Allegation:
The defendant family medicine (FM) physician negligently prescribed Levaquin® and corticosteroids, resulting in an Achilles tendon rupture that required surgery and led to the patient’s subsequent health problems and death.
The Case:
The patient, an 83 YOM (5’10”, 160 lbs.), presented to the defendant FM physician with a persistent cough, expiratory wheezing, and decreased breath sounds at the base of the left chest. His cough had persisted for two weeks following a four-day hospitalization for ascites with venous stasis edema, thought to be secondary to CHF. The patient's history of cardiac conditions included CAD, A-fib, ischemic cardiomyopathy, aortic aneurysm, HTN, pacemaker and defibrillator placement, CABG x2, and chronic kidney disease. The physician instructed the patient to resume Lasix®, and ordered a prednisone burst, along with Tussionex® for bronchitis.
At the patient’s two-week follow-up, rales were noted on the right lung with expiratory wheezing and decreased breath sounds at the base of the lung. The defendant diagnosed acute bronchitis, CHF, and cough. He suspected the patient was developing pneumonia and prescribed Levaquin® 750mg/day and prednisone tablets.
Five days later, the patient called the office complaining of pain in his Achilles tendon. He was instructed to stop the Levaquin. Four days after stopping the Levaquin, the patient called the office to report bleeding at his heel and pain at the back of his leg. The defendant made a house visit and the examination revealed marked ecchymosis of his foot and lower leg, with tenderness and bleeding at the posterior heel. He suspected a partial Achilles tendon tear/evulsion of the calcaneus due to recent Levaquin and corticosteroids, and arranged for an orthopedic evaluation.
An Achilles tendon reconstruction was performed, and the patient initially healed well. Two weeks post-op, the patient’s cast got wet and his wound macerated; a foul odor was present upon re-casting. The orthopedic surgeon prescribed Cipro® and Bactrim®, but the patient did not take it due to fear of fluoroquinolone.
Four days later, the patient was admitted to the hospital with an infection and peripheral artery disease. The cardiologist performed a balloon angioplasty on the right lower extremity, and the orthopedic surgeon debrided the wound with excision of the calcaneal heel ulcer. A wound vac was placed on the heel, and an infectious disease specialist was consulted for IV antibiotics.
The patient was discharged from the hospital and went to an inpatient rehabilitation facility for approximately two weeks. One month later, the patient was admitted to the hospital with a fever and shortness of breath (SOB). Broad spectrum antibiotics and IV Lasix were ordered. During this admission, the orthopedic surgeon and assisting plastic surgeon performed a skin graft of the heel. The patient was discharged with home health due to IV antibiotics and wound care.
Over the next three months, the patient followed up with the plastic surgeon; the skin graft was doing well. The patient also had two hospital admissions during this time. Admissions were related to SOB, hyperkalemia, weight gain of five pounds in three days, and generalized swelling of the abdomen and lower extremities.
Six days after the patient’s previous hospital discharge, he collapsed at home. His son witnessed the incident, initiated CPR and called EMS. Upon arriving at the hospital, the patient was in arrhythmia with defibrillator discharging. Pacer interrogation showed V-fib arrest with no intrinsic rhythm when the pacer turned off. The cardiologist who treated him in the ED noted the patient was in cardiogenic shock, and started mechanical ventilation, pressor support, and hypothermia. The patient again went into full arrest with pupils fixed. The family decided to stop life-saving measures, and the patient was pronounced dead.
The plaintiff’s expert testified the defendant physician failed to meet the standard of care by prescribing Levaquin to a patient who was older than 60 while taking a corticosteroid. This action led to the tendon rupture and a cascade of deteriorating events which led to death including infection, IV antibiotics, residing in a rehab facility, sedentary lifestyle and weakness.
Multiple defense experts testified the defendant physician’s treatment fell within the standard of care. The patient had advanced heart disease, and experienced multiple episodes of decompensated heart failure that were unrelated to the Levaquin administration. Although the tendon rupture and infection did not play a causative role in the patient’s death, experts believed the physician prescribing Levaquin under these circumstances was appropriate.
Verdict:
The jury returned a defense verdict in favor of the family medicine physician.
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