There are, and i expect there will be some more cocky responses to this presentation, stating malpractice was committed. The fact is, missing the dx of pyogenic spinal infection on a patient’s first visit to the ED has been the standard of care for the past 25 years (75% miss rate, Davis et al, JEM 2004, 66% miss rate, Shroyer, et al WJEM 2021). Anyone stating they’d would have diagnosed it when 75% of physicians do not, is quite frankly arrogant. Until there is a high quality risk prediction tool that is sensitive yet avoids over imaging patients—which risks exposure to radiation, over boarding in the ED, and gadolinium contrast—physicians in all specialties will continue to miss this diagnosis. Evidence is limited but screening patients with back or neck pain for the 10 Davis risk factors and then using a CRP level to decide on imaging is the most accurate approach in evaluating patients with neck or back pain who are being considered for the diagnosis of pyogenic spinal infection (Davis WT, et al. CJEM, 2020). Anyone evaluating patients with back or neck pain, including PAs, nurse practitioners, emergency physicians, hospitalists, and neurosurgeons should inform themselves of this. The only physicians I’ve seen routinely not miss this diagnosis are infectious disease specialist. This is because patient selection before they are consulted allows them to see more cases than any other specialty. In my career, I have evaluated more than 90 PSIs and missed more than five, four which either died or suffered devastating neurologic consequences. It is a very humbling diagnosis. Thankfully it’s low incidence of one per thousand back pains limits even more devastating misses and medical legal catastrophes.
Red flags all over the place. Ignoring the MRI report was a real problem but this case also reveals the issue of consultants not willing to come to the ED when consulted. I’m amazed how often this happens and they get away with it most of the time but it bit them in the butt this time. I once had a surgeon refuse to see a sick patient with free air in the abdomen on CT. I didn’t accept that and with much pushing got the guy to come in and take the patient to the OR for his perforated ulcer.
No "confidential amount" could ever compensate for this sequence of missteps and the horrible consequence. Who wrote the med/malreviewer opinion? It is rubbish - see below. Hx of spine surgery, neck pain, fever and cough on 12/21/12, dx bronchitis and pneumonia (truely?), treated then with abx, and again on 1/19/13, with abx and steroids (Question: was the cough / respiratory difficulties due to the abscess - mechanism?, ?diaphragmatic movement / phrenic nerve process?), subsequent w/u showing a mass, ddx including abscess noted by radiology, acknowledged by NS, not appropriately investigated, not ruled out, neurologic deficits documented, ongoing pain without valid explanation, diagnoses of "neck pain"....errors at every step of the way, opportunity after opportunity to make the correct diagnosis. As for the med/malreviewer opinion, 1. whether she had seen a neurosurgeon was irrelevant. Neurosurgeons can be wrong, as in this case. If her presentation included a ddx of epidural abscess, and it did, then she should not have been discharged until it was ruled out. That it was ok to discharge her because she had no signs of cord compression (if true) is a laugh. Is that the standard of care? Wait for cord compression symptoms or signs before ruling out epidural abscess, -- in a patient with this patient's history and findings? As for "a truly astonishing number of consults without any benefits", this patient did not simply have chronic neck and shoulder pain, and should not be included in that huge number of patients with chronic neck pain who do not need referral to NS. She had a history (was this history elicited at the various visits? -- if not, why not? ) as above, fever and neck pain, treated x 2 with abx and with steroids, persisting pain, abnormal MRI with abscess in the ddx, neurologic findings by NS, etc etc. 2. Copying (complete) reports into one's note might be unnecessary, but it is excellent practice -- it shows that the reports were sought, found, reviewed (hopefully), and helps to complete the picture. A summary cannot be better, can only omit information. Leaving out the part that included the ddx of epidural abscess in this case suggests to me that the PA was hoping, if abscess turned out to be the trouble, that he/she might be able to claim that he/she was not aware of that part of the MRI report, had somehow failed to see and so to copy it with the rest of the report. Bad move. 3. That 2 NSs had seen the patient is absolutely not beneficial to the defense unless review showed that both neurosurgeons had practiced good medicine. In this case both had failed miserably, and turned this poor woman's life into an ongoing nightmare. Sad case. That it took 4 1/2 years to conclude is ridiculous.
