This case involves an elderly female who presented to the emergency room with shortness of breath and fever and said she had been feeling unwell for the past week. The patient was evaluated by the emergency room physician who noticed swelling of the left pharynx. A CT scan of the neck was ordered by the ED physician. While the patient was in transit to the CT scan, her lab results showed an elevated creatinine blood level, and the scan was canceled. The patient was returned to the emergency department.

Soon after, the patient experienced worsening shortness of breath, a syncopal episode, and became unresponsive, resulting in a Code Blue. Intubation attempts by the ED physician failed. Anesthesia was called and intubation was again unsuccessful. An Otolaryngologist (ENT) was called in and performed an emergency tracheotomy. Despite attempts to revive the patient, she remained unresponsive and was transferred to the intensive care unit. It was discovered that the patient had a peritonsillar abscess. A brain MRI revealed extensive hypoxic-ischemic encephalopathy. Several weeks later, the patient died.

Peritonsillar abscess (PTA) is an infection of the head and neck caused by pus accumulation between the palatine tonsils and the superior pharyngeal constrictor muscles. A deep neck infection (DNI) is caused by bacteria invading the deep neck space and can be fatal. Incision and drainage plus antibiotic therapy, tonsillectomy à chaud, or interval tonsillectomy is recommended for PTA. PTA is typically caused by recurrent tonsillitis. The parapharyngeal space can be affected by severe PTA, resulting in a DNI. It is recommended to administer empiric antibiotics. Often, steroids are used as an adjunctive treatment.

It is common for patients with PTA to present to the emergency department with fever, severe sore throat, odynophagia, dysphagia, trismus, and even respiratory distress, and they will often require pus drainage, antibiotic therapy, and supportive therapy. Creatinine levels in the blood may be abnormal. An elevated temperature requires antipyretics as well as adequate analgesia for pain.

It is important to pay attention to the patient’s airway when evaluating peritonsillar abscesses. Immediate endotracheal intubation is necessary if the patient’s airway is compromised. It may be necessary to perform a STAT cricothyroidotomy or a tracheostomy if this is not possible. An alternative method, if resources are available, is awake fiberoptic bronchoscopy for intubating patients with significant pharyngeal edema. In this case, the negligent failure to diagnose a peritonsillar abscess and delay in intubation led to the patient’s death.

An expert in Emergency Medicine can opine on the standard of care for a similar patient and speak to necessary steps for an elderly patient with signs and symptoms of infection.

Swollen tissues can block the airway. This is a life-threatening medical emergency. An abscess can rupture into the throat if it breaks open. Pneumonia can be caused by the contents of an abscess traveling into the lungs. An ENT specialist can opine on the standard of care for treating a peritonsillar abscess.

An expert neurologist can speak to the importance of time in restoring an airway in a non-responsive patient and the effects of hypoxic brain injury.

How might airway obstruction and failure to timely intubate lead to neurologic damage?

What is the standard of care for an elderly patient presenting with swollen lymph nodes, shortness of breath, and fever?

Is a CT scan the first step in evaluating a similar patient?

What is the standard of care for restoring an airway in a non-responsive patient with multiple failed intubation attempts in the ED?

Here is what an intensive care neurologist had to say about this case:

I frequently treat patients with hypoxic brain injury. As an intensive care neurologist, I typically see 1-2 of these types of patients per week. I see patients post-cardiac arrest, post-surgical complications, and post-traumatic injuries and many of these patients have a hypoxic injury. The brain is a very sensitive organ and it is highly dependent on blood and oxygen delivery. Even a few minutes of oxygen deprivation may lead to hypoxic brain injury. A patient with an airway obstruction, such as an abscess, may be deprived of oxygen because of the mass effect of the abscess. Throughout the time physicians were unable to intubate the patient, she continued to suffer from low oxygen levels and resultant brain injury. I have reviewed two cases of traumatic brain injury, both resulted in permanent and lasting damage and I am interested in reviewing this case further.

In this case, the negligent failure to diagnose a peritonsillar abscess in an elderly female patient led to a Code Blue and multiple failed intubation attempts. Ultimately, the delay in intubation led to brain damage and the patient’s death.

