MAT # 19064647
A 57-year-old male with diabetes mellitus, hypertension, prior right transmetatarsal amputation/right diabetic foot infection with osteomyelitis, and bilateral diabetic foot ulcers present for approximately 3 months presented on Day 1 with 2–3 weeks of mid-thoracic back pain attributed to lifting. There was no reported tobacco, alcohol, drug use, IV drug use, back instrumentation, steroid injections, or recent travel.
On Day 1, vital signs included temperature 97.9°F, heart rate 94, blood pressure 166/95, respiratory rate 17, and SpO₂ 99% on room air. Exam documented mid-thoracic tenderness. Thoracic x-ray showed a T10 superior endplate compression fracture with 50% anterior height loss and no subluxation. He received ketorolac and orphenadrine and was discharged with hydrocodone and orthopedic follow-up.
On Day 3, after a fall from a toilet with back pain, EMS was called and the patient returned to the ER. In the ED/hospital, VS: 144/77; heart rate 81–83; respiratory rate 18–22; temperature 99.1°F to 97.9°F; and SpO₂ 98–99%. CT spine showed T9-T10 discitis/osteomyelitis. MRI spine was ordered for osteomyelitis, and the record reflected “no signs on exam of cord compression or spinal cord compromise.”
The patient was in DKA and was started on insulin infusion and IV fluids. He was treated for sepsis/MRSA bacteremia with IV antibiotics. A sepsis alert began on Day 3 with blood cultures, lactic acid reflex testing, piperacillin-tazobactam, linezolid and normal saline boluses.
Later infectious disease notes documented treatment with daptomycin and ceftaroline, prior vancomycin with low trough, repeat blood cultures negative to date, TTE unable to exclude aortic valve vegetation, TEE negative for vegetation, and a planned antibiotic stop date of approximately Day 64. Records say Neurosurgery was contacted but not formally consulted, and “no surgical intervention recommended.”
During hospitalization, neuro/musculoskeletal documentation included generalized weakness, decreased strength, decreased range of motion, decreased mobility, bilateral lower-extremity weakness/limited movement, and occupational therapy noting at least a 50% decline from baseline. Despite these changes, serial/repeat thoracic imaging was not performed before discharge.
The patient was discharged to skilled nursing on Day 16 with a PICC line, Foley catheter, oxygen, fall precautions, WBAT to the left lower extremity with post-op shoe, and ongoing IV antibiotics. During his SNF stay the patient went 2.5 days without administration of his ceftaroline due to it not being available on the formulary, but it was eventually obtained and recommenced. All doses od daptomycin during that time period appear to have been administered.
On Day 26, the skilled nursing record documented unresponsiveness. CPR was initiated, and EMS arrived around 05:00, documenting PEA rhythm. Hospital arrival was at approximately 05:23 with Lucas compressions in progress. ROSC was documented by 07:15, and targeted temperature management was initiated.
Post-arrest, CT head was ordered. CT chest/abdomen/pelvis with contrast was ordered for post-arrest/cardiac arrest/intubated/hypoxic status, management of osteomyelitis/joint infection/diabetic foot infection, and HAP/VAP. CRRT was planned/used. The record documented acute lactic acidosis present on admission, acute kidney injury requiring dialysis, metabolic acidosis, acute hypoxic respiratory failure on ventilator, and neurologic exams showing persistent unresponsiveness to pain.
PC did not improve. Death occurred on Day 30. The death certificate listed hypoxic brain injury, cardiopulmonary arrest, and sepsis with septic shock secondary to MRSA. Other significant conditions included acute kidney injury on dialysis, metabolic acidosis, and acute hypoxic respiratory failure on ventilator.
Expert Review Questions
In a 57-year-old diabetic patient with a T10 compression fracture and T9-T10 discitis/osteomyelitis, did the standard of care require neurosurgery and/or interventional radiology consultation for possible source control, biopsy, drainage, or (considering steady decline in neurologic function) operative management been initiated for suspected spinal infection or abscess?
Should repeat thoracic spine imaging have been obtained before discharge, or with ongoing symptoms/weakness, to assess progression of discitis/osteomyelitis and/or possible epidural abscess or phlegmon?
Was the patient appropriate for discharge to a SNF that did not have his required antibiotics on its formulary?
