Failure to diagnose a foreign body and to follow up

by Olga Maystruk, Designer and Brand Strategist, and 
Karen Werth, Senior Risk Management Representative

Presentation and physician action

An eight-year-old girl was brought to the emergency department (ED) of a large hospital with a groin injury from a bicycle accident. Examination revealed a 4.5 cm inguinal laceration with excessive vaginal bleeding and a possible split of the hymen. The patient also vomited once while in the ED.

A head CT and pelvic ultrasound were performed and found to be normal. The attending ED physician administered a local anesthetic with epinephrine, prepped the wound, and closed it with a single layer of eight sutures. The physician’s note stated: “Explored for foreign body, but nothing was found.”

While in the ED, the patient was also seen by a pediatric gynecologist. While the patient could not tolerate an extensive vaginal examination, the pediatric gynecologist noted that vaginal bleeding was minimal and had possibly clotted through natural processes. The patient was then discharged home with instructions to her mother to return the patient to the ED if she had worsening symptoms or was using one pad per hour.

Two days later, the patient had a temperature of 103 degrees and reported foul-smelling wound discharge. The mother took the patient to see her pediatrician, Pediatrician A, who diagnosed the patient with cellulitis. Pediatrician A prescribed both oral and topical antibiotics (mupirocin and clindamycin), and acetaminophen with codeine. The patient’s mother was told to contact Pediatrician A if the patient’s condition worsened.

While at home, the patient’s condition worsened, but the mother did not contact Pediatrician A.

Two days after the visit with Pediatrician A, the patient was taken to a different ED with urinary incontinence, worsening of the wound appearance and discharge, and a temperature of 104 degrees. A CT scan of the abdomen/pelvis showed a fascial defect between the child's rectus abdominis and external oblique muscle.

The patient was taken emergently to the operating room, where a pediatric surgeon found extensive necrotizing fasciitis and soft tissue infection of the left groin and abdominal wall into the extra peritoneal space. Additionally, a 3x7 cm piece of cloth possibly from the patient’s clothing during the bicycle accident, was discovered embedded deep in the wound between the rectus abdominal muscle and external oblique muscle.

Four days after surgery, the patient underwent a CT cystogram which showed an extraperitoneal bladder leak, an injury likely from the bicycle accident.

The next day, the child was returned to surgery for bladder repair, wound debridement, and wound VAC placement. The patient returned for VAC replacement and wound debridement six more times every three days.

During a follow-up visit with the pediatric surgeon three months later, it was noted that the patient was recovering well and reported no pain. She was negative for fever, chills, dysuria, urinary frequency, or incontinence. The wound appeared to be healed and all the surrounding tissue was negative for erythema.

Six months later, the patient was taken to a psychiatrist who evaluated the patient and noted symptoms of PTSD, anxiety, depressive reaction, and organic depression all due to the infection.

The patient also received an assessment from a physical medicine and rehabilitation physician. The report stated the patient needed monthly physical therapy and psychiatry visits, bi-monthly visits with a psychotherapist, two-to-four visits annually with a rehabilitation specialist, and an abdominal MRI every three-to-five years.

Allegations

A lawsuit was filed against Pediatrician A alleging failure to explore the wound and detect the foreign body, and failure to follow up.

Legal implications

Two of the three expert consultants for the defense stated that Pediatrician A acted within the standard of care. One consultant noted that at the time of the visit there was no evidence of a significant infection; therefore, the physician’s outpatient management was correct. However, given the next set of events two days later, it was difficult to judge the severity of infection based on the records. This consultant believed the primary issue in this case to be the incorrect closure of the initial laceration, leaving a foreign body inside. The mother’s failure to act immediately and follow the physician’s orders were also seen as factors in this case.

The other consultant for the defense was more critical of Pediatrician A and felt he did not meet the standard of care. This consultant stated that since fever and foul odor are indicators of a severe wound infection, a reasonable treatment would have been to refer the patient to the ED, admit the patient to the hospital, start IV antibiotics, and consult general surgery. This consultant felt that had Pediatrician A met the standard of care the patient's infection would have been less severe, but surgery and a prolonged hospitalization would have still been likely or required.

A consultant for the plaintiff noted that while Pediatrician A’s antibiotic orders were appropriate, failing to schedule a 24-hour follow-up appointment was below the standard of care.

Disposition

This case was settled on behalf of Pediatrician A.

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