- 5/30/22: A 37-year-old female patient presented to the ED complaining of a foreign body in the sole of her left foot, present for 3-5 days with worsening pain and tenderness. She was noted to have a medical history of asthma and hypertension, and reported having run out of her antihypertensives for the past month. Her pulse was noted to be 117, blood pressure 199/113, O2 saturation 99%, and temperature 98.4. Physical exam showed "a small opening in the plantar aspect of her left foot, just below the callus, can see a black foreign body." The foreign body turned out to be a piece of glass, which was removed via a small incision with an 11 blade. That procedure note described swelling and erythema to the foot, and noted: "no pain appreciated by patient, did not require any anesthesia." The patient was sent home with a prescription for Keflex 500 mg QID for 7 days. She was instructed to follow up with her primary care doctor within 2-4 days.
- 6/4/22: The patient returned to the ED requesting a wound recheck. She reported that she had been unable to get in to see her primary care doctor, but that the wound "has been healing well, minimal pain, redness is completely resolved, no longer having purulent drainage." The patient's pulse rate was 112, blood pressure 227/116, O2 saturation 97%, and temperature 97.6. Her foot was examined and described as "well-healing laceration on plantar aspect of left foot. No erythema, edema noted." No other abnormal findings were noted, and the patient was described as asymptomatic despite her high blood pressure. She was discharged home with a refill for her lisinopril, which she had been out of, and she was given a dose in the ED as well. The reassessment note said that her blood pressure was trending down without intervention, but no second set of vitals was documented. The patient was instructed again to follow up with her primary care doctor.
- 6/15/22: The patient returned to the ED complaining of blistering and drainage from the wound site on her foot, with onset 2 days earlier. She reported that she had completed the course of Keflex prescribed on 5/30, and had gradually been walking more on her foot as she was able to bear more weight. The patient's pulse was 130, respiratory rate 18, blood pressure 125/67, O2 saturation 99%, and temperature 99.4.
The ED note states: "There is a blistered area covering the plantar surface of the foot also. Slight redness of the foot, not extending to the ankle or the lower leg. Denies fever or difficulty breathing or nausea or vomiting...." Under medical history, hypertension was listed, along with a note stating "no diabetes." The physical examination part of the note described "Plantar surface of the left foot is mostly covered by an intact blister, with the former foreign body removal point in the mid arch. There is a slight redness and tenderness at the borders of the blister[], not extending onto the dorsal surface of the foot or into the ankle." Under "Differential Diagnosis," the doctor wrote:: "Infected blister on the plantar surface of the left foot, status post removal of foreign body 2 weeks ago. There many be some localized cellulitis, but not extending onto the dorsal foot or ankle. The patient is significantly tachycardic, although this is consistent with vitals at her prior visits and may be chronic. Clinically do not suspect sepsis or any infection beyond the local area." An x-ray was obtained and read as showing plantar soft tissue swelling but no residual foreign body or other abnormal findings. The doctor noted: "used scissors to unroof[] the infected blister/callus on the plantar surface of the left foot, removing large pieces to expose underlying skin. Released some purulent material. The original wound on the plantar surface of the foot is not open or draining, nontender, nonfluctuant." A nonstick dressing was applied and the patient was discharged with a prescription for Keflex, 500 mg BID for 10 days and instructions on dressing changes. She was also instructed to follow up with her primary care provider in 1-2 weeks, and to return with worsening redness, pain, or fever.
- 6/20/22: The patient returned to the ED complaining of a worsening infection in her foot, pain, swelling, fever, and the inability to bear weight. This time, the ED doctor noted that the patient's risk factors included "diabetes mellitus (uncontrolled due to non compliance)." The patient's pulse rate in the ED was 130 again, respiratory rate 18, blood pressure 144/80, O2 saturation 98%, temperature 98.7. The physical exam note described her left foot as "markedly swollen, dorsal and plantar aspects, tender. Erythema noted plantar and dorsal aspects. Noted 40% plantar epithelial loss with multiple small cut (undetermined depth). Proximal plantar with 3 cm area of hyperpigmentation with partially overlying epithelial skin, suspected hematoma vs wet gangrene." A CT of the foot showed generalized swelling throughout the foot, with focal severe swelling in the intrinsic muscles, suspicious for infectious myositis, as well as a 2 x 1 x 2.5 cm abscess along the central band of the plantar fascia, and severe soft tissue swelling around the first metatarsal joint, concerning for early osteomyelitis. Labwork was done for the first time, and the patient's white blood cell count was 38.40. Hemoglobin was 6.9, and hematocrit was 20.8. Blood glucose was 437, and her A1C was 14.6%. The patient was admitted and started on cefepime, vancomycin, and Clindamycin per infectious disease recommendation. She was ultimately diagnosed with gangrene or necrotizing fasciitis, and underwent amputation of the second through fifth toes, with a DermaSpan graft. Transmetatarsal amputation of the foot was recommended, but the patient refused. Wound and tissue cultures grew 3 different candida species and Lactobacillus acidophilus. The bone sample sent to pathology was negative for osteomyelitis at the time.
