Malpractice

Abstract

FigureFigureA man presented to the ED with sudden onset flank pain. He was afebrile, and his vital signs were normal except for tachycardia of 105 bpm. A urinalysis was positive for nitrite and 15 WBC, and a urine sample was sent for culture. A CT scan showed a ureteral stone and minimal hydronephrosis. His pain was treated, he said he felt better, and he was discharged with instructions about treatment and follow-up for a kidney stone. The culture was reported the next day to the PA in the ED as growing Klebsiella. The PA called the patient and left a voicemail advising him of the culture result and the need for an antibiotic. He asked the patient to call the ED to obtain a prescription for Macrobid. The patient didn't return the call, but returned to the ED two days later. He was septic with significant hydronephrosis and was admitted. Despite aggressive treatment, including a nephrostomy to reduce urinary back pressure and drain infected urine, he decompensated rapidly and died. His family filed a lawsuit. The Plaintiff's Case The plaintiff's counsel believed that his client should have been treated with an antibiotic based on the urinalysis, but he could not find an expert who would support his claim that failure to do so was negligent. The survivors of the deceased lost interest in pursuing the claim. The Defense's Case The defense counsel had no difficulty securing strong expert opinions that the patient's care was within acceptable standards and not negligent, that is, that failure to treat with an antibiotic at the initial visit did not cause the patient's death. The Verdict The care at the initial ED visit was considered within the standard, given the lack of fever and the presence of only mildly abnormal urine findings. Despite the lack of medical decision-making addressing the possibility of a serious complication, expert review of the case felt this was a judgment call rather than negligence. The case was dismissed without prejudice, meaning that it could be refiled should circumstances change. Takeaways Pyelonephrosis is a serious complication of ureteral stones, aggravating an existing ureteral blockage due to viscous pus that cannot easily pass through the ureter. If a urinalysis shows sufficient evidence of concurrent infection in the presence of ureteral obstruction, antibiotics should be given and the patient admitted. This patient had minimal if any evidence of impending pyonephrosis. (Medscape eMedicine. March 23, 2021; https://bit.ly/3ViNnS4.) As often mentioned, physicians are not prophets. We cannot predict with certainty which patients will deteriorate and which will improve. We can only treat each patient according to the standard of care. We depend on patients to follow instructions. The PA in this case had no reason to assume that the patient was any worse than he was 24 hours earlier, and he had no reason to have him return to the ED emergently. We depend on patients to assess themselves and respond if things are worse.