Three Visits: The Patient's Story

  A previously healthy adult traveler presents to a community emergency department with cough, sore throat, headache, and a tight neck. She returns the next morning, and again that same night. Each visit, the clinical picture sharpens. Each visit, the differential narrows in the wrong direction. By the third visit, bacterial meningitis is no longer a possibility a workup could have caught — it's a diagnosis announcing itself in the resuscitation bay.

Transcript

SPEAKER_00 2:36

The content of On the Record is provided for educational and analytical purposes only. It is not legal advice, and it is not medical advice. Case facts, verdict information, and procedural history are drawn from publicly available court documents. Clinical roles, expert witnesses, and the venue of the proceedings are anonymized in accordance with the chartered defense brand standards for this season. The opinions provided are my own personal opinions and should not be taken as medical or legal advice. I'm providing commentary on these cases to encourage all of us to review our practice and documentation so that we don't find ourselves in a medical malpractice case.

SPEAKER_01 3:38

The first visit was for a headache and fluoic symptoms. The second visit was on the morning of day two for vomiting, severe neck pain, a recent history of fever, and a markedly elevated white blood cell count. And she was discharged home after that visit with a working diagnosis of viral syndrome and cervical muscular strain. Between the second visit and the third visit, her family called the emergency department to report that she had become confused. She returned later that same evening in extremis. What happened over the next 24 hours is the reason this case went to trial. And the reason it produced a verdict that was upheld on a post-trial motion for a new trial and later considered on appeal. Tonight, in episode one, I am going to stay out of the way until the very end. Brian is going to walk us through all three emergency department visits: the admission, the deterioration, and the autopsy, the clinical record as the trial court received it. And then I will come in at the end of the episode to pull the clinical picture together and set us up for episode two, where we start working through the expert witnesses and the legal case. This is on the record. I am Michael Coleman. This is season five, episode one.

