Question: Does this expert testimony reflect the standard of care in emergency medicine: “Ordering blood cultures necessitates hospital admission and antibiotic administration”?
Explore This IssueACEP Now: Vol 36 – No 05 – May 2017
The patient’s emergency department records were not provided for this review, so the patient’s symptoms, physical examination, lab testing, and emergency department treatment were obtained solely from the expert witness deposition transcript.
The patient was a 53-year-old male with a past medical history including hepatitis C and chronic anemia who presented to the emergency department with weakness, fever, vomiting, loose dark stools, and a rash. There were also notations that the patient had experienced “flu-like symptoms” for almost a month. The patient had been prescribed a course of ciprofloxacin for a urinary tract infection but discontinued it approximately one to two weeks prior to his emergency department visit due to the appearance of a rash. During his evaluation in the emergency department, he was persistently tachycardic with a heart rate of 120. He was given IV fluids, and multiple tests were performed, including blood cultures. Lab results showed that the patient was hyponatremic, had a stable hematocrit of 30, and had a positive nasal swab for influenza. His white blood cell count was normal without a left shift, and his lactate level, urinalysis, and chest X-ray were also normal. The following day, preliminary results of the blood cultures were positive for gram-positive cocci. That day, a message was left on the patient’s voicemail, instructing him to return to the hospital. He did not return until three days later. He died shortly thereafter from septic shock, disseminated intravascular coagulation, and multisystem organ failure.
The expert witness faulted the treating emergency physician for several issues. This review addresses the expert’s repeated assertions that because blood cultures were performed, the patient should have been admitted to the hospital and treated with intravenous antibiotics due to a suspicion of bacteremia.
Excerpts from the expert’s deposition testimony include the following:
“One would not order blood cultures and discharge a patient home with a suspicion for bacteremia,” although at the same time noting that bacteremia “sometimes resolves spontaneously.”
“If blood cultures are ordered, that means that bacteremia in the bloodstream is suspected. There is no test to prove that it exists immediately. So unless there is a reason to suspect that someone could have occult bacteremia, like the conditions I mentioned, the treatment is admission and intravenous antibiotics. Otherwise, this happens [referring to the patient’s death from sepsis]. You don’t send otherwise relatively immunocompetent patients home with bacteremia. You treat them.”