Warfarin + a twisted back = bad outcome
A FALL DOWN A FLIGHT OF STAIRS in her home caused an 85-year-old woman to twist her back when she grabbed for the bannister (she caught herself before landing). She was taken to an emergency department, where the staff noted that she was taking warfarin; she was diagnosed with acute low back pain and strain. The patient continued to receive anticoagulation therapy.
Because the patient also had decreased sensation in her lower legs, a magnetic resonance imaging (MRI) scan of the lumbosacral spine was ordered. The wet read of the MRI reported degenerative joint disease at L4-5 and mild-to-moderate spinal stenosis at L1-2, L2-3, L3-4, and L4-5, with no other abnormalities. The radiologist who issued the formal report described similar findings.
The next morning, the patient complained of numbness in her legs. She couldn’t move either leg and needed help to turn in bed. By noon, she had minimal motor control of her legs and couldn’t stand.
The attending physician was notified, but didn’t assess the woman. When a nurse called the doctor to let her know that the physical therapist had concerns about the patient, the doctor said that she’d address the concerns the following morning.
A neurologist ultimately assessed the patient and reported that she had neurologic deficits in her legs that interfered with her ability to walk. The patient continues to have significantly impaired function in her legs.
PLAINTIFF’S CLAIM The radiologists failed to identify abnormal signal intensity on the MRI, which should have raised concerns about bleeding and prompted an immediate assessment. The patient’s warfarin therapy wasn’t managed properly.
THE DEFENSE Subdural bleeding in the spine is rare. The fall caused the neurologic impairment, which was unlikely to improve regardless of the timing of diagnosis or treatment. The proper orders were given based on the reported MRI results. Discontinuing warfarin posed a risk in light of the patient’s history of mini-strokes.
VERDICT $1.5 million Massachusetts settlement.
COMMENT Although we could debate the cause of this patient’s disability, anyone on warfarin is at risk for occult bleeding and requires careful assessment after a fall or injury.
Colon cancer blamed on failure to screen
AFTER HER PHYSICIAN LEFT HIS PRACTICE, a woman started seeing another doctor in the practice almost exclusively. The second doctor never discussed or recommended colon cancer screening. Seven years later, at 66 years of age, the patient was diagnosed with stage IIB adenocarcinoma of the colon. She underwent surgery to remove part of the large intestine and required 6 months of chemotherapy.
PLAINTIFF’S CLAIM The doctor was negligent for failing to recommend colon cancer screening. The patient wouldn’t have developed cancer if she’d undergone screening.
THE DEFENSE A screening recommendation wasn’t required because the patient visited the doctor’s office only for acute-care issues.
VERDICT $357,130 Illinois verdict.
COMMENT Even patients who are casual users of our practices should receive clearly documented screening recommendations or requests to have a complete physical.
Quinolone leads to tendon damage in patient with known allergy
SINUSITIS PROMPTED A 35-YEAR-OLD WOMAN to visit an otolaryngologist. The physician prescribed moxifloxacin, despite the woman’s well-documented history of allergy to quinolone antibiotics.
After 2 doses of the drug, the patient developed a reaction marked by tendon damage in the hips. She suffered ongoing limited mobility, which affected her work and interfered with her ability to pursue her hobbies.
PLAINTIFF’S CLAIM The doctor was negligent in prescribing moxifloxacin.
THE DEFENSE Although moxifloxacin belongs to the quinolone antibiotic class, it has differences that make prescribing it a matter of judgment.
VERDICT $203,614 Kentucky verdict.
COMMENT Although we don’t know the exact nature of the patient’s “allergy” to quinolone antibiotics—we all know of cases in which allergy is defined as a bit of diarrhea or stomach upset. I have to wonder whether the decision-making process that led to using moxifloxacin (instead of another antibiotic) was documented clearly.