Files:
Q: Was the weakess generalized or more prominent in the lower extremities? Was there a sensory deficit?
A: more prominent in lower EXT
Q: Does the chart say that Neurosurgery was contacted but not consulted or was Neurosx consulted and they didn't write a note?
A: 1st CCM note: “Discussed with neurosurgery, recommend medical therapy.” ID notes later state: “Neurosurgery contacted by CCM no surgical intervention recommended.”
Do you believe there might have been medical error?
First of all, given the decline in neurologic function in the face of new onset compression fracture, as well as evidence of spinal infection, neurosurgery should have been formally consulted for possible operative management. Second, there is no excuse for missing days of antibiotics, therefore discharge to the skill nursing facility should have been delayed at a minimum.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Given the above, it is certainly possible that the infection spread leading to sepsis and cardiac arrest although this is not for certain. He certainly had risk factors for underlying heart disease.
What makes you a good expert for this case?
I am board certified in Anesthesiology and Critical Care Medicine, and have been in practice for over 30 years, primarily in large academic medical centers. In addition, I have been doing expert witness work for over 15 years, having been involved in more than 25 cases.
How often do you encounter cases similar to this one in your practice?
Once or twice a month on average.
Do you believe there might have been medical error?
Standard of care would have required formal neurosurgery consultation for a patient with concern for discitis/osteomyelitis. However, the treatment course would’ve likely been the same, meaning that it is unlikely that an actual surgical intervention would have resulted out of the consultation. SOC considerations regarding obtaining repeat imaging would depend on how his worsening symptoms were assessed and interpreted (e.g., worsening OM vs. deconditioning) clinically. The discharge to SNF was appropriate unless it was known to the hospital that the SNF would face challenges with the antibiotic availability. In addition, it is beyond the standard of care expectation for a hospital to be able to foresee availability challenges for IV antibiotics at a skilled nursing facility.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is unlikely that neurosurgical consultation would have changed the course. Whether repeat imaging would have impacted the ultimate outcome is also quite uncertain. The same holds true for a relatively short interruption in antimicrobials several weeks into an extended treatment course.
What makes you a good expert for this case?
What makes you a good expert for this case? I am a senior administrative physician leader at a quarternary academic center who has deep experience and expertise in clinical emergency care and operations. As an EM and CCM boarded physician, I have in-depth knowledge of comparable cases for both the ED and inpatient management.
How often do you encounter cases similar to this one in your practice?
I see patients presenting who present with concern for discitis/OM and similar clinical question/needs several times a month.
Do you believe there might have been medical error?
It is difficult to say but the timeline suggest that things were missed. It would be unusual for a 57 yo to progress from mild back pain and mild disability to significant osteo and sepsis resulting in arrest without SIRS being documented.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Omission also points to causation however difficult to opine without full record.
What makes you a good expert for this case?
Perioperative expert and critical care trained and boarded.
How often do you encounter cases similar to this one in your practice?
spine degeneration, diabetic ulcers, osteomylitis, sepsis. With great frequency
Do you believe there might have been medical error?
Since there was more prominent weakness of the lower extremities, imaging of the spine should have been repeated and Neurosurgery consulted, especially if there also was a sensory deficit (unclear from the vignette). It appears that the primary contacted Neurosurgery and whether they asked for a formal consult or not is essential to determine responsibility. Further chart review is necessary to understand why Neurosurgery did not recommend repeat imaging. The patient should not have been sent home without verifying availability of prescribed antibiotics. This is usually Social Work responsibility.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It appears that the error is likely to have caused possible irreversible neurologic injury. However, the link between the error and death is less clear, and further review is necessary to determine why antibiotics failed. It would be uncommon for missing a day or two of antibiotics would result in irreversible sepsis from osteomyelitis.
What makes you a good expert for this case?
I think the best experts for this case are a neurosurgeon, and ID. Critical Care, my specialty can help clarify the workflow and coordination and the treatment of sepsis later on. If Critical Care is still requested, I believe I am good expert due to my extensive experience in surgical CC, including spine surgery, as I work in an orthopedic SICU and as I have reviewed multiple charts for legal purposes throughout my career.
How often do you encounter cases similar to this one in your practice?
I encounter similar cases on a weekly basis
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