Monday, March 18, 2019

Dr. Daniel Musher’s Conclusions on Hospital Patient’s Cause of Death Help Clear Med Mal Defendant

The Trial: Harper v. Vick, a 2016 Georgia medical malpractice trial, in which a patient went into cardiac arrest hours after arriving at a hospital ER suffering from neck swelling and complaining of difficulty breathing. Plaintiff, the patient’s widow, claims doctors were negligent in failing to intubate him to keep his airway open.

The Expert: Dr. Daniel Musher, a professor of infectious disease at Baylor University’s College of Medicine, testifies for the defense.

The Verdict: For the Defense.


By Gary F. Gansar, MD, FACS; Senior Medical Director, AMFS

Dr. Daniel Musher, a Baylor University professor and expert in infectious disease, provides crucial testimony for the defense in a 2016 Georgia medical malpractice trial over treatment of a patient who went into cardiac arrest hours after arriving at a hospital ER complaining of difficulty breathing and neck swelling.

Central to the plaintiff’s case was whether the patient had been intubated in a timely fashion. However, Musher concludes the patient’s infection and sepsis, combined with his weakened immune system from previously diagnosed myelodysplasia, a blood disorder, actually caused his death, regardless of the intubation’s timing.

The professor begins by explaining why the antibiotic Clindamycin used to treat the patient. A patient with a swelling and pain under his jaw, similar to the symptoms in this case, is likely to have an infection. Although it may typically be better to use Amoxicillin, a Penicillin antibiotic, as a first-line drug for an infection like this, this patient was allergic to Penicillin, so an alternative was necessary. Clindamycin is, “a good effective drug” to use instead, Musher notes.

Musher goes on to detail the defendant’s empiric treatment of the patient. An empiric treatment implies that the treating doctor does not know the cause of the infection, but must treat that infection based upon experience with infections like this. In this case, where the patient had a critically low blood platelet count, it was necessary to treat the patient empirically, because the alternative would have required incising the swollen area to take a sample. Such an invasive procedure would have risked substantial hemorrhage due to clotting difficulties. Since experience shows that infections in this area are usually susceptible to Clindamycin, Musher concludes the defendant’s choice of this antibiotic was appropriate.

But Musher explains that the patient actually suffered from a very rare infection, Ludwig’s Angina, involving the Pseudomonas bacteria. Different bacteria reside in different areas of the body, Musher explains. Thus, the organisms of the mouth are different from those in the colon. Pseudomonas bacteria are not generally found in the mouth or neck. Infections with swelling and pain originating under the jaw have been assigned a special name, Ludwig’s Angina. But Musher says in his search of the world’s literature on the subject, he was able to find only a few very rare cases of Ludwig’s Angina involving Pseudomonas.

Musher then turns to the patient’s lab work. He notes the white blood count in infection is expected to be higher than normal and rise if the infection worsens. In this case, serial white blood counts started off very low and declined further because the patient’s previously diagnosed myelodysplasia suppressed his immune system, making it difficult for the body to generate white blood cells needed to fight off infection. Similarly, the platelet count became dangerously low due to this disease. “His hematologic disease is progressing rapidly,” Musher tells jurors.  

Musher then explains the sepsis he believed ultimately proved fatal. When bacteria enter the bloodstream, it is referred to as bacteremia. Sepsis is the body’s response to a bacterial infection. It is characterized by fever, rapid breathing rate, rapid pulse, confusion, and a rising white blood count. In an immunocompromised patient, such as one with myelodysplasia, sepsis is especially devastating. The defense mechanisms of the body are so weakened that even the proper antibiotics might not save such a patient. When this patient presented to the ER, he was already experiencing sepsis.

Musher says that the fact that a CAT scan did not confirm an abscess under the jaw was due to the patient’s inability to form enough white blood cells to make an abscess. In such cases, the bacteria are not confined, and instead spread easily throughout the body’s tissues. This is especially deadly with virulent organisms spreading in patients that cannot fight them off. Pseudomonas would not be considered so dangerous in a normal patient, but in the case of someone with a very poor immune response, such as this patient, it is highly virulent and “associated with bad disease and bad outcomes.” The professor says that, in a patient such as this, the mortality rate would, in his experience, be as high as 75%, even when given the appropriate antibiotics.

Musher’s cogent explanation behind his conclusions helped sway the jury to a defense verdict in the case.

 

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Gary Gansar, MD, is residency trained and Board Certified in General Surgery. He previously served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Mercy Hospital and Touro Infirmary in New Orleans, LA. Dr. Gansar also served as Clinical Instructor and Professor of Surgery at Tulane University. He received his MD and served as Chief Resident at Tulane University Medical School. Dr. Gansar joined AMFS as a consulting medical expert in 2011 and has served as Medical Director since Nov. 2015. In this capacity, Dr. Gansar provides consultation, review and guidance to attorney clients.