Living in Houston, Texas, I have seen a lot of local coverage about the devastation from Hurricane Harvey.
As an attorney focusing on medical malpractice cases, one article, in particular, really caught my attention. A woman died of flesh-eating bacteria (also called necrotizing fasciitis) after a cut on her skin was exposed to floodwaters from Hurricane Harvey. What an unexpected, sad, and frightening thing to happen.
What is necrotizing fasciitis?
Necrotizing fasciitis, or flesh-eating bacteria, is a serious bacterial skin infection that destroys the soft tissues. It can be deadly because it spread so quickly. The key to survival is getting prompt medical treatment, which will lead to antibiotic treatment to kill the bacteria and likely surgery.
Any time a patient goes to the doctor or emergency room seeking treatment from a cut or laceration, necrotizing fasciitis should be an the physician’s differential diagnosis list. Another sign to look out for is pain that is out of proportion to the apparent injury.
When a doctor evaluates a patient, he or she must assemble a differential diagnosis list containing all of the possible causes of the patient’s signs, symptoms, or illnesses.
The standard of care requires the physician to rule out each potential diagnosis from the differential diagnosis list, starting with the most dangerous one, before making a final diagnosis. To follow any other diagnostic process poses a needless danger to patients. I think that the story of the past medical malpractice case against an emergency medicine group shows why.
A 45-year-old man was working at home and cut his hand. He cleaned the area, put on a bandage, and went to bed. The next morning, he was experiencing more pain in his hand that he had expected, so he went to the emergency room. By the time he arrived, it was about 13 hours after his injury.
The first person he saw the emergency room was a triage nurse, who wrote in his medical record that he had pain in his left wrist, which was worse with motion. Providers also documented the presence of a deep 2 cm laceration in his left hand, and ordered an x-ray about 20 minutes before the emergency physician saw the patient. The radiologist interpreting the x-ray suspected a subtle avulsion fracture. The patient’s wrist was also swollen around the area.
The doctor did not do his own examination, but relied on the triage nurse’s assessment, and diagnosed the patient with a fracture, gave him pain medications, and discharged him from the emergency room a mere 34 minutes after he arrived.
The patient returned to the emergency room 27 hours after he was discharged with obvious full-blown it necrotizing fasciitis. He had to be air-lifted to a trauma center, and faced a long hospitalization with multiple surgeries. Long-term, he was left with a nearly useless and scarred left upper extremity.
In the medical malpractice lawsuit that followed, the patient alleged that the emergency room physician did not do his own assessment, but relied on the triage nurse’s evaluation, which was inaccurate. He pointed out that he had hurt his hand, not his wrist, and experienced no pain until the next day, all of which was not accurately documented by the nurse. The x-ray was done even before the doctor saw the patient, so the patient felt that the doctor had “anchoring bias,” relying on the triage nurse’s opinion, rather than going through the differential diagnosis process.
This case shows that physicians should follow the standard of care by both reading nursing notes and taking their own patient history. Moreover, physicians cannot rely on a lab value or x-ray result as a means of saving time and skipping basic steps in the differential diagnosis process.
Anchoring and confirmation bias by healthcare providers
I think that the patient was right and alleging that the emergency room physician skipped steps that are necessary for patient safety, at least partially because of anchoring and confirmation bias. This is another reason why complying with the standard of care and going through the differential diagnosis process every time is essential.
In a healthcare setting, anchoring bias can occur when an emergency medical technician (EMT) or nurse, who sees the patient before physician, makes a mistake or introduces extraneous information that draws attention away from the medical issue.
While this should not be a problem when the physician uses the differential diagnosis method required by the standard of care, if he or she decides to skip those steps, the result can be devastating.
This is, in my opinion, exactly what happened in a stroke case that I handled in Houston a few years ago. In that case, the EMT told the triage nurse that the young patient had been drinking and using marijuana before she slumped over on the couch with symptoms that a friend thought clearly indicated stroke.
The patient was seen by a young neurology resident physician who skipped the differential diagnosis process, diagnosed her with a psychogenic reaction (a diagnosis of exclusion that basically means “it’s all in your head”), and sent the patient home quickly. I believe that doctor read the EMT and triage nursing note and was unwittingly biased and jumped to an unfounded conclusion.
Unfortunately, that person was having an active stroke and will live with the lifelong consequences of misdiagnosis and poor medical treatment.
We are here to help
If you or someone you care for has been seriously injured because of medical malpractice, call the experienced attorneys at Painter Law Firm, in Houston, Texas, at 281-580-8800, for a free consultation about your potential case.
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Robert Painter is a medical malpractice and wrongful death attorney at Painter Law Firm PLLC, in Houston, Texas. He represents patients and their families in medical negligence and wrongful death lawsuits against hospitals, doctors, surgeons, and anesthesiologists.
