Teen dies when blood culture protocol botched [PODCAST]

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“Address the patient’s chief complaint first. In this case, the other symptoms were only side effects of the main problem.

Pay attention to lab work. In this case, the elevated white blood count and the related blood culture results.

Keep an open mind, broaden your differential and document your medical decision-making (MDM), especially when sending a patient home with pending blood cultures.

Avoid anchoring bias and premature closure based on a patient’s self-diagnosis. This teen’s report of a lifting injury does not comport with his signs and symptoms.

Follow your hospital’s procedures on abnormal lab results.

Don’t automatically write off ‘preliminary’ culture results.”

Charles A. Pilcher is an emergency physician and editor, Medical Malpractice Insights – Learning from Lawsuits.

He shares his story and discusses his KevinMD article, “Teen dies when blood culture protocol botched: What can we learn from this tragedy?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show, we have Chuck Pilcher. He is an emergency physician, and he’s the editor of Medical Malpractice Insights: Learning from Lawsuits. His KevinMD article is titled “Teen dies when blood culture protocol botched: What can we learn from this tragedy?” Chuck, welcome to the show.

Charles A. Pilcher: Thank you, Kevin.

Kevin Pho: So we’ll get into your article and case in a little bit, but just first off, briefly share your story and journey to where you are today.

Charles A. Pilcher: Well, actually, my story and journey is really about stories. I found out years ago that stories are really the most powerful teaching tool we have, and they’re a lot better than going to conferences or summaries from insurance companies. I was the medical director of our emergency department for 25 years and have done case reviews for attorneys, both plaintiff and defense, for most of that career. In about 2014, I started writing an educational newsletter, which is what we’re talking about today, Medical Malpractice Insights: Learning from Lawsuits.

Why did I do that? Well, in 2014, during that year, I was contacted by four different plaintiff attorneys here in Washington State, each asking me to review a case of a missed spinal epidural abscess. Each case had led to permanent paralysis, and each case was a totally preventable incident. Each of those cases ended up settling out of court, and each settlement had a nondisclosure clause or confidentiality clause, so no one could really talk about it. It was like a gag order. No one learned anything. Maybe the defendants learned something, but no one else did, not the rest of the emergency medicine community.

I realized that every plaintiff in these cases hoped that, with the lawsuit about their misfortune or whatever they wanted to claim, they wanted to make sure that this wouldn’t happen to someone else. And I realized that that was going nowhere, because we end up in these confidentiality clauses burying the learnings, and we end up burying the next patient. So in 2014, I just decided this has to stop. I started writing Med Mal Insights and telling those stories.

I really think if you anonymize them, keep it just to the facts, and don’t talk about settlement amounts, you can actually share the information and find out how we can keep it from happening again. So there are no names and no settlement amounts, just the facts of the story, the plaintiff and defense arguments, the result, and, most important, the learnings or takeaways for our colleagues.

Kevin Pho: Now, you’ve been doing this, of course, for many, many years, and I’m sure you’ve reviewed hundreds, if not thousands, of cases. A lot of medical malpractice is really a black box for a lot of physicians, and the statistics show, as you know, that a lot of physicians, the majority, I’m sure, will eventually face a liability lawsuit sometime during their professional career. As you review these hundreds, if not thousands, of cases, what are some of the themes that emerge that physicians should watch out for from a lot of these cases that go poorly?

Charles A. Pilcher: There are definitely a few themes, and there are a few very common incidents that have the biggest pitfalls for docs. The themes seem to be things like what’s called anchoring bias, making up your mind before you really talk to the patient. That was the case with most of the spinal epidural abscess cases. In fact, I think I’ve totaled up that I’ve seen about 14 of those since then. But I think the good news is that people have read my newsletter, and I don’t think any of them have ever missed one. In fact, I’ve had feedback: “Thanks for sending me this, because I caught my first one last night.”

But anchoring bias is really something we have trouble dealing with, because you pick up a chart that says back pain, you look, and the guy’s been here before. He could even be a drug seeker. If you don’t think about the possibility that this could be a spinal epidural abscess, especially in people who use IV drugs, who are more at risk for an SEA. So anchoring bias is really a big problem.