SPEAKER_00 5:00

The patient was a generally healthy, community-dwelling woman in her early 60s, with no immunocompromised condition. A few years before the presentations at issue, the patient had undergone a transmastoid resection of an acoustic neuroma. The surgical site was repaired with bone wax, an autologous fat graft, and fibrin glue to seal an interoperative cerebrospinal fluid leak. That operative history becomes relevant on both sides of the causation dispute later in the season. We flag it here as a fact in the record. On the afternoon of day one, the patient presented to the emergency department and was evaluated by an emergency physician. We will refer to that physician as physician A. The chief complaint at the first visit was headache. The patient reported a recent influenza-like illness with body aches, congestion, and fatigue, and a fever earlier in the week. Physician A charted a working assessment of influenza-like illness with migraine recurrence, administered a parental migraine treatment, and discharged the patient after her headache improved. Physician A was not named as a defendant in the subsequent litigation. The patient returned to the same emergency department the following morning. The triage nursing record documents the chief complaint as nausea, vomiting, and continued neck pain. Pain was rated 10 out of 10. Triage blood pressure was 155 over 88. She was a febrile at triage. She was seen by a different physician this time. She had had a respiratory infection that she felt was improving. She had had a fever earlier in the week. She had recently been on a trip during which she had lifted heavy luggage, and she attributed her neck discomfort to that mechanical event. A strain from handling the bags. She reported a chronic intermittent history of neck strain. She described the current neck pain as more severe than her usual neck strains. She had been vomiting and had not been able to maintain fluid intake. The reason she had come back was that she was not feeling any better, and her neck pain might have been a little worse despite some initial improvement from the previous day's treatment. The physician seeing her today charte references to influenza-like illness, stomach upset, and a returning migraine consistent with the inherited frame from the prior day chart. The physician performed a physical examination. The physician described the examination as including evaluation of the head, eyes, ears, nose, and throat, the cardiopulmonary examination, the abdominal examination, the extremities, and a neurologic screen. She also described a cervical spine examination that included palpation of the perispinal muscles and assessment of cervical range of motion in multiple planes. At to deposition, the physician was asked whether the physical examination she described had been fully documented in the chart. She testified, in substance, that she had not documented everything she had done at the bedside. The charted entry for the neurological examination read, in its entirety, no meningeal signs. The physician ordered a complete blood count with differential, a basic metabolic panel, and a urinalysis. The complete blood count returned a white blood cell count of 19,000 with 92% neutrophils. Consistent with a left shift, the basic metabolic panel showed mildly elevated glucose and a potassium abnormality. The urinalysis was documented in the record as normal. Contemporaneous with her review of the laboratory results, physician B charted the following. Continuing in the same note, I am quite concerned about the possibility of a bacterial infection. At subsequent deposition, the physician clarified that her concern at the moment of that chart entry was focused on a deep neck or perispinal bacterial process, a decitis, a retropharyngeal process or perispinal infection rather than on bacterial meningitis. The physician ordered magnetic resonance imaging of the cervical spine with and without contrast. She did not order a lumbar puncture, blood cultures, or empiric antibiotics at this point in the workup. The cervical MRI was performed and was read by the staff radiologist on duty that morning. The impression flagged meningial enhancement in the cervical region and recommended clinical correlation, as this could be seen in meningitis. The impression also included a parenthetical observation that the appearance could be a sequela of a prior lumbar puncture. With this MRI report, the physician returned to the bedside and discussed the imaging finding with the patient. The patient reported that she had had a prior lumbar puncture approximately five years earlier. Physician B adopted the prior lumbar puncture attribution as her working explanation for the meningial enhancement on the cervical MRI. She also contacted the physician that examined the patient on the previous day, who was working in the same department that morning. And the two physicians discussed the case briefly. During this discussion, the physician that saw her the previous day noted he did not have suspicion for meningitis. The patient received a parental dose of analgesic during the visit and an anxiolytic before the MRI. On her subsequent bedside evaluation, the patient reported that her headache and back pain had resolved and that her remaining pain was localized to her neck. At deposition, physician B described an encounter in which the patient spontaneously demonstrated cervical range of motion at the bedside, flexing the chin toward the chest and extending it. And stated that she believed the pain was a neck strain and was much improved compared to her presentation a few hours earlier. The chart entry at that point included the following. And I have opted not to perform an LP at this time. The patient was discharged with final diagnoses of viral syndrome and cervical muscular strain. The discharge instructions directed her to continue specified maintenance medications and to follow up with her primary care physician. The contemporaneous nursing note reflects that the patient ambulated out of the emergency department unassisted, under her own power, with a normal gait. The chart also contains the sentence The patient's elevated white cell count remains a mystery. The patient was discharged from the emergency department, and the patient returned home. Over the hours that followed, her symptoms worsened. The record reflects recurrent headache, photophobia, and progressive alteration in mental status. Between the second visit and the third visit, the patient's family became alarmed enough at the change in her mental status that they called the emergency department to report that she had become confused. Later that same evening, on the evening of day two, she was brought back to the same emergency department for the third time. On arrival at the third visit, she was in extremis. She was evaluated by a different emergency physician. In the emergency department, she had a seizure and subsequently required intubation. A lumbar puncture was performed at that point. Purulent cerebrospinal fluid was obtained under what was thought to be elevated opening pressure, and a rapid antigen test on the cerebrospinal fluid was positive for Streptococcus pneumonia. Broad-spectrum intravenous antibiotics were started. She was admitted to the intensive care unit. A ventricular drain was subsequently placed due to concern for hydrocephalus and increased intracranial pressure. Despite full critical care management, she did not recover neurologic function. Within 72 hours of her first emergency room visit, the patient passed away. An autopsy was performed. Gross and microscopic findings confirmed acute pneumococcal meningitis with ventriculitis. More on this in later episodes.

