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The emergency physician contacted the on-call internist and the on-call orthopedist (a member of a group that had a spine specialist). The patient was admitted to the orthopedic floor with neurologic checks every two hours. Spinal precautions were not ordered.
 
When the patient arrived on the orthopedic floor, his neurologic status was described as being normal. On the orthopedic floor, the patient was reportedly not seen by either the admitting physician or the spine specialist for more than 24 hours. He developed signs consistent with alcohol withdrawal and was transferred to the telemetry floor. During the following 24 hours, the patient developed incontinence and was eventually rendered a paraplegic from spinal cord compression.
 
Expert Testimony:
 In excerpts from the expert witness deposition, John Flaherty, MD, an associate professor at Northwestern Medical School, testified that ankylosing spondylitis is “one of the first diseases that you study in medical school.” He went on to state the following:
–In 21 years of emergency medicine practice, he had seen 500 to 600 cases of ankylosing spondylitis and had been the diagnosing physician in approximately 150 to 200 of those cases.
–Spinal fractures occurring in ankylosing spondylitis are “almost always unstable,” represent an “extreme risk,” and “almost always lead to neurologic damage unless they’re attended to right away.”
–There is a “two to three times greater incidence of spinal cord compression” in ankylosing spondylitis patients suffering from spinal fractures and such statistics are “well described in medical textbooks and in the medical literature.”
–Spinal fractures in ankylosing spondylitis can be compared to acute myocardial infarctions in that they are “one of the few true emergencies we have.”
 
The expert faulted the emergency physician for:
 
–Failing to understand the pathophysiology of spinal fractures in patients with ankylosing spondylitis (which the expert also called “brittle spine disease”)
–Failing to have the patient either evaluated in the emergency department by a spinal surgeon or transferring the patient to a hospital where the patient could be immediately evaluated by a spinal surgeon
–Failing to admit the patient to the intensive care unit–Failing to perform a rectal exam on the patient
–Attributing weakness on the patient’s re-examination to a “pain response” instead of spinal cord injury
 
You be the judge
Do the expert’s statements represent the standard of care in emergency medicine regarding ankylosing spondylitis? Are his criticisms of the emergency physician’s actions justified?
Send your thoughts to This email address is being protected from spambots. You need JavaScript enabled to view it. . We’ll publish the verdict in the August print edition and online.
 

Comments   

# MD, chief of staffWWD 2007-07-24 17:23
Where does Northwestern find all those cases of ankylosing spondylitis, and where did they find Dr. Flaherty? I am truly impressed with his diagnostic acumen and await the study that must be forthcoming on the extraordinary prevalence of A.S. in his area.
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# Biased ExpertsJ.F.S 2007-08-11 23:44
Frankly, I thought where have I been! I have been practicing for many years and cannot recall that many patients with A.S. Either I do not know what it looks like or, I have missed a lot of A.S. I went back to may handy ER radiology text and I don't think I have missed that many cases.
I am waiting for the day when the so called experts will be unbiased. I suspect Dr. Flaherty's reimbursement determines his type or expertise. Did Dr. Flaherty think the consultants should have come to take care of their patient?
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