Case 32 Fever and cough after an ankle fusion

Ethel was 68. At the age of 23 she was knocked off her bicycle by a car and fractured her left ankle. Over recent years her ankle had become increasingly painful. An X-ray confirmed secondary osteoarthritis of the left ankle and an orthopaedic surgeon performed an ankle fusion. Although Ethel had a slight pyrexia she was discharged from hospital four days later in a below knee cast with crutches.

The following day Ethel’s husband requested a home visit because he was worried about his wife. She felt feverish and had developed a cough. Dr Macdonald visited at 3 pm. He noted that Ethel had had ankle surgery five days earlier and now had a cough. On examination her temperature was 37.1 °C, although her husband said it had been 38.5 °C earlier in the day. On chest auscultation Dr Macdonald found crackles at the left base. The below-knee plaster did not appear to be too tight and Ethel was able to move her toes. Dr Macdonald prescribed amoxicillin 250 mg tds for a presumed chest infection.

Would you have done anything differently?

Later that evening Ethel’s husband went to check on her. She was confused and disorientated. He rang NHS direct who advised him to dial ‘999’. When the ambulance arrived at 10 pm Ethel had a temperature of 39.5 °C. Her pulse was 140/min, BP 85/50 and an oxygen saturation of 86%. She was taken to hospital.

The admitting doctor recorded a 2-day history of fever and breathlessness and a cough that day. There was no headache or photophobia. Findings on examination were temperature 40, pulse rate 160, BP 100/60, respiratory rate 30/min, generalized erythema but peripheral cyanosis and scattered crackles in the chest. A diagnosis of suspected septicaemia was made and Ethel was admitted to the ICU. She developed renal failure and despite intensive treatment she died. A post-mortem showed changes in keeping with septic shock. A toxin producing Staphlococcus aureus was isolated from the lungs and left ankle.

It was alleged that Dr Macdonald’s assessment was inadequate and that had he adequately assessed Ethel he would have admitted her to hospital.

Do you think the claim will succeed?

Expert comment

Early discharge of patients post-operatively is occurring more frequently and general practitioners need to be able to assess problems that arise. Mild degrees of fever are usually caused by infection but can also be caused by venous thrombosis. Many minor post operative infections can be treated in the community with oral antibiotics and do not require readmission. Thus, most competent general practitioners would routinely treat patients at home with superficial wound infections, minor degrees of cellulitis, bronchitis, pneumonia (if the patient is low risk) or a urinary tract infection.

Indications for admission would usually be:

• a clinical suspicion of septicaemia;
  
• pneumonia with ‘high-risk’ features as defined in the British Thoracic Society Guidelines (respiratory rate over 30, low blood pressure, confusion, co-morbidity);
  
• a clinical suspicion of DVT;
  
• a wound abscess that is likely to need surgical drainage;
  
• clinical suspicion of an occult abscess;
  
• a pyrexia in which the cause is uncertain.

Septicaemia would be suspected if a patient has any of the following features:

• a high fever (often taken as being over 38.5 C°);
  
• systemic symptoms of rigors or sweats;
  
• confusion;
  
• a petechial rash;
  
• features of septic shock: low blood pressure (systolic < 100 mmHg), fast heart rate (over 100 at rest), low urine output, mottled skin colour, cold peripheries;
  
• headache in a febrile patient with any of the above features would lead a general practitioner to consider the possibility of meningitis with septicaemia.

Therefore when assessing the recent onset of fever in a post-operative patient a general practitioner should enquire about the following:

• symptoms that may give an indication of a focus of infection – symptoms of pneumonia or bronchitis, symptoms of a urinary tract infection, wound pain or headache;
  
• symptoms that may suggest septicaemia: rigors, sweats, confusion, headaches, nausea, vomiting or diarrhoea.

In 2006 Thompson et al. (Thompson et al., 2006) described more subtle and earlier clinical features of meningococcal septicaemia in children and young adults. They identified three features in particular: cold hands and feet; leg pain; and abnormal skin colour (pallor or mottling).

The temperature pulse and blood pressure should always be measured to differentiate minor infection from septicaemia. The general practitioner should also examine the wound for signs of infection, listen to the chest, recording the respiratory rate if a chest infection is suspected, and dipstick the urine if there are symptoms of a urinary tract infection or the cause of the pyrexia is unclear. Capillary refill time should be assessed, although the evidence for its usefulness is relatively poor (Lewin & Maconochie, 2008). It is also important in the post-operative patient to check the legs for signs of a DVT.

In this case Dr MacDonald’s entry in the notes was rather brief. He does not appear to have ascertained if the cough was productive or associated with breathless or chest pain. There is no record to suggest that he enquired about other possible causes of a post-operative pyrexia. Although he recorded the temperature he failed to record Ethel’s pulse rate and blood pressure. He did look at Ethel’s left leg but gives no indication that he considered the possibility of a DVT.

If the patients pulse and blood pressure had been normal, Dr MacDonald’s presumptive diagnosis of a chest infection would be reasonable. Ethel had had a raised temperature earlier in the day and had a cough and chest signs (Lewin & Maconochie, 2008). However the dose of antibiotic he prescribed was inadequate. The Health Protection Agency recommend amoxicillin 500–1000 mg tds for an adult with a community acquired pneumonia.

If Ethel had had a tachycardia (PR >100 at rest) or hypotension (systolic blood pressure <100–110) then Dr Donald should have suspected more serious sepsis and admitted her.

It may be that Ethel was not particularly unwell when she was seen and that her condition deteriorated rapidly over the course of the evening. In this circumstance the diagnosis of septicaemia would have been understandably missed.

The difficulty with the case for Dr Donald’s defence is that, because the pulse and blood pressure have not been recorded, it remains uncertain whether Ethel had clinical features of septicaemia at the time of his assessment. Dr Donald’s poor note-keeping may be taken by the Court to indicate poor practice. In addition Dr MacDonald did not record providing any safety netting advice.

Legal comment

We do not know whether Ethel looked particularly unwell. But this could simply reflect the poor standard of Dr Donald’s note-keeping. It will be difficult for him to prove just how well she was. This in itself will make it difficult to defend the standard of care provided to Ethel. But it may be that on her husband’s own evidence Ethel’s condition would not have warranted immediate admission. The question would then be whether Dr Donald’s safety-netting was good enough.

At the very most, Ethel would have been admitted to hospital six or seven hours earlier than she was. An expert in infectious diseases will be asked to give his opinion on whether earlier admission would have saved her life.

The case may be worth £50 000, depending on Ethel’s role in the marriage. The case is not straightforward. The parties will probably negotiate a settlement at a discount on the full valuation.

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