Allegation
The patient alleged failure to diagnose malaria, resulting in delayed treatment, prolonged hospitalization and amputation of multiple toes.
Case Details
A 42 YOF was brought to an emergency department (ED) in Los Angeles by ambulance after experiencing a syncopal event at the airport. She had traveled to Los Angeles from her home in Georgia for a work conference. Of note, she had returned from a two-week trip to Africa two weeks prior. She had not taken any prophylactic medication for malaria despite being advised to do so. The patient told the ED physician that, while on the plane from Georgia, there was a passenger seated near her who was frequently coughing. During the ED visit, the patient did not mention her recent trip to Africa, nor was she asked about international travel.
In the emergency department, the patient reported a two-day history of fever, nausea, and body aches. Vital signs were normal except for a heart rate of 116. The ED physician ordered a CBC, basic metabolic panel, and a urinalysis. At the end of her shift at 07:00, she wrote a conditional order to discharge if labs were unremarkable; otherwise, she was to be contacted. The lab results were posted to the medical record after the ED physician’s shift ended and after she had left the hospital. The labs revealed a normal WBC count, but positive left shift, thrombocytopenia, and an elevated creatinine level.
The incoming ED physician did not see the patient or review the medical record. A nurse documented that the patient was cleared for discharge by the incoming physician. The patient was advised to see her primary care provider upon returning home; however, this specific instruction was not included in the written discharge instructions. The patient returned home to Georgia later that day. She did not follow up with her primary care physician as instructed.
Four days later, the patient was admitted to a hospital in Georgia. Her son had disclosed her recent trip to Africa and that she had not taken prophylactic antibiotics. The patient was diagnosed with cerebral malaria, and rapidly declined, requiring intubation. She remained in a coma for four weeks, developed multi-organ failure and required significant vasopressor support, resulting in bilateral necrosis of her toes. The patient ultimately underwent amputation of her L 2-4 and R 2-5 toes.
The patient filed suit against the first ED physician, the ED nurses, and the hospital, but for unknown reasons, did not name the second ED physician as a defendant.
Expert Testimony
Plaintiff’s expert opined that it was a deviation from the standard of care for the ED physician to not specifically ask the patient about foreign travel when she presented with symptoms of nausea and fever. Defense experts disagreed and stated that inquiring about foreign travel was not required, especially when the patient’s recent travel history had been discussed during the ED visit. The plaintiff’s expert also stated that the ED physician, the ED nurse and the hospital were negligent in not ensuring review of the patient’s labs. The plaintiff’s expert argued that if the ED physician was aware of the abnormal labs, she would have ordered further testing which would have led to the diagnosis of malaria. Furthermore, the order regarding the conditional discharge was in the EHR system but not within the medical record itself, making it not as apparent. The defense expert stated that the ED physician was not at the hospital when the labs returned and had left instructions to be notified if abnormal. Furthermore, even if the ED physician had seen the labs, malaria would likely not have been considered. The patient denied being told to follow up with her primary care physician upon return to Georgia, although she had signed an acknowledgement of receiving the discharge instructions, both oral and written.
Resolution
During trial, the plaintiff’s attorney changed strategy to focus solely on the emergency department nurses and the hospital. The defense attorney was able to secure the dismissal of the ED physician.
Risk Reduction Strategies
Establish a standardized methodology for communications, such as SBAR, during hand-offs and other transitions in care. Include physician to physician, nurse to nurse, and physician to nurse.