Medicolegal Issues

Malpractice Counsel: A Pain in the…Scrotum

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A 52-year-old man presented to the ED for evaluation of right scrotal pain and swelling. The patient stated that the pain started several hours prior to presentation and had gradually worsened. He denied any trauma or inciting event to the affected area; he further denied abdominal pain, nausea, vomiting, dysuria, polyuria, or fever. The patient’s remote medical history was significant for type 2 diabetes mellitus (DM), which he managed through dietary modification-only as he had refused pharmacological therapy. The patient admitted to smoking one half-pack of cigarettes per week, but denied alcohol or illicit drug use.

At presentation, the patient’s vital signs were all within normal range. The physical examination was remarkable only for right testicular tenderness and mild scrotal swelling, and there were no hernias or lymphadenopathy present.

The emergency physician (EP) ordered a urinalysis and color-flow Doppler ultrasound study of both testes, which the radiologist interpreted as an enlarged right epididymis with hyperemia; the left testicle was normal. The urinalysis was normal.

The patient was diagnosed with epididymitis and discharged home with a prescription for oral levofloxacin 500 mg daily for 10 days. He also was instructed to take ibuprofen for pain, apply ice to the affected area, keep the scrotal area elevated, and follow-up with a urologist in 1 week.

Approximately 8 hours after discharge, the patient returned to the same ED with complaints of increasing right testicular pain and swelling. The history and physical examination at this visit were essentially unchanged from his initial presentation. No laboratory evaluation, imaging studies, or other tests were ordered at the second visit.

The patient was discharged home with a prescription for a narcotic analgesic, which he was instructed to take in addition to the ibuprofen; he was also instructed to follow-up with a urologist within the next 2 to 3 days, instead of in 1 week.

The patient returned the following morning to the same ED with complaints of increased swelling and pain of the right testicle. In addition to the worsening testicular pain and swelling, he also had right inguinal pain, nausea, vomiting, and fever. Vital signs at this third presentation were: blood pressure (BP), 124/64 mm Hg; heart rate (HR), 110 beats/min; respiratory rate, 20 breaths/min; and temperature, 99.8o F. Oxygen saturation was 98% on room air.

The patient was tachycardic on heart examination, but with regular rhythm and no murmurs, rubs, or gallops. The lung and abdominal examinations were normal. The genital examination revealed marked right scrotal swelling and tenderness, as well as tender right inguinal lymphadenopathy.

The EP ordered an intravenous (IV) bolus of 1 L normal saline and laboratory studies, which included lactic acid, blood cultures, urinalysis, and urine culture and sensitivity. The EP was concerned for a scrotal abscess and ordered a testicular Doppler color-flow ultrasound study. The laboratory studies revealed an elevated white blood count of 16.5 K/uL, elevated blood glucose of 364 mg/dL, and elevated lactate of 2.8 mg/dL. As demonstrated on the ultrasound study performed at the patient’s first presentation, the ultrasound again showed an enlarged right epididymis, but without orchitis or abscess. The scrotal wall had significant thickening, consistent with cellulitis. The EP ordered broad spectrum IV antibiotics and admitted the patient to the hospitalist with a consult request for urology services.

The patient continued to receive IV fluids and antibiotics throughout the evening. In the morning, he was seen by the same hospitalist/admitting physician from the previous evening. Upon physical examination, the hospitalist noted tenderness, swelling, and erythema in the patient’s perineal area. The patient’s BP had dropped to 100/60 mm Hg, and his HR had increased to 115 beats/min despite receiving nearly 2 L of normal saline IV throughout the previous evening and night.

The urologist examined the patient soon after the consult request and diagnosed him with Fournier’s gangrene. He started the patient on aggressive IV fluid resuscitation, after which the patient was immediately taken to the operating room for extensive surgical debridement and scrotectomy. The patient’s postoperative course was complicated by acute kidney injury, respiratory failure requiring ventilator support, and sepsis. After a lengthy hospital stay, the patient was discharged home, but required a scrotal skin graft, and experienced erectile dysfunction and depression.

The patient sued all of the EPs involved in his care, the hospital, the hospitalist/admitting physician, and the urologist for negligence. The plaintiff’s attorney argued that since the patient progressively deteriorated over the 24 to 36 hours during his three presentations to the ED, urology services should have been consulted earlier, and that the urologist should have seen the patient immediately at the time of hospital admission.

The attorneys for the defendants claimed the patient denied dysuria, penile lesions, or urethral discharge and that the history, physical examination, and testicular ultrasound were all consistent with the diagnosis of epididymitis. For this reason, they argued, there was no indication for an emergent consultation with urology services. The jury returned a defense verdict.

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