Several months later, the patient required further resections of the 3rd-5th metatarsals for suspected acute osteomyelitis, with additional tissue grafting. She again refused the recommended transmetatarsal amputation. It is unclear right now if she will eventually have to have one.
Files:
No questions yet!
Do you believe there might have been medical error?
6/15 visit met criteria for further investigations, suspect the patient was already infected at this visit. Her tachycardia and physical exam findings of the foot are concerning.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Earlier intervention on 6/15 (expanded labs, CT, IV antibiotics, admission) would have likely mitigated the disease progression or at least would have led to earlier intervention. The physician evaluating the patient seems to have been unaware of her diabetes, a significant risk factor.
What makes you a good expert for this case?
One of less than physicians in the national triple board-certified in emergency medicine, critical care medicine and EMS (prehospital medicine). I work at the second-highest acuity ED in the nation and frequently evaluate patients with complex problems in the ED, including complicated skin and soft tissue infection. I also see the trajectory of patients like this after the ED as a surgical intensivist.
How often do you encounter cases similar to this one in your practice?
Once a quarter in ED, 10 times a year in the ICU/inpatient setting
Do you believe there might have been medical error?
The visit on 6/15/22 shows a tachycardia of 130 which according to the limited summary provided was unexplained. Patients should never be discharged from the emergency department with a heart rate of 130. One explanation would be early sepsis. Another more likely explanation would be the compensation for a severe anemia which was documented on the visit of 6/20/22. Laboratory studies should have been ordered which would likely have shown a severe anemia and diabetes out of control and the patient would undoubtedly have been admitted on 6/15/22. An x-ray showed plantar soft tissue swelling and purulent drainage was noted when the blister was unroofed. The physician seemed to have relied on the fact that the wound was "nontender". This is meaningless in a diabetic patient who undoubtedly had diabetic neuropathy. This is clear from the visit on 5/30/22 when the glass foreign body was removed after an incision with a scalpel, where "no pain appreciated by patient, did not require any anesthesia.." This clearly indicates that the patient has significant neuropathy and thus one cannot rely on the report of non-tenderness of a wound to conclude that there is no deep tissue infection. Furthermore, she was given a prescription for Keflex when the same antibiotic failed to eradicate the foot infection when it was prescribed on 5/30/22. The standard of care required that the patient be admitted to the hospital for further evaluation and treatment.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Had she been admitted on 6/15/22, she would have had a more complete evaluation of the foot infection with imaging studies such as an MRI scan which would have identified a deep tissue abscess. She would have had a surgical consultation and a surgical procedure to drain the abscess as well as intravenous antibiotics. The infection would more likely than not have been controlled thus avoiding the subsequent amputations.
What makes you a good expert for this case?
I am board certified in Emergency Medicine by the American Board of Emergency Medicine. I am board certified in Internal Medicine by the American Board of Internal Medicine. I am board certified in Critical Care Medicine by the American Board of Internal Medicine. I am a Fellow of the American College of Emergency Physicians (FACEP), a Fellow of the American Academy of Emergency Medicine (FAAEM), a Fellow of the American College of Chest Physicians (FCCP), and a Fellow of the American College of Physicians (FACP). I am an emergency medicine physician with substantial professional experience over the past forty years while assigned to provide emergency medical coverage in a general acute care hospital emergency department. I have also relied upon my education, training and substantial experience as a practitioner and teacher for more than forty years. By virtue of my education, training, and continued substantial experience as an emergency medicine physician, I am intimately familiar with the standard of care for general acute care hospital emergency department physicians providing emergency medical coverage in the same or similar locality, in like cases, and under circumstances similar to those present in this case. During that time, I have taught emergency medicine to physicians in training and in practice, as well as to students, interns, residents, fellows, nurses, paramedics, nurse practitioners and physician assistants in all stages of their training. I am intimately familiar with the standard of care for emergency department physicians and nurses who assess patients with complaints of foot infections from foreign bodies and foot infections in diabetic patients. I am intimately familiar with the standard of care for emergency medicine physicians who evaluate patients with signs and symptoms of cellulitis, foot abscess, diabetes, and hypertension
How often do you encounter cases similar to this one in your practice?
Diabetic patients with foot infections are commonly seen in the emergency department. Throughout my forty plus years of practice in a level 1 trauma center emergency department, I would estimate that I have seen diabetic patients with foot infections at least 1-2 times per week.
Do you believe there might have been medical error?
Thank you for the opportunity to review this case. Initially, on the first two visits, it seems like the standard of care was met, although the tachycardia did not seem to be definitively addressed. On visit three however, she was again tachycardic, and had evidence of a worsening infection. The standard of care, would indicate that labs, and potentially further imaging should’ve been addressed, and more broad-spectrum antibiotics should’ve been administered. She was put on a sub standard dose of antibiotics, which may have contributed to her worsening condition although her underline diabetes, which seemed to be uncontrolled, was likely a major contributing factor.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again, on the third visit, the standard of care did not seem to be met. Laboratory studies were not checked, and she was again put on a sub standard dose of antibiotics given a presentation of a worsening infection in the setting of abnormal vital signs.