SPEAKER_01 15:03

That is the clinical record as the trial court received it and as the jury would hear it. We basically have a fairly healthy lady that had been on a trip recently and had been moving some heavy objects. She had flu-like symptoms upon arrival home that included fevers, myalgias, and stiffness in her neck. These symptoms had been ongoing for a few days, and then she sought care in the emergency room. Over the course of 48 hours, she would be evaluated twice and discharged home, and on the third visit, at which time she was dramatically different in her presentation, was admitted. And the diagnosis was made. We go through these cases to learn not to criticize or critique another physician's work. Reasonable physicians may read the record and come to different conclusions. We will see this as the experts battle it out in our next episode. There is one piece of information from this patient's past history that is likely to be a significant piece of the puzzle as to her presentation and her rapid decline. She has undergone a microsurgical resection of an acoustic neuroma roughly five years before this hospitalization. The surgery was performed via a transmastoid approach. She had a CSF leak following the procedure, which was repaired. The barrier was made with bone wax followed by autologous fat graft and finally a fibrin glue. This was supposed to recreate the natural barrier. I don't think any of the physicians realized that this information could be relevant. And honestly, I didn't either, until I started reading the expert statements. What would normally provide the natural barrier to prevent infectious organisms from entering the subarachnoid space? In this case, could have provided either a nitis for organized infection growth with subsequent spread or provide a direct portal into the subarachnoid space from the upper respiratory tract. That could explain an atypical presentation for this patient that led two physicians to believe she did not have a more serious infection, such as meningitis, despite there being some specific wording and triage notes regarding neck stiffness. And on the second visit, a more explicit description of the patient being unable to touch her chin to her chest due to this pain and stiffness. The physician that saw her during the second visit noted that the patient had significant improvement in her neck exam, which might have led to reassurance that this shouldn't be a bacterial meningitis. The patient's acoustic neuroma surgery has meningitis as a complication, and that makes sense. I would think of that as a complication in the acute setting or subacute time frame following the surgery. I'm not sure I would think of this being a complication you would see years later. And I don't think I mean it as a surgical complication at this point, but um more of a nitus or portal for a pathogen to enter the CSF. So I think that is something important to remember. The surgical and past medical history need to be obtained on all patients and integrated into our acute care visit. It's not always the case, but sometimes that information may provide some clue or information that might alter the course. In this case, it might push you to image her brain and consider the lumbar puncture, even if you were moving away from bacterial meningitis as a potential diagnosis. This surgical history might provide a plausible reason as to why her symptoms might not have been classic, or her presentation not looking like a textbook meningitis patient. The experts will start to focus their attention on this barrier as the weak link in the chain of causation of this patient's catastrophic infection. Combine that with a streptococcus, pneumonia, upper respiratory infection, or pneumonia, which may have been the initial event that led to seeding of the mastoid air cells. And you have a plausible mechanism for an unusual meningitis presentation in a patient whose anatomy is not the anatomy the textbook is describing. The call to action for all of us is straightforward. Look at every patient's past medical and surgical history and reason through which elements might be creating an atypical presentation for the patient standing in front of us on this shift. I think that is important to note again. Another thing to bring up here is about bacterial meningitis in general, because the numbers are not what most of us carry around from training. The classic triad we were all taught, fever, neck stiffness, and altered mental status together, is present in only about 41 to 44% of adults with culture-proven bacterial meningitis. Less than half the better decision rule in the published literature is the cardinal four rule. Approximately, 95% of adults with bacterial meningitis will present with at least two of four features: headache, fever, neck stiffness, and altered mental status. Two of four, not three of three. And also note that the bedside physical exam signs are less sensitive than most of us believe. In modern adult disease, the Koenig sign has a sensitivity around 5%. Brudzinski is also around 5%. Passive neck flexion as a test for neutral rigidity is around 30%. Those are the published numbers. What this means as a teaching point and nothing more is that in the early phase of adult bacterial meningitis, the presentation may not look like the textbook picture we all studied. The patient may be lucid, the patient may not have a fever, the patient may be able to demonstrate cervical range of motion at the bedside. The classical picture may be the late picture, or in some patients, it may not be present at all. The early picture can be quieter and more nonspecific, and in a patient with prior surgery adjacent to the meninges, it may not follow classical teaching at any phase. The next issue worth bringing up is the inherited diagnostic frame. A chart had been created the afternoon before. A working diagnosis of influenza like illness with migraine recurrence had been entered, a treatment had been administered and had produced symptomatic improvement. That chart was available to Physician B at the second visit and was reviewed early in the evaluation, according to her deposition. A patient who returns to any emergency department within 24 hours of a Previous visit is a patient whose prior frame deserves to be actively retested rather than passively inherited. That return visit itself is a soft signal. It is a clue that there may be more going on than what was uncovered at the first encounter. It is a time to pause and flag this as an important encounter, the kind of encounter that earns a fresh walk through the differential rather than a confirmation of the inherited frame. This is important because the patient was returning for basically the same symptoms, so any relief she had from the day one visit was likely transient and related to the medications and IV fluids administered. With that in mind, we should expand our differential diagnosis. I would just use that second presentation as a sign to pause and scrutinize this chart and the objective data. On a similar topic, if this is not a patient known to frequent the emergency room, that might be another clue that there may be more going on. Some patients are known to minimize their symptoms or rationalize a benign cause to their symptoms, and these are the patients we must be very careful with. We are probably expecting patients to overplay their symptoms if we had to choose between the two options. But in this case, if the patient was stoic and rationalizing her symptoms to a more benign neck sprain that might allow the physician to get some false sense that she is not very sick and subsequently move away from meningitis. That is where observation is key, looking for the subtle clues that this patient is, in fact, sick and needs more evaluation. I always like to look at the documentation pattern. On this series, we usually see documentation that strengthens or weakens the case even when care was above the standard. The charted relevant neck exam in its entirety was no meningeal signs. The physician's sworn testimony at deposition was that the exam she actually performed at the bedside was more detailed than that, and that she could not say she had documented everything she had done. That is a common documentation pattern across emergency medicine and inpatient medicine. Most of us, on a busy shift, will at some point document the quick version of an examination we actually performed in greater detail. The quick version is faster. The quick version fits the workflow. The quick version is almost always defensible in the moment. This case is an illustration of how the quick version can harm you when the chart later has to stand on its own in a courtroom. I would