Failure to Diagnose Peritonsillar Abscess Leads to Patient Death

The test was ordered but the results were never communicated to the patient. Because he never heard from the physician’s office, the patient assumed that the test had come back normal. The patient came back a year later for another screening and the results came back well above 4.0 ng/mL. It was later discovered that the patient’s original lab results were high enough to warrant a biopsy 12 months earlier. The physician’s office alleged that the results were never sent to their office. The patient’s health rapidly deteriorated and he was diagnosed with prostate cancer. The patient died within 19 months of receiving his diagnosis.

Most primary care organizations now recommend against routine PSA testing. If a test is performed, it should only be after a discussion about potential harms and very few, if any, benefits. Abnormal test results of any kind should be communicated to a patient in a timely fashion. Any lab tests ordered that do not arrive in the office should be traced. Office procedures should be in place to ensure both occur. It is not an adequate defense to say that the lab test was not received in the office. I was an expert witness for a case in which the primary care doctor did not conduct PSA testing on a patient who was later diagnosed with prostate cancer. The problem for this doctor was that he ordered the PSA test in the first place and then did not act on the results. This error gave the appearance of having led to the patient's advanced prostate cancer while in truth, screening was unlikely to have affected this outcome and should not have been done, to begin with.

What is the standard of care regarding documentation of lab orders ordered on a patient? What is a doctor's duty to follow up on labs orders when they are not received? What is the standard of care to report abnormal PSA results to patients? What is the standard of care to advise a patient with an abnormal PSA on treatment options?

This case involves an otherwise healthy 55-year-old male patient in New Mexico with a family history of prostate cancer on his paternal side who saw his primary care physician for a prostate cancer screening.

Physician’s Failure To Communicate Lab Results Leads To Delayed Cancer Treatment

The patient went back to her pulmonologist for a followup appointment after completing the medication treatment and was told by her pulmonologist that she was recovered. However, the patient continued to be symptomatic and expressed concern about her symptoms. The pulmonologist assured her that she was fine. Within the month, the patient began feeling weaker and experienced difficulty walking and sleeping. The patient then began coughing up blood and losing weight. She returned to the pulmonologist, who decided to do a lung bacterial culture. The culture came back positive for mycobacterium avium complex (MAC). He was referred to an infectious disease physician and treatment for the MAC commenced. In spite of multiple treatments, the patient ultimately required oxygen full time.

I have treated many cases of MAC and have several patients under my clinical care currently that are on active MAC regimens. I am currently a co-investigator on a clinical trial testing a nebulized antibiotic for MAC at my university. The classic symptoms of pulmonary MAC infection are cough, weight loss, fatigue, and intermittent low-grade fever. The standard workup includes chest CT and multiple sputum samples for AFB smear and culture. Alternatively, one bronchoscopic specimen can be used if pt is unable to produce sputum. Classic cases of pulmonary MAC involve nodular and bronchiectactic lung disease, often progressing to more cystic and cavitary disease. The presence of typical lung changes with repeated isolation of MAC from sputum samples is classic. Therapy is prolonged, often problematic, and not infrequently complicated by the emergence of drug resistance to the macrolide or rifamycin derivative (less commonly the ethambutol). In those cases, we'll send for drug resistance testing -- although it is expensive.

Please describe your experience diagnosing and treating MAC? What sort of symptoms would make you consider MAC? What is the standard work up and diagnosis criteria for MAC?

This case involves a middle-aged woman who was diagnosed and treated for tuberculosis.

Patient Is Left On Permanent Oxygen Following Delayed Infection Diagnosis

This case involves a patient who underwent a left total hip arthroplasty (hip replacement) to repair damage caused by severe osteoarthritis. Following the surgery, the physician prescribed anticoagulant medications. The patient developed left leg and foot pain and swelling. Due to the pain and swelling, the patient visited the emergency room eight days after surgery for evaluation. The emergency room found the patient to be neurovascularly intact at that time. Additionally, a Doppler ultrasound was negative for deep vein thrombosis.

The patient followed up with two scheduled orthopedic post-operative visits. He also had one unscheduled visit 12 days after surgery. His chief complaint of swelling and pain was consistent throughout his postoperative course. The patient alleges that despite his numerous visits and complaints, no one performed a vascular examination.

The patient was later found to have a femoral artery occlusion, which caused acute limb ischemia. As a result of the continued lack of blood flow to the limb, the patient required a below-the-knee amputation of the left leg.