It appears not only in epidural abscess but in cases like pulmonary embolus. I’ve always said that when you pick up a chest pain chart, the first thing you think of should be aortic dissection, pulmonary embolus, collapsed lung, anything but an MI, because nobody’s going to miss the MI. By the time you see the patient, the nurse has already done the troponin and the EKG and handed it to you. So start thinking about the things that it could be that isn’t an MI.

Kevin Pho: All right. So there’s one case that you talked about on KevinMD. It’s titled “Teen dies when blood culture protocol botched: What can we learn from this tragedy?” For those of you who get a chance to read your article on KevinMD, tell us a little bit about the case.

Charles A. Pilcher: This is a 17-year-old male. He came into the emergency department with pain in his left shoulder after lifting several hundred pounds at the gym. At least that’s the way he presented it; that’s what he thought was going on. After that lifting incident, about three days later, he woke up at four in the morning in severe pain, so severe that his parents actually called 911 and had him taken to the emergency department with this left shoulder pain.

When he got there, the pain was radiating to his wrist. He actually had a fever, he was nauseated, he was vomiting, and he had a headache and a cough. He was producing green sputum, and yet his chief complaint was shoulder pain and limited range of motion in his shoulder. X-rays of the chest and left humerus were negative. His white count was 19,000, and then a spinal tap was done. I’m not quite sure why, but I guess it had something to do with the fact that he had a headache. Blood cultures were done and sent to the lab, and after about 11 hours in the emergency department, he was just discharged with a diagnosis of shoulder sprain, placed in a sling, and treated with Motrin.

The next morning, the lab calls and says that there’s a preliminary report that shows that gram-positive cocci are present in both of his preliminary blood cultures. The conversation between the lab, the nurse, and the physician on duty at that point was really not well documented. When the case did develop, the doc claimed that he was never told, that he never told the nurse, “Well, this is a preliminary report, so let’s wait for the final.” But that was the claim of the nurse. The nurse claimed that she was told by the doc, “Let’s wait for the final.” Anyway, he ends up developing, or actually having, a septic arthritis in the left shoulder, and he died after a long battle with sepsis.

There are a lot of things going on in this case. We could talk about the plaintiff’s arguments and the defense arguments, but one of the key things here, I think, is that the patient had pain out of proportion to his presenting complaint and the story behind it. Pain out of proportion is always a red flag. The doc in this case didn’t really focus on the shoulder pain. He looked at a lot of the other things, the nausea, vomiting, the fever, maybe the white count, but he didn’t really keep his mind open. You stay focused on why this patient came to the emergency room. He came in for shoulder pain.

So this was a classic case of anchoring bias, in that he went in there with an idea of something else being wrong. The teen’s report of a lifting injury didn’t really comport with the signs and symptoms he was presenting with. A white count of 19,000 was a red flag too, and there really wasn’t any follow-up on the cultures at the time. The patient went back to his PCP with this pain between the time that he presented to the ED first and the time he was finally diagnosed, and his PCP had never gotten the culture results, preliminary or otherwise, or been notified that the patient was even in the emergency department. So he didn’t know, and in fact he ordered a second set of blood cultures, because he was thinking that there may be something really wrong with this kid.

So with that communication, there was also a big loss of communication between the patient, his family, the ER doc, the nurse, and the PCP. I think the message here is don’t write off preliminary blood culture results. Take them seriously, especially if both bottles are growing the same organism at the same time.

Kevin Pho: Now, from a liability standpoint, what was the outcome there?

Charles A. Pilcher: Let’s see. The outcome of that one was that it settled in arbitration for an undisclosed amount, against the hospital, the emergency nurse, and the emergency physician. The primary care physician was left out of the case, because he actually was the one who kind of realized this kid was sick. The only odd thing about it was that he suspected a deep-tissue infection but sent the patient home. He didn’t send him back to the ER; he just sent him home, waiting for the blood cultures.

Kevin Pho: Now, you’ve been doing this for so long, reviewing liability cases for the newsletter. Is there anything surprising that you’ve learned from reviewing all these cases and telling these stories?

Charles A. Pilcher: I think the number one thing I’ve learned is the power of stories to change behavior. I mean, you get an annual report from your insurance company or med mal insurer, and it talks about all the things that we can do better, and who ever reads those things? But stories are really powerful teachers. There’s an interesting fact that fiction stories outsell nonfiction books, on average, by about 250 times. People want to read novels. They want to read stories. They don’t want to read reports.

