So, the lady's dog gets hit by a car, causing it to bite her, causing an infection resulting in permanent injury, causing her to hire the world's most incompetent malpractice attorney, causing him to hire an out-of-state "expert" who is clueless about the right antibiotic for pseudomonas. I'd say the root of the problem is that the plaintiff is just about the unluckiest person on earth.
Nov 15, 2023·edited Nov 15, 2023Liked by Med Mal Reviewer
Of note, not a minor detail either considering how malpractice is handled, the literature references supplied by the “expert” are from 2015, two years after the visit in question. Sorry try again. Can’t be used to support the claim. Terrible attorney. Terrible expert.
I was taught the same, although in practice will do some loose sutures if its in a cosmetic area. They actually did a randomized study on this and surprisingly there was no difference in infection rates between suture and non-closure: https://pubmed.ncbi.nlm.nih.gov/23916901/. I thought about including this article in my analysis but decided against it because there wasnt a good sub group analysis of hand infections, which seem to be much more high risk than other locations.
I agree with everything you said, and was particularly shocked by the claim that Augmentin can treat Pseudomonas. It's common knowledge in medicine that this isn't true. However, I do think the care at the urgent care was not good. If a patient has a worsening infection after 2 days of antibiotics, I would not just discharge home and tell them to continue the same antibiotic. The answer is either to admit for IV abx or dc with different abx.
In regards to closure if a wound is large and gaping like this one was I myself do a loose closure.
Yeah it does seem a little suspicious to do nothing at the follow-up visit. Might have been in that challenging zone where the patient can feel the swelling getting worse but its not visibly obvious and no erythema or other red flags have set in yet.
I will say, the fact that, if I'm reading it correctly, culture ID (and susceptibilities?) was known on September 7th but the antibiotics were not changed for 5 days is below the standard of care. All the stuff regarding closure is definitely way outside my scope. The patient should have been contacted and a new script called in that day.
I actually didn't catch that, good eye! I would assume that the lab didn't call it in as a critical finding, so the doctor probably didn't look at it until her follow-up visit. Seems like an opportunity to improve how the system works.
I’d have to double check my lab’s SOP but I’m fairly certain we do treat positive cultures with known pathogenic orgs as critical values. The AST result the following day wouldn’t get called but in this case knowing the bug was sufficient to know coverage was wrong.
Figured I would follow up especially since I was wrong. Positive cultures from "non sterile sites" are not considered critical values outside of a few orgs (mycobacterium and select agents aka bioterror bugs). A hand bite wound is not a "sterile site" and thus this would not have been delivered as a critical value.
In this state they are anonymous when the lawsuit is filed, and only become public when the defense asks to depose them or goes to trial, and it never got that far. Also an editorial decision that I don't dox people.
You can't at least unredact the name of the attorney? I want to make a card to keep in my wallet, in case I'm ever involved in a bad outcome, I can discreetly leave the card on the patient's bedside table ha ha
So, the lady's dog gets hit by a car, causing it to bite her, causing an infection resulting in permanent injury, causing her to hire the world's most incompetent malpractice attorney, causing him to hire an out-of-state "expert" who is clueless about the right antibiotic for pseudomonas. I'd say the root of the problem is that the plaintiff is just about the unluckiest person on earth.
Terrible luck. I wonder what the attorney told the plaintiff... wouldn't be surprised if he lied about the reason it was dismissed to save face.
Of note, not a minor detail either considering how malpractice is handled, the literature references supplied by the “expert” are from 2015, two years after the visit in question. Sorry try again. Can’t be used to support the claim. Terrible attorney. Terrible expert.
Good point, I hadn't caught that
Wow, that attorney is incompetent.
One of the worst I've seen, which is actually good depending on your viewpoint.
Hard to keep track of all the mistakes and incompetency in this case but as the saying goes "when it rains, it pours".
Interesting case. I always learned not to primarily close animal bites except in rare cases
I was taught the same, although in practice will do some loose sutures if its in a cosmetic area. They actually did a randomized study on this and surprisingly there was no difference in infection rates between suture and non-closure: https://pubmed.ncbi.nlm.nih.gov/23916901/. I thought about including this article in my analysis but decided against it because there wasnt a good sub group analysis of hand infections, which seem to be much more high risk than other locations.
Sounds fair, I do similar and generally leave them unless of cosmetic concern
I agree with everything you said, and was particularly shocked by the claim that Augmentin can treat Pseudomonas. It's common knowledge in medicine that this isn't true. However, I do think the care at the urgent care was not good. If a patient has a worsening infection after 2 days of antibiotics, I would not just discharge home and tell them to continue the same antibiotic. The answer is either to admit for IV abx or dc with different abx.
In regards to closure if a wound is large and gaping like this one was I myself do a loose closure.
Yeah it does seem a little suspicious to do nothing at the follow-up visit. Might have been in that challenging zone where the patient can feel the swelling getting worse but its not visibly obvious and no erythema or other red flags have set in yet.
Literally started going "Oh no no no no no no no" out loud when I read the expert witness claim the pseudomonas would have been covered by augmentin.
I will say, the fact that, if I'm reading it correctly, culture ID (and susceptibilities?) was known on September 7th but the antibiotics were not changed for 5 days is below the standard of care. All the stuff regarding closure is definitely way outside my scope. The patient should have been contacted and a new script called in that day.
I actually didn't catch that, good eye! I would assume that the lab didn't call it in as a critical finding, so the doctor probably didn't look at it until her follow-up visit. Seems like an opportunity to improve how the system works.
I’d have to double check my lab’s SOP but I’m fairly certain we do treat positive cultures with known pathogenic orgs as critical values. The AST result the following day wouldn’t get called but in this case knowing the bug was sufficient to know coverage was wrong.
Figured I would follow up especially since I was wrong. Positive cultures from "non sterile sites" are not considered critical values outside of a few orgs (mycobacterium and select agents aka bioterror bugs). A hand bite wound is not a "sterile site" and thus this would not have been delivered as a critical value.
Interesting, thanks for the follow-up!
NAME the expert. Needs to be publicly shamed. Poor experts should not be shrouded in anonymity.
In this state they are anonymous when the lawsuit is filed, and only become public when the defense asks to depose them or goes to trial, and it never got that far. Also an editorial decision that I don't dox people.
You can't at least unredact the name of the attorney? I want to make a card to keep in my wallet, in case I'm ever involved in a bad outcome, I can discreetly leave the card on the patient's bedside table ha ha