Mr. B, aged 12 years, felt ill during class on a Thursday and was sent to the school nurse. The nurse took his temperature, which was normal, and called his mother to pick him up. The boy’s mother took him to a federal clinic, where he was seen by Ms. M, a 35-year-old nurse practitioner (NP).
Mr. B reported mild to moderate pain in his left groin that had begun two days earlier. Ms. M noted that the boy’s left thigh muscle was tender to the touch but showed no bruising. Mr. B’s BP was 135/68 mm Hg. When asked about athletic activities, Mr. B told Ms. M that he had been playing softball on the day that the pain began. Ms. M diagnosed the boy with muscle strain, gave him an injection of ketorolac (Toradol) for pain relief, and prescribed ibuprofen. She also told Mr. B to rest for the next few days and to apply ice to the area.
The boy was then discharged. Later, Mr. B’s mother called the clinic to ask whether she could give her son liquid acetaminophen instead of ibuprofen, as the child had difficulty swallowing the pill. Ms. M told her that that would be fine.
Two days later, Mr. B’s condition had worsened, and his father brought him to the emergency department (ED) of the clinic. The boy had to be carried in by his father and fell asleep on the exam table while waiting to be seen. The treating clinician in the ED was Mr. D, an experienced NP.
Mr. D had been working at the clinic for a decade and had worked elsewhere as a licensed practical nurse and a registered nurse prior to getting his advanced-practice degree. Triage notes indicated that Mr. B’s complaint was severe pain to the left hip, and the triage nurse indicated that he had been evaluated at the clinic on Thursday and was prescribed ibuprofen/acetaminophen.
On this visit, the boy’s pulse was 150 beats per minute and his BP was 97/57. In addition to the hip pain, Mr. B exhibited a rash. A hip x-ray revealed no fractures. Lab work ordered by Mr. D showed a normal WBC count and an elevated erythrocyte sedimentation rate (18 mm/hr). The percentage of granulocytes was elevated at 95.1%, outside the normal range of 37% to 79%, and the boy’s lymphocytes were 2.9%, well outside the normal range of 20% to 45%.
A CT scan was read remotely by an on-call radiologist in another state. The radiologist noted that the boy had been in pain for five days and was unable to ambulate and that the scan showed fluid to the left greater trochanter, which could indicate bursitis or a bursal tear.
The radiologist also recommended an MRI. Mr. D contacted a local orthopedist and set up an appointment for Mr. B in two days. After preparing the referral, he diagnosed Mr. B with “possible bursitis vs. possible bursa tear” and sent him home with prescriptions for acetaminophen and hydrocodone (Lortab), diphenhydramine (Benadryl), and acetaminophen.
Mr. B spent the rest of the day in bed, unable to walk and with a worsening rash. The next morning, he was having difficulty breathing, so his father brought him back to the ED, where he was found to be profoundly neutropenic and in septic shock. Mr. B was given IV fluids and antibiotics and was airlifted to a university medical center, where he was diagnosed with septic arthritis of the hip.
A bacterial culture showed that the infection would have been treatable with broad-spectrum antibiotics earlier on, but at this point, the boy was in acute respiratory distress and had ischemia in all of his extremities. He remained in the pediatric intensive care unit for two months before passing away.
After his death, his bereaved parents sought legal counsel. After studying the medical records, the plaintiff’s attorney filed a lawsuit in federal court against the clinic, alleging that the boy’s death was caused by negligence.
At trial, the plaintiffs argued that the clinicians should have ruled out a possible infection, since, at least at the second visit, all signs pointed to one. The plaintiffs also argued that the standard of care was breached by the clinicians and that a CT was not a suitable method to differentiate a systemic bacterial sepsis from an orthopedic injury. The defendants countered that infection was not suspected because the boy had no fever.
The court sided with the plaintiffs and awarded the family $1.9 million.
The court found no negligence in the first clinic visit in which Mr. B was treated by Ms. M. However, the court determined that Mr. D was negligent and did not meet the standard of care in his treatment of the patient at the second clinic visit.
The court pointed to a number of factors that led to this conclusion. Although the defendants claimed that a lack of fever was a strong argument in defense of Mr. D’s failure to diagnose infection, the court disagreed for several reasons.
First, the combination of other signs and symptoms did indicate potential infection, which should have been ruled out. Second, the fact that the boy was taking acetaminophen could have accounted for the lack of fever.
Another factor that the court looked at was lethargy. Mr. B was found sleeping on the table in the ED, which is unusual behavior for a 12-year old and an abnormal sign. The rash was also an indication of infection and should have pointed to sepsis rather than a hip injury.
Finally, the lab work showed multiple indications of infection. According to the court, the standard of care at that point would be to rule out infection. This could have been done with a blood culture on-site, or the boy could have been referred to a facility with the means to aspirate the hip for a sample to culture, neither of which was done. The court found that Mr. D had not met the standard of care owed to his patient.
This tragic story highlights the importance of ruling out the most serious differential diagnoses first. For a more complete picture, Mr. D should have looked at all of the signs, lab work, and symptoms rather than focusing on the boy’s hip.
By focusing solely on the hip, even in the face of abnormal lab work, Mr. D missed something that he should have caught. There were numerous signs of infection despite the lack of fever: the blood work showed indications of infection, the boy’s BP had dropped significantly from the first visit, his pain had increased, he had developed a new rash since the previous visit, and he was far too lethargic for a child his age.
In light of all of these signs, Mr. D should have suspected infection and should have ruled that out as a potential diagnosis before treating it solely as an orthopedic injury.
Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.