Med Mal Case: Meningitis [Do you use betadine or chlorhex for LP?]

[bbc586]

So this is actually an anesthesia/pain management case, but has strong cross-application to EM (or anyone doing LPs).

Patient had a spinal epidural injection.
Died of meningitis about a week later.

Plaintiff attorney says its because they used betadine, not chlorhex for sterilization.

Expert witness claims the same thing in his opinion (likely paid a huge amount)

Only problem? Chlorhex says don't use near the meninges.

However, some research showing the Chlorhex is actually better at sterilizing the area.

Do you use betadine or chlorhex? ---> Expert Witness Case #23

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[Birdstrike]

Do you use betadine or chlorhex? ---> Expert Witness Case #23

Chlorhexidine, because it works slightly better for sterilization and because it is clear and cleans up easily.

 

[gamerEMdoc]

Once again, I can't believe some of these things go to trial. Sad, but laughable. Is there really a "standard of care" of what to use? Hell, betadine is in most LP kits, if anything I'd argue that would make it the standard of care. To get sued for something like this is just yet another sad example of how lawsuits have literally nothing to do with the standard of care.

 

[RustedFox]

Once again, I can't believe some of these things go to trial. Sad, but laughable. Is there really a "standard of care" of what to use? Hell, betadine is in most LP kits, if anything I'd argue that would make it the standard of care. To get sued for something like this is just yet another sad example of how lawsuits have literally nothing to do with the standard of care.

So much this.
IT'S IN THE DAMN KIT.

 

[Pudortu]

It says not to use chlorhexadine for LP/Meninges contact on the package.
Damned if you do.
Damned if you don't.

 

[WilcoWorld]

"The lawsuit was withdrawn 4 months after it was filed; a confidential settlement was reached."

No wrongdoing or anything close to negligence going on here. I imagine the complication of infection was even on the consent form that the patient signed. If the goal is to fight for what's right, you fight this case to the end. But unfortunately that's not what the malpractice insurers are interested in - they want to avoid a big payout, and permanent disability cases are the biggest payouts. That's probably why they settled this one.

 

[Birdstrike]

Once again, I can't believe some of these things go to trial. Sad, but laughable. Is there really a "standard of care" of what to use? Hell, betadine is in most LP kits, if anything I'd argue that would make it the standard of care. To get sued for something like this is just yet another sad example of how lawsuits have literally nothing to do with the standard of care.

Agree.

I've never had an infection with any LP or epidural in 20 years, chlorhexidine or betadine. But be sure, if you have someone die from meningitis a few days after sticking a needle in their previously healthy spinal canal, you're going to buy yourself some depositions, whether you did everything right or not.

To a lawyer. Bad outcome = payday.

Whether a mistake was made or not, is irrelevant to them. They know how persuasive it is to tell a jury of non-medical people, "Something must have been done wrong, after all the patient died!" It's persuasive, even if false.

 

[GeneralVeers]

This is just an example of a no-win, nuisance lawsuit. I don't see these going away.....ever as the lawyers are the ones who make the rules.

 

[Tipsy McStagger]

I use chlorhexidine. Not sure that there was negligence here though.

 

[DeadCactus]

Med-mal law is about lawyers fighting over corporate money when bad luck hurts a patient. We need to stop pretending it is about medical care or standard of care or even quality of documentation. Provide care you're happy with, be polite to patients and family members, don't take on stupid risks protecting "healthcare resources" for a system that doesn't empower you to do so, document reasonably, and move on.

 

[DrDrummer]

Someone recently scoffed at the notion that one reason that I won't do LPs on non-emergent indications is the real risk of devastating complications, even if you do things right. Rare? Absolutely. But possible? Very much so.

 

[GeneralVeers]

Someone recently scoffed at the notion that one reason that I won't do LPs on non-emergent indications is the real risk of devastating complications, even if you do things right. Rare? Absolutely. But possible? Very much so.

Agree completely. Only real reason I do it now is for meningitis concern. Everything else is low yield (SAH) or non-emergency.

 

[CliveStaples]

Does anybody have a case of a CT negative SAH that was LP positive which ended up altering management? I'm not sure this pathology actually exists.

 

[gamerEMdoc]

Does anybody have a case of a CT negative SAH that was LP positive which ended up altering management? I'm not sure this pathology actually exists.

Saw it once in residency actually. Person came in classic story, CT was negative. Got the LP. Decompensated in the ED, repeat CT was positive for a large SAH. LP fluid came back later and was bloody. Didn't change management because they decompensated in the ED, but that's the only time I've seen a case where a patient had a SAH with initially a neg CT go on to then decompensate like that and have a positive LP or repeat CT shortly after.

My understanding of the data is in high risk cases, the chance of a missed SAH with a CT within a few hours is like 1/300.

 

[CliveStaples]

Saw it once in residency actually. Person came in classic story, CT was negative. Got the LP. Decompensated in the ED, repeat CT was positive for a large SAH. LP fluid came back later and was bloody. Didn't change management because they decompensated in the ED, but that's the only time I've seen a case where a patient had a SAH with initially a neg CT go on to then decompensate like that and have a positive LP or repeat CT shortly after.

My understanding of the data is in high risk cases, the chance of a missed SAH with a CT within a few hours is like 1/300.

Funny enough, this sounds like a case where having the CT done within 6 hours of symptom onset would not have necessarily been fool-proof.

 

[Rekt]

Interesting. I've seen many LP kits and all of them had betadine. I was always taught that Chlorahexadine can cause theoretical meningeal irritation if you don't wait for it to dry all the way unlike betadine.

