John D. Bibb, MD, FACEP, Lead Co-author
William C. Dalsey, MD, FACEP, Lead Co-author
Case Number Four
This malpractice case involving the diagnosis and treatment of meningitis was referred to the ACEP Standard of Care Review Panel for review of the plaintiff’s expert’s testimony regarding violations of the standard of care. Our review was based on depositions provided for our review but we did not have access to the medical records. The panel reviewed the testimony and its truthfulness was assessed by majority vote of the panel. The purpose of this presentation is educational. Names of those involved in the case are redacted and unknown to panel members.
A 26-year-old female presented to a physician in a private office with a complaint of earache and her eventual, unfortunate outcome was ventilator dependent quadriplegia. A diagnosis of otitis media was made in the office on March 13, and the patient was started on ciprofloxacin. On March 16, she presented to another physician with complaints of headache, neck pain, fever, and vomiting "since last night." A diagnosis of gastroenteritis was made and the patient was discharged home on ciprofloxacin and phenergan. Later that day at 9:30 pm, she presented to a small hospital emergency department with the above complaints and additional symptoms of confusion and inability to follow commands. On physical exam she was febrile and had neck stiffness. The emergency physician considered both meningitis or phenergan side effects in his differential diagnosis and sent the patient to CT. The CT was normal and a lumbar puncture was performed. No opening pressure was measured. The fluid was cloudy with more than 6,000 white cells and the gram stain showed gram-positive diplococci. Ceftriaxone 2 grams IV was administered two hours after the patient first presented to the emergency department. The patient was admitted to the ICU and the emergency physician wrote admission orders. The emergency physician discussed the case with the private doctor, but he did not see her until 4:30 am. The emergency physician was called to see the patient by the nurses shortly after admission because her mental status had deteriorated further and there was a question of posturing. It took the emergency physician one hour to go up to the ICU to reevaluate the patient. The patient looked worse with a Glasgow Coma Scale of about 10. The emergency physician called a neurosurgeon at a referral center who said there were no neurosurgical indications for the patient. The emergency physician then talked with the private physician again and a staff neurologist. No change in therapy was suggested at that time by the consultants. The patient was eventually transferred to a tertiary care center and a subarachnoid bolt was placed. Increased intracranial pressure was documented and a ventriculopertioneal shunt was done.
The plaintiff’s expert testified that delay on the part of the emergency physician in giving the ceftriaxone led to a worse outcome for this patient. He could not quantify the extent of this increased worse outcome. He testified that ACEP and the American Infectious Disease Society (sic) both have guidelines stating that antibiotics for meningitis should be administered within "one hour of hitting the door." In fact, ACEP does not have a clinical policy statement on this issue. The Infectious Disease Society of America states in 2004 guidelines that the administration of antibiotics for suspected bacterial meningitis should be "emergent" but does not specify a time frame.1 The standard of care is generally defined as what other physicians would do in the same or similar circumstances. A paper published in 1989 found that the average time to antibiotic administration for bacterial meningitis is three hours.2 The panel agrees that administration of antibiotics for suspected bacterial meningitis should be emergent. Ceftriaxone is an appropriate antibiotic for suspected meningitis and was given within two hours. However, the opportunity to give timely, appropriate antibiotics to this patient was lost well before the emergency department visit. Ciprofloxacin is not a drug of choice in the treatment of otitis media. The presentation at the second office visit was highly suggestive of partially treated meningitis. The patient should have been referred to the emergency department immediately from the office. Today, a good course of action for this case would be prompt blood cultures, decadron, vancomycin, third generation cephalosporin, CT Head, and then lumbar puncture.
The plaintiff’s expert also testified that it is the standard of care to measure an opening pressure when doing a lumbar puncture. Had that been done, he opined, the patient’s increased intracranial pressure would have been discovered earlier and treatment to reduce that pressure could have been instituted. The expert for the defense stated that when opening pressure is 30 cm or greater, the spinal fluid will squirt out of the needle.
The panel was of the opinion that emergency physicians frequently do not measure opening pressure. We also agreed that we do not use the opening pressure from a lumbar puncture to determine the need to initiate treatment for increased intracranial pressure. We are not aware of substantial evidence to prove that such aggressive measures improve patient outcomes in meningitis.
The plaintiff’s expert testified that almost 100% of bacterial meningitis patients should be treated at a large referral center and that this patient should have been transferred there almost immediately. He felt that meningitis patients can’t be treated at community hospitals and that most are transferred. The Panel did not agree. He also testified that her outcome would have been better if her intracranial pressure had been controlled earlier. He felt that most meningitis patients receive intracranial pressure monitoring and aggressive treatment of increased intracranial pressure. The Panel felt there is no evidence for this statement and that this is not the current standard of care. It is interesting that the emergency physician was told by the neurosurgeon over the phone that there were no indicated neurosurgical interventions in this patient. Yet, the patient did receive a subarachnoid bolt and subsequently a ventriculoperitoneal shunt. So, according to the plaintiff’s expert, the emergency physician should have talked to somebody else at the other hospital about taking this patient in transfer. The panel felt that the emergency physician exceeded the current standard of care by involving the neurosurgeon and asking for his advice regarding neurosurgical treatment.
Finally, the plaintiff’s expert criticized the nurses. He testified that the emergency nurse should have known that prompt antibiotics were indicated in this patient and discussed that with the physician. Further, the nurses should have advocated transfer of this patient, and if the physician did not respond to this suggestion, the nurses should have gone up the hospital chain of command. The panel agreed that this is not the role of nursing at the standard of care level. When nurses have advanced knowledge of a subject and can make helpful suggestions, this provides a contribution to the team providing care but it was not their responsibility to "over rule" the clinical decisions and judgments of the emergency physician.
In the opinion of the Standard of Care Review Panel, it was unfortunate that the emergency physician and the emergency nurse lost this case particularly since all others involved in the case were excused. The terrible outcome for the patient rather than the facts of the case probably played a key role in the decision by the jury to "do something" for this family. Additionally, the inaccurate and false testimony of the expert may have convinced this jury to believe that there was a significant breach in the standard of care and that this resulted in the patient’s bad outcome.