This case demonstrates how, despite evaluations by physicians in several specialties, there can still be delays in diag noses. In this case, a lawsuit was brought by a minor plaintiff and his parents for failure to diagnose left testicular torsion.
Facts of the Case
The 14-year-old plaintiff presented to the emergency room at 7:08 pm on a Friday night for evaluation of left testicular pain. The plaintiff was seen and evaluated by the emergency room physician. The chief complaint obtained during triage was testicular scrotal pain on the left side. The history taken by the emergency room physician documented that the plaintiff developed sudden intense pain in his left testicle around 6:30 pm that evening. On examination, the patient exhibited moderate distress. The external examination documented a normal male pubic hair pattern and both cords and testes within normal limits and without lesions. No further testicular examination was documented.
The emergency room doctor ordered a trans-scrotal ultrasound, which was preliminarily read by a radiologist. The interpretation was suggestive of left epididymitis. This radiologist also documented in the report that the study showed bilateral flow. The next day, an “official” reading of this ultrasound was performed by a second radiologist, who confirmed the diagnosis of left epididymitis. A urinalysis obtained in the emergency department was negative for blood, nitrates and leukocyte esterase. The plaintiff was treated for pain with Percocet and was discharged on Bactrim and Vicodin. His parents were advised to obtain follow-up care with a urologist the following morning. They were given the name of a urologist. The patient was advised to return promptly to the emergency room if his pain became worse or he developed a fever.
According to the plaintiff’s father’s deposition, the family did contact the office of the on-call urologist the next day for follow-up care. However, this urologist did not treat pediatric patients and recommended that they seek a pediatric urologist. The plaintiff’s father made an appointment with a pediatric urologist but was unable to get an appointment for six days. By the time the plaintiff was seen by the pediatric urologist, he had continuing complaints of left testicular pain. A repeat scrotal ultrasound was performed, which showed evidence of left testicular torsion. The urolo gist immediately admitted the plaintiff to the hospital and performed an exploration of the left hemiscrotum and left orchiecto my. Subsequently, the plaintiff underwent a right trans-scrotal orchiopexy, an excision of the right appendix testicle and one month later, an appendix epididymitis.
During his deposition, the emergency room physician testified that he had diag nosed epididymitis solely upon the ultra sound interpreted by the radiologist. The MLMIC emergency medicine experts who reviewed the case were concerned that the emergency room physician had failed to adequately document a testicular examination and that this lack of documentation raised questions about whether a physical examination of the patient was actually performed. However, since the plaintiff testified at his deposition that the emergency room physician did, in fact, palpate his scro tum and feel the inside of his thigh, this concern was eliminated. Interestingly, the plaintiff’s attorney never asked the emergency room physician at his deposition why he did not order a urology consultation, which might have changed the treatment and disposition of the patient. However, MLMIC’s emergency physician reviewers determined that, based on the results of the patient’s physical examination and the radiologic diagnosis, the emergency department physician had no basis to request an emergency urological consultation.
The damages claimed by the minor plaintiff included pain and suffering, physical scarring, a cosmetic deficit and a deformity at the surgical site. It was also anticipated that the minor plaintiff would later need to undergo the insertion of a testicular prosthesis.
MLMIC’s experts all concurred that the MLMIC-insured radiologist incorrectly read the initial preliminary ultrasound and made an incorrect diagnosis. The radiology experts opined that one of the images clearly showed flow which went up and down, which is an abnormal flow pattern. As a result, the lawsuit was ultimately settled on behalf of the radiologist who performed the initial preliminary reading for $250,000. Although his diagnosis was confirmed by the second radiologist, that confirmation occurred one day later, which was too late to have saved the testicle if read correctly.
Legal Analysis
This case presents several very obvious risk management issues. As often occurs, calling a specialist to the emergency department to see a patient is within the judgment/purview of the emergency department physician. This must be based on the patient’s symptoms, age and any preexisting conditions. From a risk management perspective, testicular torsion is a very serious diagnosis that must be ruled out when assessing a minor patient presenting with these particular complaints. Therefore, calling for a specialty consultation is prudent because the window in which to diagnose testicular torsion timely is relatively short. The failure to have a urologist assess the patient can lead to a delay in diagnosis, resulting in permanent injury to the patient.
Another issue that became very important in this case was the lack of adequate documentation by the emergency department physician. Fortunately, the patient testified at his deposition that the physician did, in fact, perform a physical examination. However, if the plaintiff had not so testified, the alleged failure of the emergency department physician to examine the patient might well have resulted in a finding of his liability.
One of the most serious problems in defending this case was the incorrect reading of the films by two different radiologists. The expert physician reviewers retained by MLMIC concurred that the inaccurate preliminary reading of the film by the first radiologist was a substantial cause of the plaintiff’s injuries. This radiologist had the last clear chance to prevent the patient’s injuries. If the flow had correctly been read as abnormal, there may well have been time for a urologist to perform surgery immediately. Thus, the viability of the plaintiff’s testicle could have been preserved. However, the reviewers did not believe that the second radiologist who overread the study incorrectly would be found liable since his incorrect reading the following day was not the one that actually caused the plaintiff’s injury. This gave him a valid defense to the question of causation (proximate cause). By the time the second radiologist performed his interpretation, it was unlikely that the testicle was still viable. Therefore, the second radiologist did not have to participate in the settlement of the case. However, from a risk management and best practice perspective, both readings should have been carefully reviewed by a hospital peer review commit tee and appropriate corrective actions taken if deemed necessary.
Neither the urologist on call, who declined to see the patient the following day nor the office of the pediatric urologist treated the plaintiff’s complaints as an emergency. While some responsibility for this may have been inadequate com munication by the emergency department physician and the nursing staff when discussing the discharge instructions, they should have emphasized to the family the critical nature of the need for immediate follow up by a urologist. Finally, the fami ly should have been more assertive to have their son seen more promptly because of his continued pain.
In summary, a confluence of failures by multiple individuals resulted in the minor plaintiff’s loss of a testicle and the ensuing sequelae he faced.
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This document is for general purposes only and should not be construed as medical or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, medical or professional obligations, the applicable state or federal laws or other professional questions.
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