This case involves a 49-year-old male who presented to the hospital with an infected foot that resulted in the amputation of the toe. Imaging studies showed that the infection may have spread to the bone and osteomyelitis was a possible diagnosis. The patient was started on vancomycin and had a PICC line placed for the administration of the medication. Soon after the vancomycin was started the patient became dizzy, diaphoretic, short of breath, and complained of a burning sensation in his chest. A code was called and the patient was intubated and resuscitation efforts lasting approximately 40 minutes. Unfortunately, the patient remained in asystole despite all efforts with epinephrine, atropine and calcium gluconate. He was pronounced dead 5 days post admission with pulseless electrical activity/cardiac arrest. According to autopsy reports, the cause of death was ischemic cardiomyopathy in which there is significant left ventricular interstitial fibrosis. Contributing factors included pulmonary edema and early bronchopneumonia associated with an acute anaphylactic response.

Anaphylaxis is a medical emergency that may require resuscitation measures such as airway management, supplemental oxygen, large volumes of intravenous fluids, and close monitoring. Administration of epinephrine is the treatment of choice with antihistamines and steroids often used as adjuncts. A period of observation for between 2 and 24 hours is recommended for people once they have returned to normal due to concerns of biphasic anaphylaxis.

The issues are whether or not the allergic response should have been anticipated and whether or not the responses to the reaction were appropriate.

Location: Florida M.D., University of Illinois College of Medicine Internship, Michael Reese Hospital & Medical Center Residency, Internal Medicine, University of Oregon Health Sciences Center Fellowship, Infectious Disease, University of Oregon Health Sciences Center Board Certification: Internal Medicine, Infectious Disease Active Medical License: FL Fellow, American College of Physicians, Society for Health Care Epidemiology of America, Infectious Diseases of America Member, Physicians for Social Responsibility, Association for Professionals in Infection Control and Epidemiology, American Society for Microbiology, American Physician Fellowship Former H******* C******* E************* O***** H***** S******* U********* Former A******** P******** D******* o* I********* D******* O***** H***** S******* U********* Former P******** o* M******* D******* o* I********* D******* I****** U********* S***** o* M******* Former P******** o* C******* M******* D******* o* I********* D******* U********* o* M**** M***** S***** o* M******* Former E******** R*** P******** G****** M******* H******* Current A******** P******** m****** c***** i* t** s******** Current C********* P******** p****** p******* Published over 25 peer-reviewed articles

Vancomycin Allergy Causes Severe Anaphylactic Response

This case involves a fifty-nine-year-old man. The patient previously had ORIF of the mandible done by a maxillofacial surgeon. The open approach implemented two screws via the lag technique in addition to a plate with four screws. On follow-up, an x-ray revealed the furthest screw distal to the chin was displaced. Given the risk of the hardware, and by his conjecture, healed mandible, the decision was made to remove the hardware. A fistula was also visualized and he had an elevated white blood cell count prior to the procedure. The patient then consulted another maxillofacial surgeon who found a mucosal fistula upon physical examination. He noted that the osteomyelitis/infection/fistula and pain was a result from the retained screw from the original procedure. The second maxillofacial surgeon decided to operate due to persistent osteomyelitis and continued antibiotic use. He removed the retained surgical screw in the neck of the mandible.

Retained surgical foreign bodies are rare medical errors that have the potential to cause significant harm to the patient and carry profound professional and medico-legal consequences to physicians and hospitals. Risk factors for this problem are well described and include both patient care processes and working environment issues. Foreign bodies have a very high propensity for infection. An infection would have been unlikely in the absence of a foreign body. (ie surgical screw)

1. Was the retained surgical screw the cause of the ongoing osteomyelitis?

Maxillofacial Surgeon Leaves Screw Fragment in Mandible Causing Osteomyelitis

This case involves an eighty-two-year-old male patient who was a nursing home resident. He had a past medical history of dementia and severe falls which prompted his family to seek 24-hour care for the patient. The patient suffered a fall in his bedroom at the nursing home when he slipped on the hardwood floor. The patient was discovered by a member of the nursing staff and was rushed to hospital via ambulance. An X-ray revealed that the fall had resulted in a fracture of the right femoral head. The patient required surgery to replace the hip. The patient underwent the procedure which was successful. He was discharged back to the nursing home following the surgery. Several days after discharge the patient began complaining of fever and pain in his right hip. The patient returned to hospital where investigations revealed he was suffering from osteomyelitis. The patient underwent treatment for the infection but did not survive. He died two days after hospitalization. The family of the deceased alleged that the nursing home did not take adequate measures for fall risk reduction. They believe that the facility should have taken various precautions, for instance: putting down mats. This was never done until after the incident.