A DVT (deep vein thrombosis) is a blood clot that forms in one of the deep veins and is commonly found in the legs. The clot restricts blood flow, causing damage to the limb. DVT can be fatal if the clot moves or breaks off, which can cause a stroke or pulmonary embolism.

There are several clinical symptoms of a DVT. Physicians often use ultrasound imaging to confirm, diagnose, and locate the clot. However, the Doppler ultrasound failure rate for DVT of the femoral artery can be up to 60% with a general accuracy of 77%. The test accuracy is largely dependent on the skill of the technician. In this case, the persistence of clinical symptoms required additional investigation.

The prevention and treatment of blood clots after hip and knee replacement surgery is a well-established component of patient recovery. Joint replacement patients are at the highest risk for developing deep vein thrombosis 2 to 10 days after surgery. These specific patients also remain at risk for clots for at least three months post-surgery.

Healthcare professionals are provided extensive training on preventing the occurrence of blood clots in patients. Due to the high risk, surgeons prescribe a combination of treatments including exercise and physical therapy beginning the first day after surgery and continuing for several months. Compression stockings and anti-clotting medicine to reduce the body’s ability to form blood clots are the standards of care in most patients.

In this case, the standard of care departure and inappropriate management of left leg pain and swelling post-hip replacement led to life-changing damages including acute ischemia of the left lower extremity that resulted in a below-the-knee amputation.

An orthopedic surgeon with a specialty in hip replacement can opine regarding the standard of care as it relates to post-operative management. This expert can also speak to the warning signs that the physician ignored in this case as well as the proper course of action and patient prognosis.

What is the standard of care for all postoperative hip replacement patients?

What is the recovery rate for timely diagnosed DVT in a hip replacement patient?

What preventative measures do physicians take to ensure surgical patients don’t suffer clots?

What is the failure rate for Doppler Ultrasound DVT screening?

When is further testing warranted in a suspected DVT patient with a negative ultrasound?

What impact does below-the-knee amputation have on the patient’s medical prognosis and quality of life?

Here is what the orthopedic surgery expert in this case had to say:

I perform total hip arthroplasties every week and have done so for the past 25 years. A postoperative patient usually has an arterial examination to check if they have good circulation. After that, a doppler on their arterial and venous slides should be completed. It is also important to check for any arterial collusion and examine the patient's arterial pulses, feet, nail beds, and any potential cast lines.

The physician’s inappropriate follow-up and management of the patient’s left leg pain and swelling after a hip replacement led to the patient having to undergo a partial leg amputation.

Physician’s Failure to Diagnose Post-Hip Replacement Pain Leads to Amputation

This case involves a female patient with a chief complaint of a large lump in the front of her neck. Multiple outpatient providers evaluated the mass. The patient initially received a diagnosis of a localized MRSA neck abscess.

A subsequent lumbar puncture revealed meningitis. An ENT surgeon performed surgical drainage of the abscess. A further pocket of infection, unfortunately, remained and continued to compromise the patient’s cervical spinal cord. The patient required a subsequent neurosurgical intervention. Ultimately, she suffered severe, permanent neurologic deficits, including quadriplegia (tetraplegia).

In the epidural space of the vertebral canal, a cervical abscess is a collection of pus-filled infectious material caused by a bacterial infection. Neurological sequelae can result from compression of nerve structures and the spinal cord itself at the condition’s peak.

Spinal meningitis infection is a medical emergency. In addition to causing brain damage, paralysis, and strokes, the infection left untreated can be fatal in some cases. Meningitis can have long-term health effects. The symptoms may include seizures and hearing loss. The complications associated with bacterial meningitis tend to be more severe than those associated with other forms of meningitis, such as viral.

Unless identified and treated early, the formation of an infectious collection within the spinal canal can quickly lead to permanent disability and death. It is imperative that physicians recognize spinal epidural abscesses even in the absence of traditional risk factors.

MRSA should be considered a potential pathogen in deep neck space abscesses. A high index of suspicion is prudent as well as aggressive treatment, including incision and drainage, along with culture-directed medical therapy. Surgical drainage may be the most important aspect of treatment. In this case, the failure to remove the secondary source of infection fell below the standard of care. The patient became paralyzed after a second cervical abscess site was neglected and spinal meningitis was not diagnosed in a timely manner.

A neurosurgeon can speak to causes of paralysis, the complications of a cervical abscess, and the need to promptly diagnose and treat spinal meningitis to ensure the complete removal of infectious abscesses.

