Knowledge of ankylosing spondylitis and its sequelae
The vast majority of the physicians responding to this scenario felt that the expert overstated his experience with ankylosing spondylitis, who claimed to have seen approximately two cases per month during his career. If we assume that the average incidence of ankylosing spondylitis is 1 in 750 and that the expert worked 2000 clinical hours per year, he would have to see 1500 patients every month or 9 patients every hour of his career in order to meet his threshold.
Several physicians were unable to substantiate the expert’s assertions about the literature and statistics available on ankylosing spondylitis, some noting that the topic only received cursory review in emergency medicine textbooks. No one was able to find any literature comparing spinal fractures to myocardial infarctions, alluding to spinal fractures in ankylosing spondylitis patients as a “true emergency,” or even describing the incidence of spinal cord compression in ankylosing spondylitis patients with lumbar spine fractures. While internal medicine and rheumatology textbooks do have more information on ankylosing spondylitis, emergency physicians are held to the standard of a reasonable emergency physician—not to that of an internist or a rheumatologist. Requiring an emergency physician to possess advanced knowledge in every specialty would require that we become experts in every specialty—a standard which is clearly unreasonable.
With or without ankylosing spondylitis, certain diagnostic procedures and therapeutic precautions need to be considered in any patient with a spinal fracture. Assessing a patient for signs of spinal cord injury is important. The physician properly ordered a CT scan which showed several spinal fractures and no signs of cord injury. The patient’s neurologic status was intact both in the emergency department and after being transferred to the medical floor.
I fail to recall learning about ankylosing spondylitis in medical school at all, let alone being “one of the first diseases” that I studied. Nor do I recall hearing anything about this illness during residency either at a bedside or during a lecture.
My edition of Tintanelli does make a passing reference to transverse fractures being common in ankylosing spondylitis and subject to cord compression but doesn’t quantify this risk.
In short, Dr. Flaherty’s testimony strikes me as inflated at best and certainly does not represent the knowledge of an average practitioner of Emergency Medicine.
The EP identified his patient as having spinal fractures and transferred him to the care of a spine specialist. Assuming that the EP accurately described the patient’s injuries to the specialist, he should not be held liable for the judgment of that specialist as to when to see the patient.
More importantly, it is not at all clear how the EP’s alleged failures in any way contributed to the patient’s injuries. How could the EP’s alleged failure to do a rectal exam or admit the patient to an ICU in any way have caused this patient’s spinal cord compression? All the more so when the patient sustained his injuries 5 days prior to presenting to the hospital and arrived neurologically intact.
—Mitchell Heller, MD
With regard to the "expert" testimony, Dr John Flaherty's opinions seem to be another case of a $1000-per-hour hired gun, paid to exaggerate and distort medical literature for the plaintiff's case. While true that patients with ankylosing spondylitis are at increased risk of fractures with even minor trauma, he goes too far in the quotes of "almost always unstable" and "extreme risk." It is just plain laughable that he compared it to an MI and stated they are "one of the few true emergencies we have". I studied for the EM oral boards three years ago and don't ever remember coming across a practice or test case involving AS. Is the Board missing out on a "true ED emergency"? I think not. The fact is, this is a rare disease, not a "bread and butter" emergency medicine case. Dr John Flaherty, from Northwestern Medical School, should be ashamed of himself.
With regard to standard of care, this patient had an unstable fracture at L1 given the posterior body and posterior elements were affected. Also, sounds as though there was distraction of fracture fragments posteriorly into the spinal canal. Spinal precautions should have been ordered by the ED doc and enforced by the floor. Additionally, the orthopedist and internist both should have seen this patient much sooner than 24 hours out. However, the ED doctor did his job to find the cause of this patients back pain, then consulted and admitted the patient to the appropriate physicians. Was the patient in alcohol withdrawal while in the ED? This would make a thorough neurologic exam difficult if not impossible.
What this case really illustrates is the difficulty in evaluating and caring for an alcoholic patient who fell and fractured his back FIVE DAYS prior. He probably only came into the ED after he drank all of the liquor in his home and then was unable to go out for more. While we as emergency physicians may only see a case of Ankylosing Spondylitis once every few years, or less, we see this behavior every day.
—Aaron J Carter, MD
Barton Memorial Hospital
South Lake Tahoe, CA
—Andrew Jenis, MD
The standard of care was met by the emergency physician. The fractures were recognized and the patient was admitted. The specialist in bone diseases (orthopedist) should be responsible for more in depth work up. I'm sure the EP was seeing many more patients at the time and can't research every case he sees in real time.
Not sure why ED doc is always the scapegoat. The ED doc made a correct call to admit. Then it's the duty of the admitting physicians to reassess and render appropriate treatments accordingly. If the patient is worse, then treat the patient. However, once the patient is out of ED and onto the floor, then the on-duty physician should get to work. Not sure since when we as ED doctors have to hold every admitting doctor's hand and make sure he is doing his job. As if the chef has to get out of the kitchen to make sure the waiter is serving the customers politely. Unbelieveable!
