Legal Review & Commentary

Failure to properly treat a puncture wound results in leg amputation, brain damage: $7.1M settlement

By Jan. J. Gorrie, Esq., and Blake Delaney, Summer Associate
Buchanan Ingersoll PC, Tampa, FL

News: A child fell from a tree and sustained a puncture wound significant enough to require stitches. Because the emergency department (ED) physician failed to remove a piece of wood from the wound while he was treating the boy, the child’s leg became infected. Unfortunately, the infection was not properly treated for several days and the child developed necrotizing fasciitis, which ultimately resulted in brain damage and his leg requiring amputation. The suit settled for $7.1 million prior to trial.

Background: One Sunday afternoon, a 9-year-old child fell out of a tree he was climbing in his backyard. He immediately ran inside and showed his father the innocuous-looking puncture wound on the back of his thigh, which was bleeding profusely down the his leg and into his shoe. Before the father cleaned and bandaged the wound, he noted that the blood appeared to pulse from the wound. Because of the profuse bleeding, the father suspected the wound would need stitches. The father took the boy to the local community hospital ED, which was overflowing with its usual Sunday afternoon patient load. After waiting three hours, the boy’s leg was stitched, and he was discharged home.

By the next evening, the boy was running a slight fever. In the morning, the father called the child’s pediatrician, who advised him to come in the next day. The following morning, the leg was extremely sore and swollen. The boy was taken back to the ED and immediately referred to a tertiary hospital where the wound was surgically explored. A 3-cm piece of wood was removed from the back of the child’s thigh. By the time of the surgery, the child had developed an infection known as necrotizing fasciitis, literally a "flesh-eating" disease. Despite the administration of massive antibiotics, hyperbaric oxygen treatments, and repeated surgeries, large portions of the boy’s body tissue were literally eaten away. This destruction of tissue eventually necessitated the amputation of his right leg at the hip. As a result of systemic complications, the young boy became brain damaged and partially blind.

The boy’s parents brought suit against the community hospital, the ED physician, and the child’s pediatrician. The plaintiffs alleged that the ED physician failed to adequately explore the wound on the initial trip to the hospital and failed to provide any warning signs of a potential infection to the father. The plaintiffs claimed that the rest of the ED team failed to obtain or document a complete history of the injury, perform any independent assessment, or most importantly, advise the physician that wood particles were flushed from the wound prior to suturing. The plaintiffs also averred that the diagnostic imaging studies required by the circumstances surrounding the injury and emergency treatment were not performed. While X-rays would not have revealed the wood particle, the plaintiffs’ experts opined that ultrasound or CT scan procedures would have been appropriate and would have led to the discovery of the potentially infecting foreign material. To prove this point, the plaintiffs conducted experiments for the purpose of constructing a trial exhibit, involving imaging the legs of a lamb, punctured by similarly sized and shaped wooden fragments from the same tree, showing that the foreign bodies would have been clearly visible by ultrasound or CT.

The case was settled after mediation, which commenced with the PowerPoint presentation consisting of photographs of key exhibits and video clips of witnesses’ testimony. The video concluded with a painfully long segment of the now 10-year old boy’s unsuccessful attempt to count from one to five. The case was ultimately settled for $7.1 million among all of the defendants.

What this means to you: This case highlights the problems that can stem from traumatic lacerations, a common childhood injury.

"Emergency departments, which should be prepared to manage these injuries, should have a policy, guidelines, and/or a checklist regarding the evaluation and management of patients who present with traumatic lacerations," says Marva West Tan, RN, ARM, FASHRM, a health care consultant in Marietta, GA.

For example, in May 1999, the American College of Emergency Physicians (ACEP — www.acep.org) developed "Clinical Policy for the Initial Approach to Patients Presenting with Penetrating Extremity Trauma," which might serve as a beginning point for policy development. "Although it has not been recently updated, ACEP points out that it contains substantial content that still may be relevant to the practice of emergency medicine," notes Tan. She also recommends looking to the American Academy of Pediatrics (www.aap.org) and professional literature for information regarding recommended policies, procedures, equipment, and consent issues in pediatric care.

