News: A patient was admitted to a hospital with a bacterial bloodstream infection and was prescribed antibiotics. Unknown to the physicians, the patient developed an abscess that affected her thoracic spine. Because of the delay in the diagnosis, the abscess placed sufficient pressure on the patient’s spine to cause paraplegia, requiring frequent physical therapy sessions. Also, because of the patient’s inability to move, she developed bedsores that required hundreds of debridements.

The patient sued the physician, the physician’s employer, and the hospital, but the hospital was dismissed from the case prior to trial. The case proceeded to a jury trial against the physician and the physician’s employer. After a weeklong trial, the jury returned a verdict in the patient’s favor for $18 million.

Background: On July 28, 2014, a 58-year-old female accountant presented to a hospital in an altered state. She experienced severe back pain for approximately eight days and sought medical care in an ED on July 20, 2014, and again at an urgent care facility on July 23. The woman was admitted to the hospital, diagnosed with an infection of her bloodstream, and placed on antibiotics. Despite the patient’s history of back pain, the treating physician did not order an MRI or CAT scan.

On Aug. 5, 2014, the patient claimed she could no longer move her legs and was rendered a paraplegic. The infection migrated to her spine, a complication called vertebral osteomyelitis. She claimed that the infection then caused a spinal epidural abscess, which grew and put pressure on the spinal cord, ultimately causing paralysis. If an MRI or CAT scan had been performed, the physicians could have monitored her for the development of abscess and removed the abscess before it caused any damage, although this also would have required an earlier vertebral osteomyelitis diagnosis.

The next day, the patient underwent surgery to drain the epidural abscess — but by then, it had already put enough pressure on her spinal cord to render her a paraplegic. The patient suffered from additional injuries and complications, including a neurogenic bowel and bladder secondary to the paraplegia, and has required temporary catheters inserted with consideration of a more permanent colostomy and placement of a suprapubic catheter. The patient remained in the hospital for a month after surgery, and when she was discharged to rehab she developed a decubitus ulcer (bed sore) on her buttocks. The ulcer required hundreds of debridements over the next few years.

The patient spent about a year in rehabilitation and continues regular appointments with a spinal cord physician to prevent further deterioration. She also receives physical therapy for her upper body and has her legs stretched out regularly for more flexibility. Because of her injury, the patient can no longer work and requires assistance with transportation.

The patient filed suit in June 2016 against the hospital, the physician, and the physician’s medical group employer. The patient alleged that the physician committed malpractice in failing to timely diagnose the spinal abscess, which led to her paraplegia. The patient’s claims against the hospital included nursing negligence and vicarious liability. The hospital was dismissed prior to trial, and the case proceeded solely against the physician and the medical group. The patient sought medical expenses, lost wages, the cost of a life care plan, and damages for pain and suffering.

At trial, the defense argued that the patient showed no signs or symptoms of a spinal infection, and that the patient failed to complain of back pain during her stay at the hospital. It also claimed that the patient’s back pain resulted from a lumbar strain unrelated to the abscess. The defense argued that the organism that caused the bloodstream infection rarely causes spinal infections.

The defense agreed that the patient had an infection in her epidural space, which can be called an abscess; however, the defense disputed whether the patient had a walled-off abscess. Instead, the defense claimed, the patient was paralyzed due to a spinal cord infarction, which the physician could not have prevented. The jury deliberated for two hours and awarded the plaintiff $18 million, the largest medical malpractice verdict in the county’s history. The jury found that the physician and the employer were 90% liable for the injuries and that the hospital was 10% at fault.

What this means to you: The diagnostic process is an exercise in judgment based on the facts presented, and there is always a possibility of misdiagnosis. A medical professional should endeavor to be as accurate as possible with diagnoses, but also protect against false or delayed diagnoses in an effort to provide patients with the standard of care. When a physician doubts a diagnosis, it may be helpful to seek a second opinion by a colleague.

Another useful and necessary part of providing care within the appropriate standard is remaining abreast of trends in the medical community with respect to diagnostic and treatment methods. Given technological advancements, it is plausible that the diagnosis process in the foreseeable future may include artificial intelligence. With that said, nothing can or will replace the judgment of a human being, and the final decision with respect to any medical care must be made by a human being. Medical professionals cannot rely solely upon external sources, particularly a single source, and then blame that source when malpractice is alleged.

Hospitals face difficulties in delicately balancing making intelligent business decisions and maximizing patient care and medical resources. In this case, when the patient was diagnosed with an infection, the source should have been considered. Often, dental or other minimally invasive medical procedures are the source. In seeking the source of an infection, physicians must pay attention to a patient’s complaints and symptoms.

Abscesses within the spinal column are neither common nor unheard of, and can be caused by a tiny blister on the skin. Back pain would be the presenting symptom before the infection developed. This patient sought treatment for back pain twice before the infection spread, and the physicians should have closely considered this data point. If a CAT scan or MRI was performed, the abscess could have been drained before damage to the spinal cord occurred. During the patient’s last visit to the hospital, the physician dismissed the patient’s complaints of pain and chose to treat one symptom of the abscess (the infection) while ignoring the second symptom (the back pain). This problem reveals how diagnosis and treatment must be thorough; if a physician decides to intentionally disregard a patient’s specific complaints, it may be justified as long as such a decision remains within the standard of care.

Another lesson from this case pertains to the decubitus ulcer, which is largely preventable. This responsibility falls more upon hospitals who must ensure that staff are appropriately trained in identifying patients at risk for bed sores, and for providing sufficient monitoring to prevent sores from developing. For a paraplegic patient, the risk increases as the patient is unable to independently inform staff of developing issues. In this case, the patient suffered from significant injury as a result of the ulcer and the patient required an extreme amount of debridement, which likely influenced the jury’s view of the patient’s general treatment by the care providers.

Causation is a frequent issue in medical malpractice cases: Patients argue that injuries were caused by one medical issue, while care providers argue that the injuries were pre-existing, untreatable, or otherwise unconnected. In the typical course of litigation, this involves a complex and unpredictable battle of the experts, with laypersons on a jury evaluating competing medical experts in an effort to determine which evaluation they believe. The defense in this matter argued that the patient’s paraplegia was caused by a spinal infarction, and thus the physician’s delayed diagnosis did not result in any injury. The symptoms of a spinal infarction, which typically are present very shortly after the infarction occurs, include sharp or burning pain in the back, aching pain or weakness in the legs, loss of tendon reflexiveness, loss of pain and temperature sensation, incontinence, and, most relevantly, paralysis. Given the fact that the patient’s back pain began substantially prior to her paralysis, the likelihood of infarction causing the paralysis was low.

Conversely, a spinal cord abscess may take longer to develop since it often begins in the bone of the spine. Spinal abscesses are generally an accumulation of pus caused by an infection that puts pressure on the spinal cord. Typically, the infection is bacterial, although it is possible for the infection to be fungal. The most common infection responsible for spinal abscesses is a Staphylococcus infection that spreads through the spine. Generally speaking, spinal cord abscesses are rare. However, when they do occur, they are frequently life-threatening or life-altering, as in this case. It is important for medical professionals to affirmatively rule out such an abscess before completely discounting it, and to document such decisions thoroughly and contemporaneously in the event that a medical malpractice action eventually occurs.

REFERENCE

Decided on June 21, 2016, in the Chatham County Superior Court, Georgia; Case Number STCV1600837.