Allegation
The defendant failed to respond timely to calls and pages, as well as failed to order an immediate transfer to the hospital, resulting in infection and additional surgeries.
The Case
The patient, a 44 YOM (5’8”, 278 lbs.), with a history of complete paraplegia below T10, diabetes, and HTN, was admitted for ischial ulcer excision and muscle flap closure. The procedure was performed without complication, and the patient was transferred to a post-operative floor for a planned two-night stay prior to discharge.
At 12:33, a nurse had difficulty inserting a straight catheter. There was no urine return. Seven minutes later, the patient was incontinent of a large volume of urine, following the removal of the straight catheter. Two hours later, he was incontinent of urine again. At 14:59, Levaquin® was prescribed. At 17:30, a catheter was inserted with clear, pale, yellow urine return of 30 ml.
Five hours later, the patient was thrashing in bed. An hour after that, a bladder scan showed approximately 700 ml in the bladder. The nurse deflated the catheter balloon and attempted to insert the catheter further into the bladder, meeting resistance. The catheter was backed out of the bladder slightly, and then pushed out of the urethra, followed by a large gush of urine and blood.
At 21:39, the defendant urologist placed a three-way Foley catheter; continuous bladder irrigation (CBI) was started for hematuria. At 23:00, the catheter returned 900 ml of fluid. At some point in the next 45 minutes, the catheter became dislodged.
At 00:42 the next morning, CBI was stopped and the tip of the catheter was noted to be no longer in the bladder. The scrotum was swollen to 4 inches. At 01:55, the scrotum was swollen to 6-8 inches. For the next two hours, there was a delay in response from the defendant urologist. At 02:30, the defendant urologist performed an emergency cystoscopy for Foley repositioning. The patient received Kefzol® preoperatively. Operative findings showed urethral trauma and scrotal swelling consistent with extravasation of blood or fluid in the subcutaneous tissues. A Foley was placed, and the patient was maintained on postoperative Levaquin.
The next day, the defendant urologist evaluated the patient for discharge, and found no evidence of infection. The patient was discharged to a rehabilitation facility for ongoing wound care and antibiotics. His WBC had decreased to 13,000, and he was afebrile at discharge.
Upon admission to the rehabilitation facility, an internist evaluated the patient and noted the scrotum was edematous and weeping serosanguineous fluid. A urine culture was negative, and his WBC stabilized at 12,000. A decubitus culture later showed E. coli.
Three days later, the internist ordered a CT of the abdomen and pelvis with contrast to rule out pancreatitis. The CT revealed soft tissue gas within the base of the penis, which could be related to trauma or developing infections.
Over the course of three days, the patient developed an increasing WBC count. Staff noted drainage and odor but could not determine if it was due to the sacral decubitus or the scrotal region. The patient underwent a CT scan showing air in the subcutaneous tissue at the base of the penis; physical exam revealed purulent drainage. Fournier’s gangrene was suspected.
The day after the CT scan, a physical exam showed demarcation around the scrotum. The skin had erythema and induration of the perineum. The defendant urologist was contacted. He offered immediate transfer to the hospital for surgery, antibiotics, and hyperbaric oxygen therapy (HBO). The rehabilitation facility elected to continue to monitor at the facility rather than transfer the patient to the hospital.
The day after the initial offer to transfer, a physical exam showed the patient had erythema and induration over the suprapubic region with tenderness. Perineal necrotizing fasciitis was also added to his diagnosis. The defendant urologist was contacted, and the patient was immediately transferred to the hospital for surgery.
Operative findings included a suprapubic abscess and mild necrosis of the skin. The scrotum showed resolution of the initial extravasated fluid, but persistence of the ecchymosis/hematoma. The patient required multiple surgeries, including surgical debridement, coverage and reconstruction, antibiotics, bedside wound care, and HBO treatments.
The patient’s expert witnesses stated the defendant urologist failed to timely respond to pages. They further stated he discharged the patient prematurely. Finally, they stated the defendant failed to order immediate transfer to the hospital after learning of the CT scan results.
Defense experts were supportive of the care provided by the defendant urologist. The patient’s outcome was not affected by the defendant urologist’s response time. They also found the defendant urologist was ultimately not responsible for discharge to the care facility. Lastly, the defendant did offer transfer to the hospital after learning the results of the CT scan; however the treating physician at the rehabilitation facility declined the offer.
The Verdict
At trial, a verdict was entered in favor of the defense.
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