An injured hiker charges that deciding when to start antibiotics should never have been his call to make.

Should a patient be expected to determine whether a wound is infected? Mr. C, a 38-year-old physician assistant, learned the answer the hard way when that question led to his involvement in a malpractice lawsuit.

Mr. C worked in the emergency department (ED) of a small rural hospital. One quiet afternoon, he was catching up on his reading when a young man came limping in. Mr. N, 25, and his wife had been spending their honeymoon camping and hiking in the nearby national park.

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“I was worried about taking her on the expert trail,” Mr. N explained, indicating his wife. “She has less mountain-climbing experience than I do, so I was looking out for her and I wasn’t paying enough attention to where I was stepping. I lost my footing and slashed my leg against an outcropping.” He pointed to the back of his leg where his torn jeans were caked with dirt and blood.

Mr. C examined the wound, which was deep and contaminated with soil. He administered a local anesthetic; irrigated the wound; removed dirt, leaves, and other foreign bodies; cleaned the wound, then sutured it and dressed the leg. “No more hiking on this trip,” Mr. C advised as he finished up. Then, as Mr. N prepared to leave, the PA handed him a prescription for cephalexin (Keflex) with instructions to take the antibiotic if an infection developed.

Mr. C had been alone in the ED since his shift began. His supervising physician, Dr. U, was at home and on call. Mr. C felt no need to inform her of Mr. N’s visit. He noted the treatment on the patient’s chart and left it ready for Dr. U’s signature, as hospital protocol required.

Mr. N and his wife stayed in the area a few more days but cut their trip short and returned home. Within two weeks, Mr. N’s wound became so severely infected that he required hospitalization and underwent several skin graft procedures. He ultimately suffered permanent muscle loss because of necrosis surrounding the wound.

At his wife’s suggestion, Mr. N consulted a plaintiff’s attorney, who obtained Mr. N’s original ED records and hired a physician expert to review them. He reported that the records showed the wound was very complex, involving multiple layers —fat, fascia, and muscle — and was grossly infected.

“There’s no doubt in my mind,” the expert concluded, “that Mr. N was not treated appropriately.”

He pointed to several breaches in care, charging that Mr. C should have cleaned the wound more thoroughly, left a drain in the wound, given Mr. N a tetanus shot, and instructed him to follow up with a physician in 48-72 hours.

“But worst of all,” the expert opined, “was the way the antibiotics were handled. You can’t tell a patient to take antibiotics if an infection arises. Patients can’t be expected to diagnose infections themselves.”

Armed with this information, Mr. N’s attorney filed a lawsuit against Mr. C, Dr. U, and the hospital, alleging that their treatment had been negligent.During depositions, the plaintiff’s lawyer questioned Mr. C about his actions, with special emphasis on the prescription for antibiotics. The PA admitted that he didn’t tell the patient to start taking the cephalexin immediately but to begin the medication if he noticed signs of infection.

“Did you describe the signs of infection?” the attorney asked.

“Well, not specifically. I mean, I told him that if he developed a high fever he should take the antibiotics, but I didn’t describe signs of infection otherwise,” Mr. C replied.

Dr. U was deposed next. She testified that she was one of several physicians who took turns as the ED physician on call. Among her duties was going over the charts of any patient who was treated by a PA.

“Did you review Mr. N’s record?” the plaintiff’s attorney asked. “I looked it over at some point,” Dr. U replied, “and I did sign the chart, but I’m not sure when.”

“So,” the lawyer continued, “you saw that Mr. C noted that the wound involved fat, fascia, and muscle and was also grossly contaminated?”

“If that was in the chart,” replied Dr. U, “then I assume I must have seen it.”Just before the trial was to get under way, Dr. U’s lawyer asked the judge to dismiss the case against her because she had not seen Mr. N herself and may not have seen the chart until weeks after the visit. He also argued that Dr. U was not really Mr. N’s “supervisor.” That title belonged to the administrator who ran the hospital’s PA program and therefore did not apply to the various ED physicians on call.

The judge denied the motion, and, on the advice of their attorneys, the defendants settled out of court for $275,000.

Legal background

The judge refused to dismiss the case against Dr. U because a jury could have found her liable for Mr. N’s complications.

As the on-call physician, she was responsible for treatment provided by PAs whether she saw the patients herself or not.

During his deposition, the plaintiff’s expert testified that any physician reading Mr. C’s notes should have realized that the treatment was inadequate, contacted Mr. N, and told him to start the antibiotic and seek follow-up treatment. The fact that Dr. U didn’t review Mr. N’s records in a timely manner did not absolve her of her responsibility.

Protecting yourself

Mr. C made a grave error when he prescribed antibiotics and left it to Mr. N to decide if they were necessary. Patients do not have medical training and cannot be expected to recognize an infection if one occurs.

In this case, with the wound on the back of his leg, it’s possible that Mr. N would not have been able to view the injury well enough to determine if there was a problem. Antibiotics should not be prescribed unless the patient is being instructed to take them. They should never be prescribed for a “what if” scenario.

In addition, considering the seriousness of the wound and the level of contamination, Mr. C should have given Mr. N a tetanus booster and asked him to return in a day or two for a follow-up exam. At the very least, he should have told the patient to see his doctor on returning home.

Dr. U should have reviewed Mr. C’s notes more promptly. If she had looked at the notes a day or two or even a week after the incident, she still could have contacted Mr. N to make sure he received adequate follow-up treatment. Sometimes the simple act of taking responsibility is enough to deflect a lawsuit.

Ms. Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.