The proper protocol for a patient with a history of falls is firstly to review his or her fall assessment evaluations with re-assessment for changes in condition. Review of previous interventions for fall prevention with review of medications, review of patient’s sleep patterns. Preventative measures such as low beds, body or mattress alarms, moving the patient to a room close to high observation areas can be employed. Fall risk and the prevention of falls is based on individual risk factors. The facility has a responsibility to assess the resident’s risk factors and develop a comprehensive care plan based on those risk factors. The use of fall mats is based on the assessment made by the interdisciplinary teams. The team has to weigh the benefits and risks of such interventions. While a fall mat may not have prevented the fall it may have reduced the risk of injury during the fall. The decision to use such a mat would have been determined by factors such as, where the history of falls occurred , as well as the risk of the mat creating a hazard in the event the resident was ambulatory or mobile in a wheelchair. If the fall occurred from the patient’s bed and the injury occurred at bedside and the intervention (for example, placing a mat on slippery areas) would not have created a risk greater than the benefit it would have created, then a mat may have been an appropriate measure to prevent an injury. In this case several questions need to be asked. After the fall and return to facility did the facility attempt to restore the resident back to their prior level of activity. Did they monitor for complications after the resident underwent the orthopedic procedure?

What is the proper protocol when you have a patient with a history of chronic falling?

Nursing expert witness opines on the protocol for fall prevention in a nursing home setting

This case involves a teenage female patient who suffered a fracture of her left leg. She underwent a surgical procedure to stabilize the bone and was discharged. She returned to the hospital after experiencing increased pain. A wound culture was done at that time, and she was prescribed on antibiotics. The pharmacist noted she was allergic to this and the decision was made not to give the patient antibiotics due to her allergy. She was seen again in clinic and repeat cultures were done, which grew staph. However, no antibiotics were given. Her condition continued to worsen and she developed chronic osteomyelitis that progressed to septic shock.

I frequently practice both pediatric hospital medicine and pediatric infectious diseases. I care for patients with osteomyelitis on both of these clinical services. Our policy is that children with hematogenous osteomyelitis (i.e., osteomyelitis that occurs through bloodborne infection rather than following trauma or surgery) are admitted to the hospital medicine service and receive an automatic infectious diseases consult, so I see these patients in both my roles. In my infectious diseases role, I also care for patients with osteomyelitis following fractures or surgery. For uncomplicated acute osteomyelitis, the usual treatment is the antibiotic cephalexin in most areas with clindamycin being first line in some areas with a high prevalence of methicillin-resistant S. aureus. Treatment is initially administered intravenously with a transition to oral antibiotics once there is improvement in clinical symptoms and inflammatory markers, such as the C-reactive protein. Certain cases merit bone biopsy to determine causative bacterium. I helped develop our local treatment guidelines and am a member of the national pediatric bone and joint guideline committee. However, based on the limited information provided, it is likely that the usual paradigm of osteomyelitis treatment does not necessarily apply in this case. Specific areas of consideration include initial treatment, determining mechanism of injury, how the wound culture was obtained, and timing of symptom-onset. Delayed treatment initiation may lead to chronic bone infection, which can impair blood supply and lead to devitalized bone (i.e., bone death). In the short term, consequences of bone death may include requirement for multiple surgeries to remove dead bone. In the long term, bone death impairs normal bone growth, causing chronic disability (e.g., limp, chronic pain) or limb length discrepancy (if leg or arm bones are involved).