What are the standard diagnostic tests to evaluate a patient with a neck mass?

How might a delay in the diagnosis of an epidural abscess impact a potential adverse outcome?

What surgical measures are appropriate to ensure the removal of an abscess?

When is the evaluation of CSF for Meningitis appropriate?

What are the possible outcomes of allowing a pocket of infection to remain after surgery, and did the surgeon here fall below the standard of care?

How does a delay in the diagnosis of bacterial meningitis affect a patient’s prognosis?

Here is what the neurological surgery expert in this case had to say:

I have extensive experience with treating patients with a spinal epidural abscess. Diagnostic tests include ultrasound and CT of the soft tissues. Given the LP diagnosis of meningitis and the known abscess in the neck, an MRI of the cervical and possibly thoracic spine with and without contrast would have been a standard diagnostic test, especially if the patient was having any additional neurological symptoms. A spinal epidural abscess can cause spinal cord injury with direct compression as the mass effect of the abscess increases. Also, the lumbar puncture could have exacerbated spinal cord injury if there was already cord compression and no room for CSF flow around that portion of the compressed cord. Earlier diagnosis and surgical decompression of spinal cord compression increase the chance of preventing severe neurological compromise and increases the chance of reversal of any active neurological symptoms.

In this medical malpractice case, the physician’s failure to timely diagnosis a cervical abscess resulted in the patient suffering neurologic deficits, including quadriplegia.

Patient Suffers Quadriplegia After Delayed Infection Diagnosis

In this case, a patient with a history of smoking, obesity, and back injuries presented twice to Urgent Care complaining of shortness of breath.

Both times, a physician assistant saw him. The physician assistant diagnosed him with the flu and discharged him. The patient’s condition deteriorated two days later. It was eventually determined that the patient had a massive pulmonary embolism and passed away as a result.

Pulmonary embolism (PE) poses a serious risk of death and requires timely and adequate treatment. There is a high mortality rate, with 7.7–15% of patients dying within 3 months. PE symptoms are sometimes non-specific. As such, early recognition of PE remains a priority to prevent a delayed diagnosis and a higher rate of mortality. Shortness of breath is a major symptom.

There are many medical problems that can cause shortness of breath. A physician can easily treat several of these medical problems while others require immediate medical attention due to their severity and risk factors. Conditions such as allergies, the flu, and colds can cause difficulties breathing, but they may not constitute medical emergencies. In some cases, however, breathing difficulties may be a sign of serious medical conditions that require a visit to the emergency room. Knowing when to refer a patient to an emergency room is crucial.

Differential diagnosis and assessment of risk factors are imperative. Trouble breathing and a continued sense of breathlessness in a patient with multiple risk factors for PE require a referral to the ER. Both physician assistants and physicians are trained in awareness of the scenarios that require urgent care and those that require a referral to the emergency room.

Here, in this repeat patient with multiple risk factors for pulmonary emboli and other serious medical conditions, Urgent Care failed to properly evaluate, refer, and provide adequate care, leading to a drastic outcome.

What measures should the physician assistant have taken to ensure that a patient with shortness of breath is safely discharged?

How might a delay in diagnosing pulmonary embolism affect prognosis?

When does shortness of breath require a referral for further testing?

What are the risk factors for pulmonary embolism?

Did Urgent Care’s failure to refer to the emergency room fall below the standard of care?

Should the physician assistant have consulted an attending physician regarding the care of this patient?

Of what significance is the return of this patient with the same chief complaint of shortness of breath?

An expert in urgent care internal medicine can address the standard for evaluation and discharge of a patient presenting with shortness of breath and risk factors.

A physician assistant with experience in urgent care can speak to the standard of care and protocol for a patient presenting with risk factors and shortness of breath.

An expert in primary care can speak to mortality rates and the need to promptly investigate and diagnose the cause of shortness of breath in patients.

In this wrongful death case, a physician assistant at Urgent Care failed to evaluate and care for a patient who had a pulmonary embolism, which resulted in the patient’s death.

Physician’s Misdiagnosis Results in Patient’s Death

Anjelica Cappellino, J.D.