Tan highlights key points from ACEP for a typical emergency department policy for traumatic laceration management, in a patient who is otherwise stable: 1) history of time, date, and mechanism of injury and tetanus immunization status; symptoms; prior medical history; relevant social history; factors that can impede wound healing (such as compromised immune status); history of allergies; and a history of keloid formation to indicate the potential for scarring; 2) physical examination of vital signs; weight; pain assessment; nerve function; tendon function; vascular integrity; entrance; exit; hematoma; hemorrhage; bruits; evidence of foreign body or contamination; palpation; fracture evaluation; range of motion; and the area of the injury, including the injury’s location, length, depth, and shape, all of which can be documented on a checklist format; 3) proper wound preparation, including wound irrigation or cleansing; hair removal and debridement, and use of anesthesia prior to wound closure, all of which is dependent on the type and degree of wound contamination and on the severity of the wound itself; 4) Proper wound closure, which may involve sutures, staples, adhesives and surgical tapes, depending on the nature and location of the wound and on the clinician’s preference; 5) Consideration of prophylactic use of antibiotics, which should be tailored to an individual patient with a traumatic laceration based on the mechanism of injury, and other patient factors; and mindfulness of the potential for antibiotic resistance; 6) Time- and action-specific discharge instructions, which should be documented in the medical record, given to all patients so that the patient and family know about appropriate wound care, signs and symptoms of possible infection, compartment syndrome, retained foreign body, occult tendon or bone injury, methods for pain relief, cast or splint care, when suture or staple removal should occur, and when and how urgently to seek follow-up care if symptoms occur.

In addition to this general overview of an emergency, Tan advises that ACEP warns that wounds to the hands or feet, and wounds that suggest possible nerve, tendon, joint, or fracture involvement or which retained foreign bodies, may need additional assessment and/or exploration, imaging or consultation.

"Likewise, animal or human bites and gunshot or stab wounds may require additional evaluation or consultation. More importantly, she notes, "Experts state that most patients should have prompt primary wound closure to speed healing and reduce discomfort and the risk of infection. Relying on A.J. Singer’s October 1997 article Evaluation and Manage-ment of Traumatic Lacerations’ in the New England Journal of Medicine, the time during which wound closure is safe should be tailored to causation, location, and host factors,’" adds Tan.

The detection and management of foreign bodies in wounds, as occurred in this case, present more challenges for the emergency physician. "History and mechanism of injury as well as physical findings are important in the identification of the potential for foreign bodies. The presence of objects that are small, thin, fragile, brittle, breakable may indicate the need for further evaluation through imaging or exploration," says Tan, in her synopsis of ACEP’s 1999 policy. A decision to remove a foreign body is a complex one as exploration and removal of an object from soft tissue can cause more contamination and wound damage.

She continues, "Organic material such as wood, thorns, spines, and clothing are very reactive and, if possible, should be removed. Other individual indications for detection and management of foreign bodies relate to individualized factors, such as inflammation and persistent pain."

In this case, a complete history would have identified a fall from a tree, which would have been consistent with the wood fragments identified when the wound was originally flushed. "This important information was apparently not conveyed to the treating physician, and the remaining wood fragments were only identified and removed at a subsequent time. Failure to identify foreign bodies in wounds is a known risk management issue for emergency physicians that can be reduced by obtaining a careful history of the mechanism of the injury and complete examination of the wound," states Tan. Indeed, complete documentation and communication among caregivers of pertinent information is a crucial risk avoidance and patient safety strategy.

Further, credentialing and privilege delineation of all clinicians practicing in the ED also is a critical risk management strategy.

"Clinicians who examine and treat traumatic lacerations must have privileges to do so and should be familiar with the ED policy or guidelines for management of lacerations," Tan says.