Steven Shroyer, M.D., November 21.
There are, and i expect there will be some more cocky responses to this presentation, stating malpractice was committed. The fact is, missing the dx of pyogenic spinal infection on a patient’s first visit to the ED has been the standard of care for the past 25 years (75% miss rate, Davis et al, JEM 2004, 66% miss rate, Shroyer, et al WJEM 2021). Anyone stating they’d would have diagnosed it when 75% of physicians do not, is quite frankly arrogant. Until there is a high quality risk prediction tool that is sensitive yet avoids over imaging patients—which risks exposure to radiation, over boarding in the ED, and gadolinium contrast—physicians in all specialties will continue to miss this diagnosis. Evidence is limited but screening patients with back or neck pain for the 10 Davis risk factors and then using a CRP level to decide on imaging is the most accurate approach in evaluating patients with neck or back pain who are being considered for the diagnosis of pyogenic spinal infection (Davis WT, et al. CJEM, 2020). Anyone evaluating patients with back or neck pain, including PAs, nurse practitioners, emergency physicians, hospitalists, and neurosurgeons should inform themselves of this. The only physicians I’ve seen routinely not miss this diagnosis are infectious disease specialist. This is because patient selection before they are consulted allows them to see more cases than any other specialty. In my career, I have evaluated more than 90 PSIs and missed more than five, four which either died or suffered devastating neurologic consequences. It is a very humbling diagnosis. Thankfully it’s low incidence of one per thousand back pains limits even more devastating misses and medical legal catastrophes.
Red flags all over the place. Ignoring the MRI report was a real problem but this case also reveals the issue of consultants not willing to come to the ED when consulted. I’m amazed how often this happens and they get away with it most of the time but it bit them in the butt this time. I once had a surgeon refuse to see a sick patient with free air in the abdomen on CT. I didn’t accept that and with much pushing got the guy to come in and take the patient to the OR for his perforated ulcer.
No "confidential amount" could ever compensate for this sequence of missteps and the horrible consequence. Who wrote the med/malreviewer opinion? It is rubbish - see below. Hx of spine surgery, neck pain, fever and cough on 12/21/12, dx bronchitis and pneumonia (truely?), treated then with abx, and again on 1/19/13, with abx and steroids (Question: was the cough / respiratory difficulties due to the abscess - mechanism?, ?diaphragmatic movement / phrenic nerve process?), subsequent w/u showing a mass, ddx including abscess noted by radiology, acknowledged by NS, not appropriately investigated, not ruled out, neurologic deficits documented, ongoing pain without valid explanation, diagnoses of "neck pain"....errors at every step of the way, opportunity after opportunity to make the correct diagnosis. As for the med/malreviewer opinion, 1. whether she had seen a neurosurgeon was irrelevant. Neurosurgeons can be wrong, as in this case. If her presentation included a ddx of epidural abscess, and it did, then she should not have been discharged until it was ruled out. That it was ok to discharge her because she had no signs of cord compression (if true) is a laugh. Is that the standard of care? Wait for cord compression symptoms or signs before ruling out epidural abscess, -- in a patient with this patient's history and findings? As for "a truly astonishing number of consults without any benefits", this patient did not simply have chronic neck and shoulder pain, and should not be included in that huge number of patients with chronic neck pain who do not need referral to NS. She had a history (was this history elicited at the various visits? -- if not, why not? ) as above, fever and neck pain, treated x 2 with abx and with steroids, persisting pain, abnormal MRI with abscess in the ddx, neurologic findings by NS, etc etc. 2. Copying (complete) reports into one's note might be unnecessary, but it is excellent practice -- it shows that the reports were sought, found, reviewed (hopefully), and helps to complete the picture. A summary cannot be better, can only omit information. Leaving out the part that included the ddx of epidural abscess in this case suggests to me that the PA was hoping, if abscess turned out to be the trouble, that he/she might be able to claim that he/she was not aware of that part of the MRI report, had somehow failed to see and so to copy it with the rest of the report. Bad move. 3. That 2 NSs had seen the patient is absolutely not beneficial to the defense unless review showed that both neurosurgeons had practiced good medicine. In this case both had failed miserably, and turned this poor woman's life into an ongoing nightmare. Sad case. That it took 4 1/2 years to conclude is ridiculous.