The Georgia Court of Appeals upheld an $8.5 million verdict favoring the estate of Debbie Sain, who died from undiagnosed cancer after giving birth, finding healthcare providers liable for medical malpractice despite not awarding damages for wrongful death due to conflicting evidence.

 recently upheld a $8.5 million verdict in favor of the estate of Debbie Sain, a pregnant woman whose rare and fatal cancer was not diagnosed during her pregnancy. Sain subsequently passed away about a year after giving birth. Her husband, Jason Sain, filed a lawsuit against his wife’s healthcare providers for medical malpractice and wrongful death. The jury found in favor of the estate and awarded $8.5 million in economic and non-economic damages, but did not award an amount for wrongful death. On appeal, the appellate court rejected the defendants’ argument that the verdict was inconsistent.

Debbie Sain (at the time, age 36) became pregnant in early 2012 and had ultrasounds performed at 

 on three separate occasions in April. Each ultrasound revealed a mass in Debbie’s right adnexa (the space inside her abdomen and pelvis, between her abdominal wall and uterus, which includes all structures that attach to the uterus). The sonographers documented their findings in Debbie’s medical records.

The mass, which measured between 5.7 and 6.27 centimeters, was consistent with a dermoid (a benign tumor of the ovary that does not go away on its own), as per the sonographer and the two expert witnesses presented at trial. However, PWH’s obstetrician-gynecologist, 

, did not indicate any concern. Debbie was not advised about the mass during any of her visits, nor did her medical records indicate that her doctors at PWH took any action to remove or treat the mass. 

, one of Debbie’s PWH physicians and a named defendant, also failed to inform her maternal-fetal medicine specialist, 

, of the mass during the referral in April or May 2012. The May 2012 ultrasound performed in Read’s office also indicated the presence of the right adnexal mass, but medical records did not show that Debbie or Jason were informed of the mass before she gave birth in November 2012 via cesarean section by 

. Likewise, Long did not identify the mass during the delivery.

On January 3, 2013, Debbie underwent emergency surgery performed by Dickerson after visiting the emergency room with complaints of abdominal pain and fever. The mass, which had ruptured, was 11 centimeters when removed, suggesting that prior to rupture, the mass measured between 12 and 15 centimeters. The mass contained 

, an epithelial ovarian cancer that forms within a benign dermoid or teratoma. Debbie underwent several additional surgeries, chemotherapy, and radiation in order to treat the cancer. She passed away in December 2013 after the treatments proved unsuccessful in staving off the cancer.

In 2014, Jason filed a medical malpractice and wrongful death lawsuit against PWH and its physicians. Initially, during the pre-trial stage, the trial court granted the defendants’ motion to exclude the testimony of plaintiff expert, 

, but that ruling was subsequently changed on Jason’s motion for reconsideration. DeSimone and another medical expert, 

, testified at trial that the defendants’ failure to diagnose and treat Debbie’s mass likely caused or substantially hastened her death and but for these failures, her survival rate could have been five years (though DeSimone conceded there is only limited data available as to this particular form of rare cancer). Another expert, 

., testified that at the time of Debbie’s delivery, her cancer was likely classified as stage 1A and that had the mass been removed then, she would have likely survived. Debbie’s gynecological oncologist, 

., also testified that the rupture worsened her prognosis.

 argued that Debbie’s cancer had an extraordinarily high fatality rate, so her rate of survival likely would not have changed if the mass was removed when she gave birth.

The jury found in favor of the estate and awarded a total of 

 in damages -- approximately $7 million for pain and suffering, $1 million for past medical expenses, $500,000 for loss of consortium, and $7,000 for funeral expenses. No award was given for wrongful death.

In part on the basis of the wrongful death award, the defendants appealed the verdict, arguing that a verdict that awards damages for funeral expenses but not for wrongful death is 

 held that “the jury reasonably could have found that, while the defendants’ negligence was the immediate cause of Debbie’s death (thus justifying the award of funeral expenses…), Jason did not meet his burden as the plaintiff of establishing by a preponderance of the evidence a meaningful, reasonable monetary value for the jury to award as damages on his wrongful death claim, given the sharply conflicting evidence that was presented as to Debbie’s life expectancy.” The 

 also noted that the verdict form clearly indicated that the jury found in favor of the plaintiffs and attributed fault proportionately to all defendants, and not the plaintiff.

Overall, this case (Preferred Women’s Healthcare LLC, et al. v. Sain et al., A23A0413) is a perfect example of fact-specific circumstances that can lead to zero damages being awarded for wrongful death, yet defendants still being held liable for the claims. 

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