- 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.
- 12/27/21: 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. Op note describes "copious amounts of foul-smelling hematoma" returned as soon as an incision was made over the previous stab wound, "dishwater fluid" found with counter-incision of the bicep, which was decnrotic. Large amount of necrotic subcutaneous tissue was debrided... additional dishwater fluid found medially near the elbow and additional drainage from the forearm. Similar findings including a "large amount if infected hematoma and dishwater fluid" in the left chest wall, with a "large amount pectoralis muscle... completely devitalized." At the close of surgery, wounds were packed with Dakins moistened Kerlix wraps, with additional ABD pads and ace wrap along the arm. (See attached op reports)
- 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.” (See attached op reports.) 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: Did the ER physician consult surgery at the first visit? Was the patient given a tetanus shot or was it documented? Did EMS comment on the knife as to whether it was clean or dirty?
A: —
Do you believe there might have been medical error?
The wound should not have been closed by the ED physicians after the stab wound and he should have been on antibiotics
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Closure of the wound led to infections and necrotizing fasciitis
What makes you a good expert for this case?
I perform over 100 cases on Necrotizing fasciitis per year
How often do you encounter cases similar to this one in your practice?
We have a busy acute care surgery practice within an academic medical center. I see necrotizing fasciitis regularly as stated above
Do you believe there might have been medical error?
There was a significant delay between the time surgery was consulted with findings of necrotizing soft tissue infection and time to OR. This is a surgical emergency and ideally needs to be done within an hour of diagnosis as any delay can lead to multi organ system failure and death rapidly. Additionally, the standard of care is to return to the OR daily until no further debridement is necessary. This patient had worsening lactic acidosis with signs of progression to septic shock and it was inappropriate to delay the return to the OR an additional day.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
While the patient presented with the infection, it’s the surgeon’s job to achieve source control ideally at the index operation. As long as there is ongoing need for debridement, daily return to the OR is indicated and any delay will allow opportunity for necrotizing infection to continue to spread. Therefore, while the medical error did not cause the patient’s initial pathology, there is significant opportunity for improvement in the surgical management that could have altered the patient’s ultimate outcome.
What makes you a good expert for this case?
As an acute care surgeon, I’ve managed nearly 1,000 penetrating injuries during my career. Necrotizing soft tissue infection is something I’ve encountered many times throughout my career, both surgically and within the ICU. It is well within my preview to be an expert on this case given my extensive experience with this patient population.
How often do you encounter cases similar to this one in your practice?
As I stated above, this is something I see often in my career. Our service is consulted on this at least once a week.
Do you believe there might have been medical error?
A stab wound is always high risk for infection. The patient had risk factors for healing....ie DM, Obesity. DM creates a high glucose environment which can promote an infection and necrotizing. fasciitis (example Fornier's Gangrene). The wound depth is difficult to evaluate on an obese patient. Closing a wound in this situation would not be the recommended treatment.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Causation can be seen in this case upon this visit to the emergency room. An obese patient with a stab wound. Range of motion was documented, BUT the patient's history of obesity with diabetes places him at high risk for complication. Mainly an infection because of the DM. We frequently see Fornier's gangrene (necrotizing fasciitis of the perineum) in diabetic patient's and any break in the skin. This case involved a penetrating injury that was closed primarily. It is a contaminated wound so, a primary closure would not be the treatment of choice. The patient could have warranted an admission with IV antibiotics with a surgical consultation for possible wound exploration in the operating room.
What makes you a good expert for this case?
I have been in practice for almost 16 years. I am a Board Certified General Surgeon and an Oral Board Examiner. My recent practice involved a rural hospital where we covered every surgical issue. This case is common.
How often do you encounter cases similar to this one in your practice?
Probably every other month given the large amount of obese patients that enter the hospital and their associated co-morbidities.
Do you believe there might have been medical error?
For which decision? - Regarding the emergency medicine providers who saw the patient after the initial stab wound who irrigated, sutured it, and discharged the patient: it depends on whether the wound was fully closed or if it was loosely closed and allowed to drain. If it was a suspected dirty wound, it could also have been packed open with delayed closure. That depends on whether the wound appeared dirty or there was significant devitalized tissue. Completely closing such a wound may trap the bacteria and provide a good opportunity for them to run rampant, leading to a necrotizing soft tissue infection. Based on the information provided, I cannot tell how securely that wound was closed. If the wound was completely closed, it was more likely than not an error (6). That being said, this is an uncommon, albeit devastating complication. A dose of antibiotics in the emergency room would be appropriate but wouldn't need a prolonged course but likely would not have prevented the development of a necrotizing soft tissue infection. - Regarding the initial operation, excision debridement of skin & subcutaneous tissue & necrotic muscle of chest wall and left arm. From the operative note, it seems this operation was appropriately aggressive. For a necrotizing soft tissue infection the surgeons need to be aggressive, removing any obviously dead tissue, evacuating any purulence, opening any pockets where additional necrosis may be hiding. The standard of care would be to resect the obviously dead material, bring the patient to the ICU for ongoing resuscitation, and plan to return to the operating room in a day or so to evaluate viability of remaining tissue. Based on the operative note from the index operation, it seems an appropriate debridement, and I think it is unlikely there was an error here (4) - Regarding the decision to delay return to the operating room. On post op day #1 (12/28), the patient's lab work is getting worse with rising lactate and new acute kidney injury. This suggests to me that there is an ongoing focus of necrosis that is driving the persistent organ dysfunction. It is not clear from the above notes when the patient progressed to septic shock requiring pressors, but once pressors were added, that should have been an indication to proceed to the OR for evaluation and further debridement. The patient was getting worse, not better, and in the setting of a necrotizing soft tissue infection that had already been demonstrated to move quickly, I think there was very likely (8) an error in not proceeding to the OR on POD#1. It is possible, however, that the patient's physiology at that point was already too far gone to permit survival. - Regarding the upper arm disarticulation. This was an aggressive procedure (amputation) intended to save the patient's life. But the fact that the patient coded upon anesthesia induction, and then 2 separate times, suggests his physiology was too far deranged, his burden of injury too great, to allow him to survive despite this heroic procedure. There was no error in this procedure (1) The major source of error to my interpretation is the delay in not bringing the patient back to the OR on POD#1 when he was getting worse and instead waiting until he was in florid septic shock on 3 pressors
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Focusing on the delay in bringing the patient back to the OR: yes, this delay very likely (8) resulted in the patient's worsening multiple organ failure (septic shock, kidney failure, hyperkalemia) that contributed to his cardiac arrest and eventual death. The delay allowed progression of the necrotizing soft tissue infection. It was no longer a local process but a systemic one. Treating necrotizing soft tissue infection requires prompt, aggressive source control and frequent returns to the OR for additional debridement as necessary.