just note that if meningitis was not running through the physician's head, meningeal signs would Ike not have been mentioned at all. I only say that to better illustrate my thought that if you are documenting no meningeal signs to support your decision not to order a lumbar puncture, that specific exam should be documented thoroughly, and it should lead you to a deeper discussion in your medical decision making as to why you did not think the patient had bacterial meningitis and why, in fact, you chose not to proceed with lumbar puncture. In some cases, the patient might have refused a lumbar puncture. That should be documented as well, and it should be followed by a detailed shared decision-making documentation. And in the case you, as the physician, thought a lumbar puncture was warranted, an informed refusal should be documented. There is no evidence that this patient declined a lumbar puncture. I just wanted to give that information as a documentation consideration in the event you want to perform an LP and the patient refuses. So back to this three-word entry. This entry and the subsequent sworn concession that the documentation was not a complete record of what was done at the bedside were facts the plaintiff's experts relied on at trial. It may be worth rethinking the quick version habit, um, not as a judgment, but as a documentation practice that has real downstream consequences in cases where the chart becomes the primary witness. In this case, the plaintiff could frame the exam as incomplete and drive the narrative in a direction more favorable to their stance. The physician and her defense in general could still argue that her standard neurological exam and exam related to an assessment of meningitis includes a more thorough assessment, but time constraints or other issues led to a compressed documentation. Ultimately, though, a jury will have the final decision as to who they believe, and it seems they tend to go with the documentation at the time of the event. The next thing I would say we should consider is the way reassuring inputs can quietly stack. The bedside attribution of the meningial enhancement to a prior lumbar puncture was a plausible alternative explanation, and we need to stop and talk more about this issue. The MRI suggested meningeal enhancement in the cervical spine and posterior fossa, and stated that meningitis could be a cause of this pattern, and also that a previous lumbar puncture could give this pattern as well. The physician went back and examined the patient and discussed these findings with her. The record indicated that the patient was feeling better, and she was able to flex her neck without any signs of any stiffness or rigidity, and the patient confirmed a history of lumbar puncture many years ago. The physician did not discuss this with the radiologist, and this might be another point in the chain of events where a brief discussion could have helped the ER physician. The radiologist might have been able to clarify that it was meant to suggest a recent lumbar puncture. Sometimes discussing the patient's symptoms and lab values with the radiologist might lead them to conclude that the changes they are seeing on the MRI would be better explained as meningitis in the setting of a patient with leukocytosis and some documentation of neck pain and stiffness. So, again, this is just another point where there is a sign that something is not adding up, and another point where maybe a different action could have changed the outcome. The next reassuring input was likely the conversation with the physician that examined the patient on the previous day. The improvement of pain after parental analgesic was reassuring. The patient's non-toxic appearance at the bedside was reassuring. The nursing note that the patient ambulated out of the department unassisted under her own power with a normal gait. That too is the kind of reassuring observation a clinician relies on at the moment of discharge. It is a real bedside data point, and it weighs against a serious central nervous system process in the moment. Each of those inputs taken alone is a normal part of emergency medicine clinical reasoning. Taken together, they all cut in the same direction away from meningitis. When multiple reassuring inputs stack in the same direction, they can quietly displace a finding that is still unexplained and that is still sitting in the chart. In this case, the finding that was still sitting in the chart was a white blood cell count of 19,000 with a left shift in a patient with two visits within a span of 24 hours. When it comes to our documentation, I like to say that the chart should read as a cohesive story of a patient's flow through the healthcare system. Good care and good documentation should flow and make sense to an outside reader. It's when we start to see discrepancies in exams or documentation between the different providers and nurses and other service lines that interact directly with the patient that red flags are raised that the story is diverging. When we look at this case, initially what jumps out is a triage nurse's note documenting the neck stiffness and inability to touch her chin to her chest, but that is followed by more um consistent and reassuring exam findings from both nursing and the physician that could support clinical improvement while in the emergency room. So at least the documentation seemed consistent here for the most part. The last point I'll make here is the discharge documentation itself. The decision not to perform a lumbar puncture was charted as a conclusion. I have opted not to perform an LP at this time, rather than as a reasoning chain. The chart recorded the decision but did not record the specific clinical factors that supported it. The chart also contains the sentence: The patient's elevated white cell count remains a mystery. An unexplained leukocytosis in a patient being discharged from the emergency department is not a finding to file away and move on from. It is a stop and think moment. Rule in or rule out. A charted note that says the finding remains a mystery is not a closure of the finding. It is an open question at the moment of discharge, and a chart that documents a decision without documenting the reasoning that supported it leaves a later reader, whether that is a colleague, a patient's family, or a jury, to guess at what the reasoning was. I want to be fair to this physician. The phrase lucid and without any suggestion of meningitis supports a reading in which meningitis was in fact considered at the bedside, and her assessment at that moment was that it was not a likely diagnosis. That is a reasonable reading of the chart entry, and it is one the defense will rely on later in this case. But a single conclusory phrase is not the same as a documented reasoning chain, and the plaintiff's experts at trial were going to push on exactly that gap. I'm just trying to reiterate the point of thorough documentation or expanded documentation on the clinical decision-making process. It is important. I want to close this segment by being fair about what we can and cannot know from the record. We are not in a position to know from a medical record years after the fact what the physician was actually weighing at the moment she signed the discharge. We do not know what the patient said at the bedside about her own symptoms that may have led the treating clinicians toward a more benign working diagnosis. The chart is not a transcript of her reasoning, it is a documentation trail. What we can say is that a number of factors were sitting in the chart at the moment of the discharge decision, and that the plaintiff's experts were going to argue that the constellation of those factors in combination required a lumbar puncture before discharge under the applicable standard of care. The defense experts were going to argue that it did not. The how and the why of each side's position is what episode two is going to walk through. One last thing before we wrap up this episode. The plaintiff must show that it is more reasonable than not that this breach is the direct cause of the patient's death. Like I bring that up here because the defense will argue later that at the time of the second visit, the patient was in the process of a catastrophic neurological emergency that was beyond the point of survival. Even if a lumbar puncture were performed, the outcome would not be different. That is important to know in all malpractice cases. Just because a breach is strongly supported by the plaintiff's expert, they still must show that breach as the legal cause of death, and that tends to be much harder than merely proving a breach. Sarah, can you give us a real example of this?