—J. Ting, DO, CFII-MEI
AOBEM certified ED doc
There were some mistakes made, but I feel that the most serious ones were made by the admitting specialists. If they had attended to the patient in a timely fashion, they would have recognized the issues and been able to deal with them. I would fault the ED physician for no spinal precautions. If the pt had arrived on the floor in full spinal precautions, he likely would have been seen sooner by the admitting MD. Also, in emergency medicine, unfortunately, "if you don't put your finger in, you are putting your foot in" is true—so yes, a rectal exam might have changed the index of suspicion. In the end, however, we emergency physicians rely on our back-up specialists once the patient has been presented and admitted. The spine specialist could have insisted on spine precautions on his admitting orders, and, most importantly, seen the patient in a timely fashion. Where does our responsibility stop when we have turned over care to a "specialist"?
—Joanna Weinberg, MD
I have never learned any of the information that the expert witness states is taught in every medical school. I never knew that a fracture in a patient with a history of ankylosing spondylitis could have such consequences. So I disregard his remarks about that.
However, I do have concerns about disregarding a neurological sign, and no rectal exam, especially in light of the fracture with retropulsed fragments. But we don't know that there would have been any difference even with the rectal exam. And isn't it the responsibility of the admitting physican and consulting physician to do their job? Docs in the E/R can't be watchdogs for everyone. So, in the end, did this doctor meet the standard of care? I would say yes.
—Robert Brock Allen, MD
The ED doc did everything right and nothing wrong...I have seen a few pts with the Dx. of AS (they presented with this diagnosis) and I have never seen any of them go on to become quads. It is a chronic disease and one that is managed appropriately, most often, as an outpatient. This case is outrageous, as is the expert testimony.
Basically, the "expert witness" is full of crap. If you look at the national incidence of ankylosing spondylitis (about 1:775 people in the U.S. according to Mayo), he would have had to treat (conservatively) approximately 387,500 patients in his 21 year career, or remarkably, 18,425 patients a year all by himself. Boy, I wish he worked for me if he is THAT good. Secondly, I don't think ANY emergency physician would be recognized as an "expert" on ankylosing spondylitis. Basically, the care of the emergency physician was what would be considered the norm. The care of physicians that did not see the patient for 24 hours was not.
—Tom Richardson, MD, F.A.C.E.P.
Most ICU's would have no idea what to do for a spinal cord patient, and most orthopods wouldn't have ICU privileges. If he called Medicine to admit the patient to the ICU, he would be told that it isn't a medicine case (until he developed DT's). It isn't clear in the case study who the primary physician was.
The rectal exam may have been abnormal, which may have prompted the orthopod to either come in sooner, or ask for a transfer, but if the orthopod doesn't believe that this condition represents "one of the few emergencies that we have," which he apparently didn't, a rectal wouldn't have made much difference.
The increasing weakness is questionable—the ED physician says his neuro status was intact and his neuro exam on the floor was normal. When was there increasing weakness?
As far as the expert diagnosing 150 to 200 cases of ankylosing spondylitis, this seems to me to be analogous to making the diagnosis of diabetes on everyone with a fasting sugar of 112!—the Ivory Tower Diabetologists would probably agree, but who cares! With elderly patients (and the age of this patient is not mentioned) it would seem a more significant finding if signs of ankylosing spondylitis were NOT present on x-ray studies.
Overall, it seems to me that the ED physician did his job and did it well—he met the standard of care up to the point he wrote the admission orders. Spinal precautions were not ordered. However, if this was an orthopedic unit and spine specialists were part of the program, the nursing staff should know to follow spinal precautions whether the order was written or not. I'll bet he didn't write "Universal precautions" either. Does that make it his fault when the patient develops MRSA or the nurse gets hepatitis?
A guy gets drunk and falls; somebody has to pay. The bartender doesn't have a deep pocket, so he's off the hook for serving the drinks. The internist and orthopod contend that the ED physician didn't paint a clear enough picture or they would have done what they should have done in the first place and seen the patient before he left the ED. The poor ED guy does his job, does it well and still takes the fall. It just isn't right!
—Karl E Harnish, DO
Board Certified Emergency Physician
The neurologic deterioration occurred between 24-48 hours after the patient was seen by the EM physician and after he was transferred to a telemtery bed. Even if the EM physician wrote the initial admitting orders (and the patient arrived there stable), someone responsible for inpatient care had to give orders for that inpatient transfer. Only the internist and orthopedist can answer why they didn't see this patient.
With all due respect to Dr. Flaherty, emergency physicians don't see on average 20 patients a year with ankyosing spondylitis. Is Dr. Flaherty boarded and practicing EM, or is he in yet another specialty trying to dictate my standard of care? I hadn't heard of his claims regarding injury instability associated with AS. I'm wondering which textbooks/medical literature he is looking at. I had to do a literature/abstract search on the particular topic, since the most recent edition of Tintinalli I have gives a whopping one paragraph in discussing AS, and that's a textbook that isn't "slimming down" with each new edition. The majority of abstracts I saw on PubMed were case reports/series that talked about the association of AS with cervical fractures, not the injuries described above. If it were comparable to MI, I would have expected to learn about it more in residency and recall questions from my initial and recertifying boards on this topic. Guess I got those ones wrong.
—Jim Mensching, DO, FACEP
—Michael F. McCormack, MD
—Dwayne Bernard, MD
I think the standard of care was appropriate and met. As for performing the rectal exam...if the patient did not have any GU complaints and the neurologic exam is completely normal, a rectal exam is not necessary.
—Tony Kanluen, MD