A painful result

Plaintiff experts opined that Dr. Hospitalist should have ordered a CBC and blood cultures on admission as the CT report could not exclude an infectious process. Had a CBC been performed, it was probable that bandemia would have been present and systemic inflammatory response criteria would have been met (bandemia plus tachycardia). In addition, ET was complaining of severe pain out of proportion for exam findings, and this should have put necrotizing soft tissue infection in the differential diagnosis. The combination of systemic inflammatory response plus the severe pain would reasonably have led to a STAT surgical consult the day of admission with earlier debridement and leg-sparing surgery.

Conclusion

An individual hospitalist will admit hundreds of patients a year with routine and common problems. But admission for "pain control" is a red flag for an underlying disorder that has been missed by the ED evaluation. The diagnosis of necrotizing soft tissue infections requires a high level of suspicion. Patients that have new and persistent pain out of proportion to exam findings and in the face of high-dose opiate administration should lead to further investigation. Although ET survived, the outcome was considered catastrophic. A week before trial was to begin this case was settled on behalf of the plaintiff for an undisclosed amount.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reports having no relevant financial conflicts.