SPEAKER_02 34:35

Yes. A clean example is Gooding versus University Hospital Building, Inc. 445. So, second one, 1015, Florida 1984. In that case, the patient arrived in the ED with what was later found to be a ruptured abdominal aortic aneurysm. The plaintiff's expert testified that the emergency room staff violated accepted medical standards by failing to take an adequate history, perform an exam, and order testing. The Florida Supreme Court expressly said that this testimony established the standard of care and breach. But the expert did not testify that immediate diagnosis and surgery would more likely than not have saved the patient. The court held the evidence showed, at best, an even chance of survival. So proximate cause was not proven and the plaintiff's verdict could not stand. That is the classic breach without causation pattern in medical malpractice. You can prove the care fell below standard, but you still lose unless you can also prove that breach probably changed the outcome.

SPEAKER_01 35:44

To summarize the ending of this patient's medical care, she had a rapid decline in her mental status between the second and third emergency room visit. During her evaluation, during this third visit, she suffered a seizure and required intubation and was comatose from that point forward. A lumbar puncture was performed in the emergency room, and a rapid antigen testing results, positive for strep pneumonia and antibacterial therapy, was initiated. CT scans would suggest hydrocephalus and a ventricular drain was placed. Despite all of the aggressive care during this encounter, it was too late for the patient, and she subsequently passed away. In the next episode, we will get to the medical experts for both sides and go through their opinions as we try to establish the causation chain for each side. The previous surgery will be a big focus of the experts, and we will actually see a divergence between some defense experts on this issue, so stay tuned to see how this plays out, and what we can learn from this case that we can implement in our daily routine to better protect ourselves and our patients.

SPEAKER_00 36:55

This has been On the Record Season 5, Episode 1. Charted Defense is created by Dr. Michael Coleman. Sources for this episode are listed in the show notes. The content is for educational purposes only. It is not legal advice. It is not medical advice. Case facts, verdict information, and procedural history are drawn from publicly available court documents. Clinical roles, expert witnesses, and the venue of the proceedings are anonymized in accordance with the Chartered Defense brand standards for this season.

SPEAKER_03 40:14

The big the window story.