MedMal Confidential # 04 - Your Penicillin Allergy is Nonsense

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Hey 👋- David here!

Happy Monday, May 15th to you and the other 6K+ Insiders reading this.

Here’s what we’ll be uncovering in this edition of MedMal Confidential …

Today’s ‘Insider Information’ At-A-Glance

Read Time: 2.8 minutes

 🧠Musings: The dangerous lie of penicillin allergy

⚖Litigation: My paralyzed cousin, Winnie

 📰News: An awake colonoscopy nightmare

Read on for your insider info …

🧠Musings: The dangerous lie of penicillin allergy

10% of the U.S. Population reports being allergic to Penicillin.

But the data doesn’t back this up.

Many patients believe that being allergic to penicillin means access to a better choice of antibiotics…

But this is far from the truth.

Being labeled penicillin allergic has multiple downsides:

1. Use of more expensive and less effective antibiotics

2. Longer length of hospital stay

3. Increased risk of infection

4. Higher rate of surgical-site infections

One study by Goldberg, A in 2008, found that only 1.5% to 6.1% of patients who self-reported an allergy to Penicillin were actually allergic.

So what is used during surgery?

2 grams of cefazolin (Ancef) is the most common antibiotic administered intraoperatively.

And for good reason. It has low cross-reactivity with penicillin (1-8%) and significantly reduces the risk of surgical site infection.

Why does this matter?

Because surgical site infections are an expensive peri-operative complication.

And, they play a large role in medical malpractice litigation.

The Insider Info

• Most reported Penicillin allergies are false.

• In the absence of high-risk symptom histories, penicillin or beta-lactam cephalosporins should be administered.

• Surgical site infections play a large role in medical malpractice litigation.

• When focusing on antibiotic coverage, consider the following:

  1. The choice of antibiotic

  2. The dose of antibiotic

  3. The timing of antibiotic

  4. The route of administration

The surgical team relies on the anesthesia team to deliver the correct antibiotic, at the right dose, via the correct route, at the right time.

This isn’t always done properly.

And unfortunately, the blame for these errors is typically pinned on the surgeon.

⚖Litigation: My paralyzed cousin, Winnie

As an anesthesiologist with obstetrical subspecialty training, I hear this sort of thing a lot:

“My cousin Winnie got an epidural, and now she’s paralyzed.”

But, is she really?

Let’s start with some epidural facts:

1. There were 3,644,292 births in the United States in 2022

2. 33% were via Cesarean delivery (~1.2 million)

3. 67% were via vaginal delivery (~2.4 million)

4. Neuraxial anesthesia was used in 63% of vaginal deliveries (~1.5 million)

There are NOT 1.5 million paralyzed mothers in the US as of 2022.

There aren’t even a dozen.

The incidence of paralysis after an epidural is so infrequent it only comes up in case reports at niche conferences.

Typically, in anecdotal claims like those of cousin Winnie, there’s an alternative explanation…

The majority of nerve injuries related to childbirth can be attributed to the labor and delivery itself

These are known as “intrinsic obstetric palsies,” and they occur in 0.006-0.0092% of births (very low).

Not only are cases like dear cousin Winnie’s extremely rare, they’re also rarely permanent

For the vast majority of patients, symptoms of intrinsic obstetric palsies improve or resolve completely within 6-8 weeks.

The Insider Info

• Most peri-birth nerve palsies are due to the baby descending through the pelvic floor and maternal leg positioning - not the epidural.

• Anesthesia frequently gets the blame for peri-birth nerve palsies, but a good history and physical exam can rule out anesthesia pathology.

• Anesthesia complications such as infection and epidural hematomas are incredibly rare.

  • Prompt recognition, diagnosis, and treatment can prevent permanent injury or death

The main culprit in maternal nerve palsies is more likely to be the nurse, partner, or family member who pulls back on the patient’s leg excessively during vaginal birth.

📰News: An awake colonoscopy nightmare

It’s February 2023

The headline reads …

“San Antonio man says hospital forgot to sedate him during procedure, and he has a drug screening to prove it.”

The stated facts:

1. A patient was scheduled for an outpatient colonoscopy.

2. During the procedure, the patient claims to have never felt “loopy” or “had any time loss.”

3. Patient was “alert for the entire procedure and suffered a great deal of abdominal discomfort.”

4. Medical documents state that the patient received fentanyl and midazolam, intended for conscious sedation (see last issue for reference).

5. Patient took a home drug test and went to an official laboratory for testing within six hours

   • Both tests came back negative for fentanyl (opioid) and midazolam (benzodiazepine)

6. An attorney hired by the patient sent a demand letter stating he had received negligent treatment and endured “intense, overwhelming, and unnecessary” pain and suffering

Was this a mistake?

Was this neglect?

Was this something more nefarious?

The Insider Info

• It is not uncommon for proceduralists or surgeons to make patients promises that anesthesia can’t keep…

  “You won’t feel anything”

  “This won’t hurt a bit”

  “You’ll be all the way out”

• Fentanyl + midazolam is the cocktail typically used for conscious sedation.

  The expectation is that the patient will exhibit a purposeful response to verbal or tactile stimuli (i.e. is not fully asleep).

• For the sake of efficiency, surgical, and even patient preference, anesthetics intended for moderate sedation are commonly titrated up.

  • This could be up to the deep sedation and even general anesthesia range.

• The is a major difference between having a purposeful response under moderate sedation and being wide awake.

• In this particular case, the problem should have been addressed intra-procedure.

  • If the patient was wide awake, additional medication should have been titrated until desired sedation was reached.

A negative drug test on a patient who recently was documented to have received opioids and benzodiazepines should trigger concerns for diversion of controlled substances

Next time in MedMal Confidential …

• Could this be the answer to anesthesia awareness?

• The bill barring misleading medical titles

• Envision Healthcare braces for bankruptcy