1. How often do you manage pediatric patients with osteomyelitis? 2. Briefly, what are the standard guidelines for treatment of osteomyelitis? 3. What are the complications of delay in treatment of osteomyelitis?

Infectious Disease Expert Discusses Delayed Treatment of Osteomyelitis

This case involves a woman who developed pressure sores following a surgical procedure. The patient was admitted to an inpatient rehabilitation facility and was not found to have any pressure wounds at the time of admission. The patient was primarily sedentary during her time in the facility, however, the records indicate that the patient was not routinely assessed for pressure wounds. After 3 weeks, the patient was discovered to have an advanced stage pressure sore on her tailbone. The patient was transported back to the hospital and was diagnosed with sepsis and an infected pressure sore with foul-smelling drainage. The patient developed an infection in her bone secondary to the pressure sore. She required surgical intervention and debridement to treat the wound. An expert in wound care was sought to review the records and opine on the standard of care for prevention of pressure sores.

I am a certified registered nurse and a nurse practitioner specializing in wound, ostomy, and continence care. I am also the director of clinical operations at a large university medical center in the mid-Atlantic. I have worked with wounds and skin issues since 1993, both lecturing and publishing on the topic at the local, regional and national level. Getting people moving is essential to prevent pressure injuries. Assisting in position changes, encouraging position changes, and educating individuals on the importance of position change are all part of the standard of care. We are finding out that pressor use in the ICU setting is having an impact on the formation of pressure injury following cardiac surgery and other serious illnesses. Many pressure injuries initiate before they occur. In addition to prevention strategies, identifying initial issues and prompt intervention can prevent worsening.

1. Please describe your background in wound care. 2. What measures can be taken to prevent decubitus ulcers in rehabilitation patients?

Sedentary Patient Develops Pressure Sores During Rehabilitation

This case involves a young professional athlete who developed a bony projection on his ankle. The treating podiatrist attempted to remove the projection through minimally invasive arthroscopic surgery. During the surgery, however, the treating podiatrist created tarsal tunnel syndrome in the patient’s ankle. In the weeks following the surgery, the individual experienced extreme foot and ankle pain, as well as chills and night sweats. The treating podiatrist assured him there was no cause for concern. The athlete eventually returned to the podiatrist with painful foot ulcers and was diagnosed with osteomyelitis. The athlete required several procedures to correct the osteomyelitis but was unable to continue playing football. It was alleged that the delay in diagnosing postoperative infection caused the patient to develop debilitating osteomyelitis.

I am a board-certified foot and ankle surgeon and I'm one of the few podiatric surgeons in the country to have completed an orthopedic foot and ankle surgery fellowship in addition to my 3 years of podiatric surgical residency training. I excise ankle osteophytes (bony projections) arthroscopically on a regular basis, usually 2-3 cases per week. Tarsal tunnel syndrome of the anterior ankle is essentially a nerve injury to the front of the ankle which is very common and an expected complication from ankle arthroscopy. I have reviewed a number of similar cases involving nerve damage after an ankle arthroscopy. This is a common and expected finding after surgery and something that I warn patients about on a regular basis. The osteomyelitis component of the case would be noted as a much less common complication from arthroscopic ankle surgery. Infection risks are generally lower with arthroscopy due to the nature of the small portals where the work is done, but infection is not out of the question and again is a common risk associated with any foot/ankle surgical intervention including arthroscopy. It would be important to look at the patient/doctor records to have a full understanding of the situation and render a more educated and complete report on the standard of care.

1. How frequently do you excise bony ankle projections? 2. What steps should be taken to avoid the development of tarsal tunnel syndrome?

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Osteomyelitis Expert Witness Case Studies

Vancomycin Allergy Causes Severe Anaphylactic Response

Maxillofacial Surgeon Leaves Screw Fragment in Mandible Causing Osteomyelitis

Nursing expert witness opines on the protocol for fall prevention in a nursing home setting

Infectious Disease Expert Discusses Delayed Treatment of Osteomyelitis

Sedentary Patient Develops Pressure Sores During Rehabilitation

Podiatrist Fails To Diagnose Postoperative Bone Infection

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