What makes you a good expert for this case?
I’ve been a practicing emergency physician for over 10 years in a community setting, and routinely see similar cases. I am a board certified emergency position, and that extensive training and experience in the management of diabetic foot infections.
How often do you encounter cases similar to this one in your practice?
I routinely see these types of cases on a daily/weekly basis.
Do you believe there might have been medical error?
This is a complicated case. First ED visit: foreign body found, it was removed. Some infection noted. Antibiotics prescribed and follow up instructions given. Consider checking a blood sugar in someone with unexplained infection although the foreign body may explain the possible source of infection. Patient has fast heart rate and high blood pressure but she isn't taking her blood pressure medication. Her fast heart is unexplained and likely needed more intervention other than maybe pain medication. Second visit: seems appropriate overall. Her heart rate is still fast but otherwise sounds like she is healing. Patients can have high blood pressure and have no symptoms related to that high blood pressure. Third visit: with intervention such as deroofing the blister that appears infected, labs would have likely needed to be ordered and maybe more imaging than a xray. A blood sugar at this point would have been helpful. The bottom of the foot takes a longer time to heal so probably needed more wound care. Fourth visit: appropriate care with admission and IV antibiotics. Something to consider is how long this all took. Eleven days between second and third visit which means the patient waited a little too long by the time the blister was quite large.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The time frame between the second and third visits is 11 days. There is a possibility that the patient may have waited to long by the time a large blister formed. I think unless the blister formed overnight which I doubt is the case then a sooner visit would have been warranted. During the third visit, further workup may have been considered but I need to see more documentation.
What makes you a good expert for this case?
Emergency physician practicing at a busy academic center seeing similar patient presentations regularly.
How often do you encounter cases similar to this one in your practice?
Patients presenting with foreign bodies: several times a month Patients with infections: every shift Patients with hypertension and diabetes: every shift.
Do you believe there might have been medical error?
Initial treatment was reasonable with removal of the foreign body, with the exception of an xray prior to foreign body removal, which was not done. The case overview the patient had history of diabetes. From the provided information, that history was not recognized (or not documented) by the treating physicians until the patient was already far along in the course of the foot cellulitis. There was one aspect of the first visit that was unusual which was the lack of pain during the foreign body removal procedure without need for local anesthesia, suggesting neuropathy, which is typically associated with longstanding diabetes. This was apparently not recognized by the provider on the first day. Any indication of cellulitis after foreign body removal in a diabetic patient should have prompted lab workup including CBC/Chemistries including glucose, and perhaps lactate and blood cultures given the tachycardia (sign of more serious infection). It was on the 6/15 ED visit that the evaluation and treatment deviated significantly from the standard of care. The physician clearly did not know the patient had diabetes as that was documented. The patient presented with significant tachycardia in the setting of a foot cellulitis with abscess, red flags suggesting sepsis. The treating physician attributed this to "the patient's baseline" given previous visits, which was irresponsible. This presentation should have prompted a medical workup including CBC, Chem 7, blood glucose, cultures of wound and blood, inflammatory markers (CRP) and further imaging beyond xray with either MRI or CT. None of this was done. Furthermore, repeat prescription for keflex was not appropriate given this complicated foot infection with "blistering". This wound appearance is not typical of a straightforward cellulitis. Infections of the foot are high risk in any patient, especially diabetics. Finally, followup in "1-2 weeks" was a clear deviation from the standard of care, where close followup should have been ensured. The physician clearly did not recognize the potential severity of this infection during 6/15 visit. Finally, there was no deviation from the standard of care on 6/20, when the provider clearly recognized this patient was diabetic and provided the proper care. Unfortunately, this was a delay of the proper treatment of several days, likely leading to a significantly worse outcome for this patient down the line.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Had the history of diabetes been recognized on the 6/15 visit, the patient would have had the appropriate workup, leading to earlier identification of the severity of the infection, with appropriate consultation with podiatry or orthopedic surgery for surgical debridement, infectious disease involvement for appropriate choice of antibiotics, which would have given the patient a much better likelihood of avoiding amputation later.
What makes you a good expert for this case?
As an emergency physician with over 25 years of clinical experience, I am an expert in the evaluation and treatment of foreign bodies in the foot, foot cellulitis in diabetics, and the pitfalls of underestimating the severity of such infections. I am very comfortable providing an expert opinion on the standard of care in such patients.
How often do you encounter cases similar to this one in your practice?
The evaluation and treatment of patients presenting with foreign bodies of the foot, diabetic foot infections, and the complications thereof, are a common occurrence for me in my daily practice. Fortunately, the severity of such infections is typically recognized much earlier in the clinical course, so the outcome of amputation is relatively rare, but will see those complications occasionally as well.
Want to open a case or submit response?
Comments are accepted only from Emergency Medicine - includes all subspecialties experts.