This case raises three issues:
First, hand infections can be problematic and are often trivialized by the initially consulted clinician. The presentation of certain hand infections, such as paronychiae and felons, generally will be straightforward. Paronychiae are usually managed by the clinician who first sees the patient. Felon management is more difficult, but it still may be drained in ambulatory settings by experienced clinicians. Deeper and more troublesome infections of the hand should raise immediate concern; these include tendon sheath infection, septic arthritis, and deep space hand infections. Hand cases can become complicated, and prompt referral to a specialist is usually warranted for all but the most basic infections.
Second, clinicians must always be on the lookout for important clues pointing to an oddball cause. Here, the overlooked clue was the significance of the patient’s fishing trip. While M. marinum seems obscure, the specific bacteria is known to cause tendon sheath infections when a patient’s hand is punctured by fish spines or when a simple wound is contaminated with stagnant water in nature or from an aquarium.1 Many of us are familiar with the fungal infection sporotrichosis, which can occur after a gardener is stuck by a rose thorn. Asking about a patient’s hobbies and activities may provide a context for an injury.
Third, communication breakdown is something clinicians often just don’t “get.” After receiving the culture report, the orthopedist should have called the infectious diseases physician to discuss the unusual case. This is particularly true in light of the fact that the orthopedic surgeon injected the hand with steroids, which may have worsened the patient’s condition. Jurors would have the expectation that the case would be followed closely. Everyone is busy, but unusual cases such as this one require a quick call to help the patient and avert liability. Pick up the phone.
Furthermore, the defense strategy here seems misplaced. The defense argued that the orthopedic surgeon saw no evidence of infection but administered a steroid injection for inflammation. But how can you tell the difference from external observation alone? We’ve all been trained in the classic signs and symptoms of calor (heat), dolor (pain), rubor (redness), and tumor (swelling). But both infectious and noninfectious inflammation will produce these, so the cause would not be readily distinguishable without further investigation.
In sum, take hand infections seriously. Thanks to television shows such as House, lay jurors expect clinicians to puzzle together facts to arrive at an obscure diagnosis. So, before we discharge a patient with a common condition, it is useful to ask about the patient’s job and hobbies. We might also ask the generic question “Were you doing anything unusual?” You may just save a patient and solve a puzzle at the same time.
Finally, communication with other clinicians in complicated cases is required and expected by jurors. —DML
1. American Society for Surgery of the Hand. Hand infections. www.assh.org/Public/HandConditions/Pages/HandInfections.aspx. Accessed January 9, 2014.