Ankylosing Spondylitis: Reader Verdict

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continued from issue of June 07
Did the expert witness acurately represent what a reasonable emergency physician should know about ankylosing spondylitis? Was the emergency physician’s management of the patient appropriate? Your verdict plus a final analysis.  

The Reader Verdict:
Standard of Care Was Met         22 votes
Standard of Care Was Not Met     2 votes
Ankylosing spondylitis is a relatively uncommon arthropathy involving the spine and sacroiliac joints. The estimated incidence in the United States ranges from 0.1 to 0.2 percent. Symptoms usually begin with sacroiliitis and nonspecific lower back pain. Other organ systems become involved and the disease eventually progresses to cause ossification of the annular ligaments in the spine, resulting in a “bamboo spine.” In advanced ankylosing spondylitis, the bamboo spine causes spinal fractures to take on the mechanics of long bone fractures and may increase the risk of spinal cord injuries.
Knowledge of ankylosing spondylitis and its sequelae
The vast majority of the physicians responding to this scenario felt that the expert overstated his experience with ankylosing spondylitis, who claimed to have seen approximately two cases per month during his career. If we assume that the average incidence of ankylosing spondylitis is 1 in 750 and that the expert worked 2000 clinical hours per year, he would have to see 1500 patients every month or 9 patients every hour of his career in order to meet his threshold.
Several physicians were unable to substantiate the expert’s assertions about the literature and statistics available on ankylosing spondylitis, some noting that the topic only received cursory review in emergency medicine textbooks. No one was able to find any literature comparing spinal fractures to myocardial infarctions, alluding to spinal fractures in ankylosing spondylitis patients as a “true emergency,” or even describing the incidence of spinal cord compression in ankylosing spondylitis patients with lumbar spine fractures. While internal medicine and rheumatology textbooks do have more information on ankylosing spondylitis, emergency physicians are held to the standard of a reasonable emergency physician—not to that of an internist or a rheumatologist. Requiring an emergency physician to possess advanced knowledge in every specialty would require that we become experts in every specialty—a standard which is clearly unreasonable.

Management of spinal fractures in ankylosing spondylitis

With or without ankylosing spondylitis, certain diagnostic procedures and therapeutic precautions need to be considered in any patient with a spinal fracture. Assessing a patient for signs of spinal cord injury is important. The physician properly ordered a CT scan which showed several spinal fractures and no signs of cord injury. The patient’s neurologic status was intact both in the emergency department and after being transferred to the medical floor.


