The Doctor’s Advocate | Second Quarter 2016
by David B. Troxel, MD, Medical Director, Board of Governors
A 41-year-old female, 6 feet 2 inches tall, weighing 390 pounds, was initially seen by a neurosurgeon in November with complaints of neck and low back pain and tingling in her hands. She had no deep tendon reflexes in her arms and decreased sensation in her left hand. She had been diagnosed three years earlier with an L4-5 radiculopathy and spinal stenosis. An MRI two years prior had shown C3-4, C5-6, and C6-7 disc herniation with moderate cord compression at C3-4.
The neurosurgeon ordered an MRI and, based on the findings, performed an anterior interbody discectomy with fusion at C3-C4, C4-C5, C5-C6, and C6-C7 in January. Her symptoms improved following surgery.
In early February, she was readmitted through the ER with a six-day history of right-sided neck pain, fever, and a discharge from the surgical wound. Cervical x-rays were done, and an epidural abscess could not be ruled out. She was seen by an infectious disease specialist and started on empiric vancomycin and amikacin. The neurosurgeon debrided the wound with placement of a drain and noted that there was purulent material in the deep soft tissues. A culture revealed methicillin-resistant Staphylococcus aureus (MRSA). One week later—afebrile, moving all extremities, and ambulating well—she was discharged. Two weeks later, the wound was healing nicely without drainage, and she was continued on antibiotics.
On April 22, she was readmitted with complaints of not feeling well for three days, generalized body pain, and difficulty urinating. A hospitalist noted confusion. She reported being seen at another hospital and diagnosed with a urinary tract infection. She was afebrile.
On April 23, she was again seen by the neurosurgeon because her legs had given out and she had fallen several times. He suspected spinal epidural abscess and ordered a cervical MRI. However, the MRI at this hospital could not accommodate a patient of her size, so it could not be done. The hospital did not have a transfer agreement in place with an open MRI facility. She was seen by the infectious disease specialist, who suspected a gram-positive bacteremia of unclear source. He ordered a blood culture and started her on IV vancomycin.
On April 24, the hospitalist made arrangements to transfer her to an open MRI facility. When he saw her again on April 25, he noted decreased strength in both upper extremities. Nursing notes indicated an unsteady gait and a limited range of motion.
On April 26, the neurosurgeon noted lower extremity weakness with bilateral loss of sensation. The blood culture came back positive for MRSA. The infectious disease specialist noted that the patient had left arm weakness and trouble moving her legs. His progress note stated “Needs MRI—if transfer is necessary to accomplish this, it should be done as quickly as possible.” The neurosurgeon again requested an MRI. However, two attempts on April 27 to transfer the patient by ambulance to outside facilities were unsuccessful because she was too large for the gurney. On April 28, the neurosurgeon was told that the MRI could not be completed (four days after he had ordered it), and on April 28 she underwent a CT myelogram—which showed significant anterior epidural compression extending from the L2-3 to the L3-4 vertebral interspace, a suggestion of compression of the lower cervical cord–thoracic cord junction, and flattening of the cervical cord from C6-T1.
On the morning of April 29, she developed decreased movement and sensation in both lower extremities. The next morning, the neurosurgeon performed a wide decompressive laminectomy from C3 to T1. Somatosensory-evoked potential monitoring during the procedure showed no activity in the lower extremities. Two weeks later, the patient was transferred to a skilled nursing facility with paraplegia and a neurogenic bowel and bladder.
Patients who have experienced an adverse medical event leading to a medical malpractice claim are frequently noted to be obese (based on documented height and weight). A review of 7,065 claims from 2011 to 2013 at The Doctors Company revealed that 28 percent were identified as having a comorbidity (some with more than one) and that obesity was the most common comorbidity (8.3 percent of total claims and 19.2 percent of total claims with a comorbidity). When only closed claims were analyzed, 26 percent of claims with indemnity payments listed obesity as a comorbidity.
Obese patients commonly have a variety of comorbidities, many that are associated with a metabolic syndrome, such as hypertension, dyslipidemia, and hyperglycemia, which increases the risk of stroke, ischemic heart disease, and diabetes mellitus. These patients also have increased risk of obstructive sleep apnea (which often contributes to opioid-induced respiratory depression), susceptibility to nosocomial and postoperative infections, and weight-associated wear and tear on joints that can lead to osteoarthritis. Additionally, bariatric surgery can be associated with both surgical and metabolic complications.
An inability to fit a morbidly obese patient into a conventional MRI machine or CT scanner is a unique problem necessitating use of an open MRI or CT. As this case study demonstrates, the failure to transfer an obese patient to a facility with an open MRI machine or CT scanner in a timely fashion may result in a delay of diagnosis and/or surgical treatment—and, ultimately, in a malpractice claim.
Healthcare facilities that are unable to accommodate morbidly obese patients in their MRI machine or CT scanner or if their MRI or CT isn’t available at night or on weekends should have transfer agreements with open facilities in place so there are no delays in urgent MRIs or CT scans.
The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.
The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.
The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.
Second Quarter 2016
Obesity: A Common Comorbidity in Malpractice Claims
An Ounce of Prevention
Specialty Advisory Boards: Bringing Together Expertise
Government Relations Report
Every Aspect of the Litigation Process Is Subject to Legislative Action
The Back Page
Industry and Company News