- 12/24/21: Patient (male, 48) is stabbed with a kitchen knife around 2 am by his mentally ill sister.. Taken to ED; wound is in his left anterior deltoid, about an inch across; no indication of how deep. He can raise the arm without difficulty. Bleeding stops after a dose of tranexamic acid and a pressure dressing. They irrigate it, stitch it up and send him home. No antibiotics prescribed. Patient is told to follow up in 10 days with his primary care doctor, urgent care, or any ER for suture removal.
- 12/26/21: Daughter calls 911 after talking to her dad on the phone about his arm pain and a “gushing sound” in his arm. Fire department gets there first, checks his vitals, and documents that he does not want to go to the ER. Vitals are: BP 138/82, HR 110, RR 14, SpO2 97%, and blood glucose 186. Nothing mentioned about a gushing sound. He’s alert and oriented, and signs a form for refusal of treatment against medical advice. EMS and FD leave.
- 12/27/21: EMS brings him in to the ED around 3 pm with arm pain, swelling, and discoloration. ED provider note describes "obvious erythema to the inner aspect of the left arm along with contusions along the upper chest with visible swelling from the upper chest superior to the nipples, anterior posterior left shoulder extending down the left upper extremity to the level of the elbow." There is bloody drainage noted from the sutured wound but no frank purulence. The patient's vitals at 2:41 pm are: RR 16, HR 90, BP 125/82, T 97.5, O2 sats 98% on room air. The patient's WBCs are 47.6k.
Trauma surgery service is notified around 5:20 pm of concern for acute necrotizing infection, after a CT shows significant subcutaneous air. 3.375 g of Zosyn are given at 6 pm, 2 grams of vancomycin are given around 7 pm, and 600 mg of clindamycin are given at 8:44 pm. Trauma surgery takes the patient to the OR for emergency debridement, with a surgery start time of 9:18 pm. Extensive debridement of necrotizing infection of skin, soft tissue, and muscle of the left chest wall and entire length of the arm.
- 12/28/21: Labwork getting worse, acute kidney injury, metabolic acidosis and rising lactate, hyperglycemia and hyperkalemia. On vanco, clindamycin, and Zosyn. Plan for repeat surgical intervention “sometime later today” – but not done that day.
- 12/29/21: Taken back to the OR around 10:30 am for amputation of the left arm. He’s in septic shock and on pressors by that point, and has 3 cardiac arrests with ROSC during surgery. Surgeon finds “extensive necrosis of the pectoralis muscle and a pocket extending all the way posteriorly down the abdomen to the spine.” Codes for a 4th time in the ICU after CRRT was started. Unresponsive afterwards and made DNR by family; dies later that day from multi-organ failure.
Files:
Q: Any history of diabetes? Any other description of wound available? Nature of bleeding requiring tranexamic acid?
A: —
Do you believe there might have been medical error?
Necrotizing infections develop quite quickly in patients. Perhaps if the patient had presented to ED after calling EMS on 12/26 rather than refusing transport, an earlier diagnosis could have been made. The patient was tachycardic during the EMS evaluation at his home, suggesting possible development of infection, but he refused transport, and unless he had impaired decision making for some reason, he couldn't be forced to go to the ED. Upon presentation to the ED the next day at 2:41 pm, he had clinical signs and symptoms of necrotizing infection. With stable vital signs, imaging was appropriate. There was a delay in administration of antibiotics (8:44 PM) which is unfortunate, but the definitive treatment is surgical. Ideally, upon clinical suggestion of necrotizing infection, the surgical service should have been involved prior to CT, but surgeons were notified at 5:20 PM of the necrotizing infection. The most concerning delay was between surgery notification and OR time of 4 hours. The ER physician has little control on when the surgeon takes the case to the OR, so cannot be faulted for this delay. Unclear what led to the significant delay to OR by surgeon given the information given. It is possible that earlier surgical intervention could have saved the patient's life, but even with optimal care, the mortality rate for such cases is very high.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Given the facts presented, other than delay in antibiotics, no obvious medical error from the ED side. Early surgery involvement with significant delay to OR time. ED physician cannot control this largely.
What makes you a good expert for this case?
I practice in a high volume, high acuity ED. I evaluate patients for wounds and wound infections on a daily basis in my practice. I have seen necrotizing infections many times during my career with often devastating outcomes despite optimal care.
How often do you encounter cases similar to this one in your practice?
Not a common presentation to the ED, so I would estimate I see necrotizing infections 3-4 times a year, but remember each of them due to the stormy clinical course and high mortality. I evaluate patients for wounds and wound infections routinely on my clinical shifts.
Do you believe there might have been medical error?
As an intensivist, I am concerned about the delay in surgical treatment on 12/128/21. An initial plan for operative intervention was made, but doesn't occur until the following morning. At this point, the patient was clearly much more unstable, and the delay in surgical care is likely at least major contributor to the worsening clinical status.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is well known that timely surgical intervention (and re-intervention) is critical to prevent the often very rapid decline seen with necrotizing soft tissue infections. The surgical team documented the need for operative intervention on the 28th but there was a delay of somewhere between 11 and >24 hours (exact timeline unclear based on info provided). Even if we assume that the decision was made shortly before midnight on the 28th, the ensuing delay has a high chance of having allowed the systemic illness to progress to a worse state throughout the night.
What makes you a good expert for this case?
I am one of only a handful of physicians in the United States who is board-certified in Emergency Medicine, Critical Care Medicine, and EMS. I practice in all three specialties, and my clinical ICU practice is in surgical ICUs. I see necrotizing tissue infections both in the ED and in the ICU. I can comment on the case from the perspective of all the different phases of care (ED, EMS, ICU).
How often do you encounter cases similar to this one in your practice?
Once every 3-4 months. I see less complicated (non-fatal) cases of necrotizing soft tissue infections on a monthly basis.
Do you believe there might have been medical error?
On visit #1, the wound was described as a SW. By definition, the depth of these wounds cannot be determined even if the weapon was present in the ED. These wounds need to be treated more like puncture wounds because the depth is not known. As such, a PW cannot be adequately cleaned and irrigated and thus the standard of care is to give prophylactic antibiotics. Suturing these wounds that cannot be adequately cleaned/irrigated (a PW) is not the standard of care. This is even more crucial if the knife/weapon was not clean and if the patient has a poor ability to heal. It seems he may have been a diabetic given his elevated BS and this would be a driving factor for antibiotic use and potential observation/admission to the hospital. Discharging a patient like this would require very firm guidelines about a wound check etc. 1-2 days for a wound check would be standard. On visit #2, it seems like the correct diagnostic testing was performed and the appropriate consultants were engaged. The timeline for these actions would need to be scrutinized a bit more but seem reasonable.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The inadequate care of the initial wound led to a wound infection/necrotizing wound that ultimately led to his death. It is not hard to connect the dots. Had the wound been managed correctly (no sutures, prophylactic antibiotics, poss admission), the necrotizing infection would not have occurred.
What makes you a good expert for this case?
I have worked in the ED of a Level 1 trauma hospital for 28 years. SWs/PWs/GSWs/Lacerations are a part of our daily practice. I have done Medical/Legal evaluations/consulting for over 20 years. I hold a position at an academic MC and at at Medical School as an Assoc Prof.
How often do you encounter cases similar to this one in your practice?
Wounds of all types including stab wounds, GSWs, lacerations are a daily occurrence in our ED. Complicated wounds are common to encounter inn my practice. Complicated regarding the type of wound as well as the complicating factors of the patient (ie diabetic)
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