Practice of Medicine
Management By PA Alone Proves Inadequate in Treating Wound Infection
November 26, 2013
A woman presented to a plastic surgeon with considerable excess skin and trunk fat. She had previously had liposuction surgery. She signed a surgical consent for a belt lipectomy and liposuction of the back and inner thighs. A total of 7,480 grams of tissue was removed from the abdomen; four JP drains were placed. The patient was discharged from the surgical center the following day.
Six days post-operatively the patient called with general questions and to report that one of the drains was putting out less than 30 cc's of fluid. The office nurse instructed her to discontinue the use of her pain medications and use muscle relaxants instead. She also instructed the patient to use bikers' shorts to help alleviate the swelling in her legs. The nurse offered the patient an appointment for the drain removal, but the patient stated that she was too sick to go to the office. Later the patient claimed she asked if someone from the office could come to her home to remove the drain.
Nine days post-operatively the patient called with complaints of a temperature of 101 degrees and generalized body aches. The plastic surgeon's physician assistant (PA) spoke with her and called in a prescription for Ciprofloxacin 500 mg BID. The plastic surgeon was out of town. No supervising physician had been assigned to the PA during the surgeon's absence.
The following day the patient called the PA again with similar complaints of a 101 degree temperature and body aches. She was instructed to follow up the next day at her regularly scheduled appointment with the surgeon.
On the 10th post-op day, the plastic surgeon saw the patient in the office for her first scheduled post-operative visit. He removed all of the wound dressings, and documented that the drain looked good, and no wound separation was noted. However, there was an area of infraumbilical necrosis with ecchymosis. The central portion of the umbilical incision, and extending downward, was blistered, with dark skin noted above the closure lines. The patient's temperature was within normal limits, although she had reported having had temperatures of 101 degrees. One drain was removed.
Because of the skin discoloration, the surgeon wanted her to return to the office in two days for further follow-up. The patient returned as instructed. The surgeon documented the incision looked somewhat improved, but there was a large area in the center of the abdomen that was necrotic, with surrounding areas of redness and tender to the touch. All drains were intact. The patient reported that her temperatures had not been elevated.
On the 12th post-op day the patient returned with an elevated temperature. The plastic surgeon admitted her to the hospital on an emergent basis for re-exploration of the surgical site. Upon opening the wound, he found pus and extensive necrotizing fasciitis involving much of the abdominal wall fat.
The diagnosis was necrotizing fasciitis of the abdomen, flanks, left breast and axilla after belt lipectomy.
The patient subsequently underwent numerous debridements and skin grafts, and was eventually discharged from the hospital with 16 days of home health care.
The plaintiff claimed that the plastic surgeon and the physician's assistant failed to diagnose and treat a surgical wound infection that she developed following her belt lipectomy, resulting in the development of necrotizing fasciitis, and leading to multiple additional surgeries, treatments and pain and suffering.
The case was mediated on behalf of both the plastic surgeon and the physician's assistant with a substantial payment to the patient/plaintiff.
Risk Management Commentary
This case had been scheduled for trial because it was felt that our policyholders had reasonable expert support. Then a plaintiff's expert identified, and dated, a photograph showing necrotic tissue to the day when the plastic surgeon first saw her. Based on that photograph, it was alleged that the patient should have been sent to the hospital, and the surgeon concurred.
Under state laws, PAs are not allowed to practice without a supervising physician. When a supervising physician is going to be unavailable, a back-up on-call physician, preferably in the same specialty, should be made available to the PA. If none are available, then a referral to the ER may be appropriate.
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