the areas she strained, her upper calf and hamstring as well as around her knee radiating to her thigh.
On exam, her physician noted the pulled muscles and knee joint were very painful on palpation and range of motion. Of note, the intake vital signs for the patient were T=100.8, P=110, and BP=95/60. No respiratory rate or pulse oximetry were documented. It is unclear from the record whether the physician saw these vital signs, but he made no entry to explain why they were abnormal or as to why he was not acting on them. The physician diagnosed the patient with “acute calf and hamstring injury, possible partial tear,” advised her to avoid activities that made the symptoms worse, and referred her to physical therapy.
Later that evening, the patient’s symptoms worsened dramatically. She called the physician on-call who advised rest, ice, elevation, and ibuprofen. The following morning, she went to the emergency department where she was diagnosed with acute necrotizing fasciitis and sepsis syndrome. She underwent emergency fasciotomy, multiple follow up surgeries and skin grafts, and a prolonged hospital course including two weeks in the surgical intensive care unit. She ultimately sued the physician who saw her in clinic for, among other allegations, negligence in failing to recognize and treat her infection at the clinic visit. The on-call physician was also named in the lawsuit with allegations of failure to take an adequate history from a patient with worsening symptoms.
ANALYSIS
Allegations of negligent delay in diagnosis and/or inadequate treatment of infections and sepsis remain common. This is the case for several reasons:
There is a common misperception that infections are always easy to diagnose, that fever always equals treatable infection, and that infections are easily cured with antibiotics. When an infection is missed early in its course or when it progresses to an adverse outcome, patients or their families may assume the care team must have “done something wrong.”
Infections that ultimately become severe or life-threatening may present with subtle or non-specific findings early in their course before progressing to a severe clinical level. Infections are often more difficult to diagnose at an early point in their progression, however, allegations of missing this early “window of opportunity” for treatment when patients may be more responsive to treatment are often made in claims.
Generally, when infections present at a more advanced state, the diagnosis may be easier to make, but the infection and its complications, such as sepsis, are much more difficult to treat.
Retrospective reviews of missed infections may make them seem that the diagnosis was obvious when the reality is that the presentation was non-specific or the clinical history led the clinician to the wrong diagnosis early in their course.
In the case study, the clinician was anchored to the history of the muscle strain and missed the early signs of necrotizing fasciitis of pain out of proportion to what was expected as well as vital signs consistent with infection and likely sepsis. In retrospect, it looks like the infection should not have been missed.
Failing to document one’s thought process regarding the potential causes of and follow-up plans for abnormal vital signs can make it difficult to defend care. A reasonable thought process, even if incorrect, is more defensible than what appears to have happened in this case study—the vital signs were not reviewed or not recognized as abnormal and requiring more action.
The on-call physician was in a difficult situation where he had an incomplete medical picture and incorrectly presumed he was simply offering standard treatment advice for uncomplicated musculoskeletal injury.
Information in this article is for general educational purposes and is not intended to establish practice guidelines or provide legal advice.
Dr. Eric Zacharias is Chief Medical Officer at COPIC.