A 50-year-old man sustained a rope-burn injury to his left hand during a fishing trip in early August 2004. He subsequently presented to an orthopedic facility with complaints of a hand infection and was eventually referred to orthopedic surgeon Dr. W.

One week later, Dr. W administered a steroid injection, which caused the infection to worsen. The patient claimed that the steroid injection was contraindicated by the underlying infection. Dr. W referred the patient to Dr. C for infectious disease management.

In November 2004, Dr. W performed an incision and drainage procedure, and specimens were sent for pathology study and cultures. The pathology results were sent to both Dr. W and Dr. C, but the culture results were sent only to Dr. W. Other specimens were sent for culture in November 2004 and January 2005.

The results from the first culture, received by Dr. W in three reports, indicated “Mycobacterium,” “rare presumptive Mycobacterium marinum,” and “Myocbacterium marinum.” Dr. W did not forward these results to Dr. C and allegedly did not review the last report. Dr. C treated the plaintiff for a fungal infection based on the results of the second culture. After the third specimen in January 2005 grew acid-fast bacilli, Dr. C was informed that the patient likely had an infection caused by M. marinum.

The patient alleged that the 44-day delay in diagnosis and treatment of the M. marinum infection allowed the infection to worsen. The patient was hospitalized for one week at a major clinic and underwent three debridement surgeries to his left hand. He subsequently underwent five months of physical therapy and received long-term intravenous antibiotics for the infection.

The patient lacks full range of motion in his hand and is unable to fully open the fingers or make a tight fist. He has a trigger finger, surgical scars, and painful nodules. The hand is also extremely intolerant to temperature. The plaintiff claimed that the debridement surgeries would have been unnecessary if the initial culture reports had been acted upon in a timely manner.

The defendants claimed Dr. W saw no evidence of infection at the first office visit and that there was no sign of infection when the steroid injection was administered. The defendants claimed that the hand’s condition did not worsen after the injection and that the plaintiff was referred to Dr. C when a second fishing trip led to a flare-up that eluded diagnosis. Dr. W maintained that, during the procedure that produced the first cultures, he instructed the circulating nurse to have all lab results sent to both himself and Dr. C. Dr. W believed that Dr. C had been sent the results when he saw both their names on the pathology reports.

Continue reading to see the outcome...

OUTCOME

A $215,000 verdict was returned. The surgical center at which the procedure was performed that produced the first culture settled prior to trial for $200,000.

Continue reading for David M. Lang's commentary...

COMMENT

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

Reference

1. American Society for Surgery of the Hand. Hand infections. www.assh.org/Public/HandConditions/Pages/HandInfections.aspx. Accessed January 9, 2014.

Failure to Manage Hand Infection Results in Disability