(Please note: the names and locations of all parties have been changed to protect the confidentiality of the proceedings.)
Finally, at 1604 hours (4:04 p.m.) Dr. T., M.D., happened to drop by Mr. Smith’s room. Mr. Smith’s sister was present in the room. She told the doctor that William was losing feeling in hands. Dr. T. seemed shocked. He quickly did a neurological assessment confirming Mr. Smith’s paralysis.
Dr. T. called for a STAT MRI of Mr. Smith’s cervical and thoracic spine to rule out “epidural abscess.” He called neurosurgery for a consult.
Something was finally begun, but it would prove to be too late to prevent a catastrophic paralysis.
An urgent neurosurgical consult was performed by Dr. S., M.D. He recorded: “the neurological exam reveals that the patient has complete paralysis below the biceps level.” It was also discovered that Mr. Smith’s infection was MRSA.
Dr. S. noted:
“IMPRESSION: This is a patient who is septic with MRSA and has an hitherto undetermined period of paralysis that is, on exam, complete at the C6-7 level. The MRI findings are suspicious for disc space infection at C6-7 which would be seeding of this disc space hematogenously via the sepsis.
PLAN AND DISCUSSION
Since the patient’s neurological deficit is complete, his likelihood of making any sensible or functional recovery with any procedure at this point is low. However, without any procedure, the patient is for certain likely to remain in a state of complete paralysis. Since the duration of the completeness of the deficit is difficult to determine, and the possibility that the completeness may be recent exists, it is reasonable to propose a relatively ‘small’ procedure in an attempt to drain the infection. With this in mind, I reviewed the patient’s MRI scan with the patient’s family and recommended an anterior cervical discectomy at C5-6 and C6-7 without fusion. I would include 5-6 in the procedure since there is some spondylotic bar compressing the spinal canal in this region. I emphasized to the family that the likelihood of a substantial recovery with such a procedure would be low; however, this should be considered a last ditch heroic effort employing an operative procedure that is relatively short in duration and does not involve extensive dissection.”
E. General Hospital:
On March 27, 2002, Mr. Smith was transferred to General Hospital. He remained there until April 15, 2002, when he was transferred back to ABC Hospital.
The dictated Discharge Summary from General Hospital states in part:
“HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old gentleman with a history of squamos cell carcinoma status post lumbar laminectomy and staphylococcal infection four years prior to admission, who presented to an outside hospital on 3/23 with three months of low back pain, which was unresponsive to steroid injection. The patient acutely developed cervical paresis two days into the admission and was found on MRI to have cervical and lumbar abscesses. On 3/25/02 the patient was urgently decompressed at the C5-7 area. MRSA grew out of the cultures from that particular abscess.”
“6. Neurological status: Again as in problem #1, the patient had a cervical osteomylelitis and epidural abscess affecting his cord at C5-7. Unfortunately, the patient has recovered extremely little function of his lower extremities. It is the opinion of the Neurosurgical Service at this time that the patient will be unlikely to recover further function in his legs.” (See Part 9 of 23..)
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