"Care in credentialing may be especially important at hospitals that rely on rotating medical staff coverage for their ED, as many internists or other medical subspecialists may rarely treat traumatic lacerations in their own practice," she continues.

The rare bacterial infection in this case, necrotizing fasciitis, can destroy skin and soft tissues including fat and fascia. Tan notes that several types of bacteria can cause necrotizing fasciitis, the most common of which is group A streptococcal (GAS) bacterium that also causes other types of infections such as strep throat. She says most GAS infections are mild but, in some patients, toxins develop and spread rapidly through the blood to lungs and other organs. In fact, invasive GAS can develop suddenly, quickly becoming life-threatening with the occurrence of streptococcal toxic shock syndrome and necrotizing fasciitis. Morbidity and mortality in invasive GAS are quite high.

Tan reports, "In 2002, the CDC estimated that approximately 9,100 cases of invasive GAS in the U.S.A. caused 1,350 deaths. Streptococcal toxic-shock syndrome accounted for 5.9% and necrotizing fasciitis accounted for 6.1% of the invasive GAS cases. The overall case-fatality rate among persons with invasive GAS disease was 14.6%." Other studies report varying, but high, rates of respiratory distress syndrome, gangrene with amputation, renal failure, and death.

She relates that reports of recent cases have occurred in young otherwise healthy persons who had no underlying disease who sustained a minor injury to an extremity. "At trial, the high rate of poor outcomes in invasive GAS, even when treated appropriately, makes evaluation of causation and the role that possible delays in diagnosis planned in the outcome a complex issue for expert witnesses and for the defense in this case," notes Tan.

She states that symptoms of streptococcal toxic shock syndrome may include fever, confusion, dizziness, and a flat, red rash over large areas of the body, and symptoms of necrotizing fasciitis include pain from an injury that becomes much worse, fever, chills, nausea and vomiting, or diarrhea. "The skin may become hot, red, and swollen and, because of the speed with which necrotizing fasciitis develops, the patient may already be very sick before they are seen by a physician," says Tan.

In a case such as this, communication between the clinicians and the patient’s family would have been crucial. "Because a healthy young child suddenly developed a life-threatening condition, many caregivers probably were involved in the boy’s treatment, including an intensivist, an infection control specialist, a surgeon and perhaps other specialists," Tan surmises.

Consequently, she advises that it is critical for one practitioner to coordinate communication with the family so that they are updated about rapidly moving events and information does not "fall between the cracks."

Tan continues, "Without destroying hope, the family needs to be aware of the gravity of the condition and prognosis so that they have realistic expectations about the patient’s possible outcomes. The family may likely have many questions about how such a serious infection with such terrible consequences could have developed in such a short time, and physicians and other caregivers should be prepared to repeat information, as the family may be so shocked by the rapid course of events that they can not absorb information that is shared with them only once. Because anger and the need to place blame are common family responses to severely poor outcomes, physicians and other caregivers should be prepared and trained to deal with these responses in a nondefensive and supportive manner. Calmly listening to the family’s rage and grief may help defuse a potentially adversarial situation. Adequate disclosure and transparency about the natural course of invasive GAS, the outcomes and the care of the individual patient may help avoid the situation in which the family feels that information is being withheld or some sort of cover-up is going on. Additionally, pastoral support may be helpful if this is the family’s preference."

If the patient with invasive GAS or family states an intention to sue, the case should be referred to the risk manager for further handling.

Survivors of invasive GAS infections may need ongoing emotional and psychological support to cope with the impact of the illness. "The patient and family in this case suffered devastating losses, and ongoing communication between the primary physician and the family following hospital discharge may be very helpful," Tan says.

Arranging for continuing care, such as physical or occupational therapy, providing the family with information about community resources, and learning about support groups of people with similar illnesses or problems may also be important.

Tan suggests that the National Necrotizing Fasciitis Foundation (www.nnff.org) is an example of a support group for survivors of invasive GAS as well as family members who have lost a loved one.