 

[gamerEMdoc]

Funny enough, this sounds like a case where having the CT done within 6 hours of symptom onset would not have necessarily been fool-proof.

There is nothing in medicine that is foolproof, unfortunately. Even the best tests don't reach 100% sensitivity if studied in a big enough patient population.

 

[pkwraith]

This looks like a case where the physician likely did everything right, if this was the only nitpicky thing that the plantiff's lawyer could unearth. It's a case study of being better lucky than good, because if a timebomb zebra patient comes in, you're going to be ****ed if someone decides to sue you because they'll always be able to find some nonsense if they look hard enough.

 

[thegenius]

So this is actually an anesthesia/pain management case, but has strong cross-application to EM (or anyone doing LPs).

Patient had a spinal epidural injection.
Died of meningitis about a week later.

Plaintiff attorney says its because they used betadine, not chlorhex for sterilization.

Expert witness claims the same thing in his opinion (likely paid a huge amount)

Only problem? Chlorhex says don't use near the meninges.

However, some research showing the Chlorhex is actually better at sterilizing the area.

Do you use betadine or chlorhex? ---> Expert Witness Case #23

chlorhexadine can cause chemical meningitis

 

[thegenius]

Agree.

I've never had an infection with any LP or epidural in 20 years, chlorhexidine or betadine. But be sure, if you have someone die from meningitis a few days after sticking a needle in their previously healthy spinal canal, you're going to buy yourself some depositions, whether you did everything right or not.

Probably 'cuse he had meningitis to begin with. It is more likely he had meningitis to begin with than the LP causing meningitis. Or pt was the ONE person out of 650,420 which is probably what the odds are of getting meningitis from an LP.

 

[deleted682700]

May not be related to anesthesia. Temporal association does not mean root proximate cause. Lawyers and legal systems in America is not about truth but easy money. Does this patient have defective immune system? Any IVDA. Diabetes and is on immunosuppressant? Conveniently all this info has been deliberately omitted.
A few years back ,a bunch of patients developEd fungal meningitis after epidural steroid injection. The culprit was tr@ced back to make shift pharmaceuticals company that was not following stringent requirements for bottling the Med. It’s very important defense to note the lot no/ expiry info of the Med being injected in the chart-to help Your defense.

 

[epidural man]

So this is actually an anesthesia/pain management case, but has strong cross-application to EM (or anyone doing LPs).

Patient had a spinal epidural injection.
Died of meningitis about a week later.

Plaintiff attorney says its because they used betadine, not chlorhex for sterilization.

Expert witness claims the same thing in his opinion (likely paid a huge amount)

Only problem? Chlorhex says don't use near the meninges.

However, some research showing the Chlorhex is actually better at sterilizing the area.

Do you use betadine or chlorhex? ---> Expert Witness Case #23

I feel bad for the defendant (and the plaintiff).

BUT, I'm glad for this case because I can now use it in my favor.

Here is how.

I often hear physicians (shockingly...) indicate that somehow using a drug off-label sets you up for liability (which is completely not true but for some reason, this can be a VERY hard concept for some to grasp).

Now, I have a case, where the lawyers sued someone for NOT using a product off-label because the lawyers argued it was the right thing to do medically based on the drug, not on FDA labeling.

I suspect you ER folks are not as trapped by this concept - but somehow, many of my anesthesia colleagues are.

 

[Birdstrike]

Probably 'cuse he had meningitis to begin with.

That's very possible. The question: Can you convince a jury of your patients, of that?

 

[epidural man]

Given the case was settled though without a verdict does it really provide any legal backing to future cases?

Good question but the lawyers used it as an argument. That may set precedence.

 

[Rendar5]

The odds of a patient having asymptomatic meningitis that gets fulminant after a spinal injection is waaaaaaay lower than the odds of getting an infection from an lp or spinal injection.
Infection is a known complication of spinal access and the patient should be aware of this when obtaining consent.

 

[AlmostAnMD]

The odds of a patient having asymptomatic meningitis that gets fulminant after a spinal injection is waaaaaaay lower than the odds of getting an infection from an lp or spinal injection.
Infection is a known complication of spinal access and the patient should be aware of this when obtaining consent.

that's the problem with consent. I'm sure the patient signed a consent form and family sued anyway. What's the point in consenting?

 

[Birdstrike]

that's the problem with consent. I'm sure the patient signed a consent form and family sued anyway. What's the point in consenting?

To keep from getting sued for not getting consent.

See how they play the game?

 

[deleted682700]

Lawsuits are time consuming , mentally exhausting and lots of doctors that have been sued are excellent clinicians and have a lot of knowledge. Doctors are made to think that it is their fault. But it is most like systemic failure and complexity of the illness With Pre existing comorbid Compromise of physiological reserve. Just like any insurance for car driving, you do the best to avoid accidents/ mishaps.

I work as locums and the first question they ask me if I have any cases. I tell them do you pay me more if I don’t have. Once you know how the game is played, we have to take control of this nuisance. The difference in pay between doctors who get sued and those who have not is negligible.

it’s important to have a copy of malpractice insurance info with you. Also run a claims history and keep it in your file handy. We can ask the agents to quote our malpractice rate, varies state by state and pay for it ourselves and negotiate a better rate if that were to be a concern. please remember doctors do all the work and insurance companies make record profits. Now vulture venture capitalists from Wall Street who get free PPP Covid money are buying all the practices and enslaving us even more. They need doctors to work. You have to boldly determine not to be taken advantage of.