What makes you a good expert for this case?
I am an acute care surgeon practicing trauma surgery, emergency general surgery and surgical critical care. I am often called on to evaluate patients for necrotizing soft tissue infection. I have operated on countless patients for necrotizing soft tissue infection. I have cared for patients in multiple system organ failure from overwhelming necrotizing soft tissue infections. I have at one point performed a hip disarticulation for a rapidly advancing necrotizing soft tissue infection when a partner had done a debridement 6 hours earlier. Prompt return to the OR in that case saved the patient's life. I have often accepted patients in transfer after insufficiently aggressive debridement of necrotizing soft tissue infections, including a patient on whom I performed an upper extremity amputation.
How often do you encounter cases similar to this one in your practice?
Necrotizing soft tissue infections are not common, and overwhelming ones that move with such speed are rare. I probably see NSTIs a few times a month, but ones as severe as in this case probably 2-3 times a year.
Do you believe there might have been medical error?
It's not clear what the original treatment of the deltoid wound was. I would need to see the imaging, if any, that was done for the deltoid injury, and the procedure note for the washout and closure. It's also important to know if the providers asked about the knife, if it had been recently used on raw meat, etc, and if any antibiotics were given at the time of wound closure.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It seems like the deltoid washout was not treated appropriately. Also, its unclear if trauma surgery was called, which should have been done for a wound in this region. The error in this case was clearly made at the index procedure when the wound was closed - the subsequent treatment of the necrotizing infection, including the amputation, was appropirate.
What makes you a good expert for this case?
I am a trauma surgeon with 10-12 years experience, chief of trauma at a level 1 trauma center. I have treated hundreds, possibly thousands of patients with penetrating trauma over my career.
How often do you encounter cases similar to this one in your practice?
I see cases of penetrating trauma at least weekly. I close emergency wounds daily.
Do you believe there might have been medical error?
The key question in this case is whether an operative exploration with more thorough washout was needed at the initial presentation to the ED, especially that the kitchen knife possibly carried a significant burden of contamination and bacteria. Further review of that initial presentation is needed to determine this point. Upon presenting 5 days later, it seems there was timely and appropriate interventions, but a review can confirm it further (or not).
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If there was an indication to do a more thorough evaluation of the stab wound with exploration and operative washout, there might be causation. This would be especially true if the stab wound had penetrated the shoulder joint.
What makes you a good expert for this case?
I have near 2 decades in experience as an acute care surgeon, have treated hundreds of stab wound and necrotizing skin and soft tissue infections at the largest academic medical center in New England. In addition, I am a known patient safety expert with more than 400 peer reviewed articles about safety and quality, and deal on a daily basis with safety analysis and management of safety and sentinel events like these.
How often do you encounter cases similar to this one in your practice?
I deal with stab wounds and necrotizing skin and soft tissue infections on a daily to weekly basis.
Do you believe there might have been medical error?
I have several areas of concern. First, I would not have closed the stab wound at the initial visit. It was not mentioned that there was imaging done at the first visit to rule out vascular or other critical soft tissue injury that may have changed the management of this injury. There was definitely a critical delay to definitive treatment. The WBC was noted to be 47 at 2:41 pm, but imaging was not completed until 5:20 pm and the patient had a significant critical delay in definitive treatment (abx started at 6 pm and surgical consult at 5:20 with surgical debridement at 918 pm). With worsening clinical status, the patient should have been taken back to the OR 12 hours after the first debridement to ensure there was no more necrotic tissue present. This was not done.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This infection is a surgical disease. Antibiotics can help the tissue that still has blood flow, but the necrotic tissue must be surgically debrided emergently, and a second look operation is critical, especially when the patient continues to deteriorate clinically.
What makes you a good expert for this case?
For the last 14 years ongoing, I am a trauma and acute care surgeon at a bust verified level one trauma center. I serve as the acute care surgery medical director for the facility. We are a tertiary referral center and we see these infections many times per year
How often do you encounter cases similar to this one in your practice?
Many times per year. I manage the initial resuscitation, surgical debridement and post op ICU care
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