That’s why I think these stories are the most powerful thing, and that’s the feedback I get from readers. I’ve got about 4,300 docs reading this now, and it’s all by opt-in. There’s no website or anything. It has just sort of grown virally by people forwarding it on to others. It’s very, very satisfying in that regard.

Kevin Pho: Now, we have a lot of clinicians on this platform listening to you. So you mentioned anchoring bias as the number one thing clinicians should guard against. What other tips can you share with them from reading all these cases? What other things should they look out for or improve to prevent themselves from finding themselves in a liability lawsuit?

Charles A. Pilcher: You know, one of the other biases is what’s called confirmation bias, and that sort of happened in the case we just discussed. You’re thinking, “Well, I think I know what’s going on.” So I get the lab report, and it shows a white count of 16,000. I’ll just sort of ignore that, because it doesn’t confirm what I’m suspecting, and that’s it; that’s just a shoulder sprain. So they’ll ignore the cultures.

Or, conversely, you can get the lab report or imaging that will confirm what you suspect. Because you were thinking one thing and got confirmation that it was really that, you know, you expected the white blood count to be elevated and it was, then that eliminates the possibility of shoulder sprain. But really, the key is just keeping an open mind and not jumping to conclusions, and it’s so easy to do that when you’re seeing so many patients so many times a day.

Kevin Pho: We’re talking to Chuck Pilcher. He’s an emergency physician, and he’s the editor of Medical Malpractice Insights: Learning from Lawsuits. Chuck, what are some of your take-home messages that you want to leave with the KevinMD audience?

Charles A. Pilcher: There are some things that I’d really like everybody to take home, and these are things that are common in most of the lawsuits that I’ve reviewed and written about. Paying attention to nursing notes, lab values, and radiology reports is really crucial. I think we don’t value our radiology colleagues as much as we should. We need to treat them like consultants rather than technicians. Give your radiologist as much clinical information as possible, read their reports, and I really think that most of us should be reviewing our imaging ourselves.

Another one is handoffs. If you’re in the habit of handing off your patients at the end of your shift, do it at the bedside. Talk to the patient, introduce the new doc who’s going to be caring for that patient, and make sure you’re both on the same page about what your thought processes are. Don’t just leave and say, “There’s a patient in exam room four that I’m waiting on a CT scan for. You know, if it’s normal, they can go home.” There’s a lot more to it than that.

Your differential diagnosis is really critical. If you have a broad enough differential diagnosis, you should then use the medical decision-making section of your chart to explain clearly why you ruled out the most serious things on that differential. It’s embarrassing when I see a differential diagnosis that’s been created by an Epic macro. If you click the macro and put in the differential for abdominal pain, I mean, it’s going to look really awful in your chart when a 44-year-old male does not have an ovarian torsion and that’s in the macro. So be careful what you put in there, and make it look like there really was some thought process in your MDM.

And just since I started this project with spinal epidural abscess, I really think that when you pick up a chart and it says back pain, all you have to do is think, “Oh, could this be the patient with a spinal epidural abscess?” You can talk to them. You can probably rule out 99 out of 100 of them just by talking to the patient. If you still have a question about it, a CRP or a sed rate, or both, will give you an answer. If it’s not elevated, it pretty much proves that the patient doesn’t have some serious infection going on, certainly not a spinal epidural abscess. In fact, our neurosurgeons at our hospital say that 99 percent of patients with a spinal epidural abscess will have a shockingly high sed rate or CRP. So that would sort of honor the reason why I started this project in the first place. So that’s about it as far as takeaways.

Kevin Pho: And if people were interested in subscribing to your newsletter, how can they go about finding it?

Charles A. Pilcher: Well, I purposely don’t put this on a website, because I don’t want patients looking for a med mal expert or an attorney or something like that. I don’t want them shopping around and finding it online. So I don’t have a website for it. Probably the best way to do it is just to get in touch with [email protected].

Kevin Pho: Chuck, thank you so much for sharing your time and insight, and thanks again for being on the show.

Charles A. Pilcher: Thank you very much, Kevin.

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