Medical Malpractice Insights: Sometimes it’s a “spider bite” and sometimes it’s not

Necrotizing Fasciitis

Sometimes it’s a “spider bite” and sometimes it’s not.

Facts: A young right-handed adult female presents to a rural ED for a “spider bite” on her right elbow. She first noticed it the night before, but the pain and redness increased overnight. Review of systems is positive for a sore throat, feeling ill, and vomiting once the day before. She describes the pain in both her elbow and throat as 10/10. Past history is positive for fever of 101.4 with strep throat 3 months ago, and a fever of 99.7 with “hives” 2 weeks ago. On exam she is “calm” with normal VS and no fever. Her elbow has a 0.5 cm “ulceration” with 3 cm of surrounding induration and erythema and “no crepitus.” The EP’s MDM records “No evidence of infection” and “Not cellulitis or staph.” A bandaid and bacitracin are applied, and she is discharged with a diagnosis of “insect bite” with appropriate follow-up instructions. That night her pain worsens, she develops a fever and has difficulty sleeping. At 3 AM she calls the ED and is advised to see her PCP when the office opens. At 8 AM her PCP sees her and cultures the wound. She is diagnosed with an “elbow abscess” and placed on oral antibiotics. Within 2 hours the pain is so severe that she returns to the ED. She is diagnosed with necrotizing fasciitis, treated appropriately, transferred to a tertiary hospital, and undergoes an amputation at the shoulder after the orthopedic surgeon tells her “If they had sent you here earlier, I could have saved your arm.” She recovers and seeks the advice of an attorney who consults both an ED and ID expert before filing a lawsuit.

Plaintiff: Necrotizing fasciitis was never included in my differential on my first ED visit or my clinic visit the next day. You can’t diagnose something you never even think about, so it’s no wonder you missed it. My wound culture result [reported after the amputation/cp] grew Group A beta-hemolytic strep (GABS.) If you had done the culture in the ED when I first came in and put me on antibiotics, I would still have my arm.

Defense: Both the EM and ID experts for the plaintiff agreed on the following: There was no reason to suspect necrotizing fasciitis at the first visit. The wound looked like a typical insect bite with redness and swelling. Even if it’s a spider bite, it’s almost always inflammation, not infection and does not require antibiotics. Necrotizing fasciitis due to GABS progresses so rapidly that oral antibiotics – even 24 hours earlier – would not have made a difference. Neither would an earlier culture. Both the EP and PCP made reasonable judgments. Though hindsight proved them wrong, neither physician was negligent. The comment by the orthopedic surgeon was unfortunate and based on limited knowledge. Necrotizing fasciitis caused by GABS has a mortality rate as high as 50% – but you survived.

Result: After reviewing the records, the experts presented their opinions to the plaintiff attorney. He agreed that the defense arguments would be difficult to overcome, accepted their opinions and the matter was dropped.

Takeaways:

• Avoid the temptation to criticize another doctor’s judgment, especially when you have limited information and only one side of the story.
• POOP (Pain Out Of Proportion) is a significant marker for necrotizing fasciitis.
• That the patient was “calm” andher sore throat was as painful as her “insect bite” calls the pain level into question. Pain scores are notoriously subjective and should be corroborated by behavioral markers, as they were in this case.
• Necrotizing fasciitis has a devastating mortality rate, especially when caused by GABS.
• Making a wrong judgement is not the same as being negligent. We may not always make the perfect diagnosis at the perfect time, but we are not held to perfection. We are held to a standard of what a provider with similar training and experience would do under similar circumstances.

References:

emDOCs Podcast Part 1

emDOCs Podcast Part 2

emDOCs – Misdiagnosis and Mismanagement

emDOCs – Pearls and Pitfalls

Necrotizing fasciitis. Medscape eMedicine, Schulz SA. Updated 10.12.2022.