However, the patient may have developed weakness in one leg while in the emergency department. The physician apparently re-evaluated the patient for this change in status and attributed the symptoms to a “pain response.” No spinal precautions were ordered. Some respondents to this scenario had questions about whether such actions were proper. And, while several sources recommend that a rectal exam be performed in patients with spinal injury/back pain, no rectal examination was performed in this patient. While this column focuses on the standard of care, in evaluating whether the emergency physician was responsible for the patient’s injuries, we have to look not only at whether the physician breached the standard of care, but also at whether the breach of the standard of care caused the patient’s injuries. For example, even if we assume that failure to perform a rectal examination was a breach of the standard of care, the patient developed symptoms two days after the rectal exam should have been performed. It is therefore unlikely that failure to perform a rectal exam and the patient’s injuries are causally related. While no spinal precautions were ordered, the emergency physician contacted the specialists in managing ankylosing spondylitis and in managing spinal fractures from the emergency department. Their recommendations were noted and the patient was admitted. Those admitting physicians were free to cancel or modify any transition orders written by the emergency physician. At some point during the continuum of care the emergency physician’s duty to a patient ends. In patients who have been admitted, that point should be when the patient is admitted. The fact that an admitting physician chooses not to evaluate a patient for more than 24 hours after the patient has been admitted does not make the emergency physician responsible for the patient during those 24 hours. In summary, the consensus was that the expert may have overstated both his experience with ankylosing spondylitis and the coverage of ankylosing spondylitis in the medical literature. A vast majority of physicians responding to this scenario also felt that the standard of care was met even though the emergency physician did not provide “perfect” care. Many were astute enough to note that the patient’s injuries were likely caused by incidents that occurred after the patient was admitted. Despite some questions about actions the physician took, the emergency physician should not be held responsible for the patient’s injuries.
To see all 24 reader responses, see next page.
{mospagebreak title=Read all 24 reader responses}
Reader Responses
I am a board certified emergency physician.  In 14 years of residency and independent practice, I cannot recall seeing a single case of ankylosing spondylitis, except perhaps one or two as an incidental finding.  I have never diagnosed a case of this disease.  Therefore, I find it remarkable, astounding in fact, that Dr. Flaherty has seen 500 to 600 cases and diagnosed 150 to 200 during his 21 year career.  Perhaps Chicago is a hotbed of rheumatologic disease.
I fail to recall learning about ankylosing spondylitis in medical school at all, let alone being “one of the first diseases” that I studied.  Nor do I recall hearing anything about this illness during residency either at a bedside or during a lecture.
My edition of Tintanelli does make a passing reference to transverse fractures being common in ankylosing spondylitis and subject to cord compression but doesn’t quantify this risk.
In short, Dr. Flaherty’s testimony strikes me as inflated at best and certainly does not represent the knowledge of an average practitioner of Emergency Medicine.
The EP identified his patient as having spinal fractures and transferred him to the care of a spine specialist.  Assuming that the EP accurately described the patient’s injuries to the specialist, he should not be held liable for the judgment of that specialist as to when to see the patient.
More importantly, it is not at all clear how the EP’s alleged failures in any way contributed to the patient’s injuries.  How could the EP’s alleged failure to do a rectal exam or admit the patient to an ICU in any way have caused this patient’s spinal cord compression?  All the more so when the patient sustained his injuries 5 days prior to presenting to the hospital and arrived neurologically intact.
—Mitchell Heller, MD
With regard to the “expert” testimony, Dr John Flaherty’s opinions seem to be another case of a $1000-per-hour hired gun, paid to exaggerate and distort medical literature for the plaintiff’s case.  While true that patients with ankylosing spondylitis are at increased risk of fractures with even minor trauma, he goes too far in the quotes of “almost always unstable” and “extreme risk.” It is just plain laughable that he compared it to an MI and stated they are “one of the few true emergencies we have”.  I studied for the EM oral boards three years ago and don’t ever remember coming across a practice or test case involving AS.  Is the Board missing out on a “true ED emergency”?  I think not. The fact is, this is a rare disease, not a “bread and butter” emergency medicine case.  Dr John Flaherty, from Northwestern Medical School, should be ashamed of himself.
With regard to standard of care, this patient had an unstable fracture at L1 given the posterior body and posterior elements were affected.  Also, sounds as though there was distraction of fracture fragments posteriorly into the spinal canal.  Spinal precautions should have been ordered by the ED doc and enforced by the floor. Additionally, the orthopedist and internist both should have seen this patient much sooner than 24 hours out. However, the ED doctor did his job to find the cause of this patients back pain, then consulted and admitted the patient to the appropriate physicians. Was the patient in alcohol withdrawal while in the ED? This would make a thorough neurologic exam difficult if not impossible.
What this case really illustrates is the difficulty in evaluating and caring for an alcoholic patient who fell and fractured his back FIVE DAYS prior.  He probably only came into the ED after he drank all of the liquor in his home and then was unable to go out for more.  While we as emergency physicians may only see a case of Ankylosing Spondylitis once every few years, or less, we see this behavior every day.
—Aaron J Carter, MD
Barton Memorial Hospital
South Lake Tahoe, CA

Of the 5 “faults”, only number 5 is a problem for the emergency physician. Attributing weakness to pain is a problem easily solved by giving the patient IV morphine, and re-examining the patient in 30 minutes. If the weakness persists with pain relief, then it isn’t the pain. However, isolated weakness wouldn’t prompt me to transfer the patient or insist on emergency department evaluation by a consultant. I would tell the admitting doctors and document our conversation, of course.  SOC met.
—Andrew Jenis, MD
Cortland, NY
The standard of care was met by the emergency physician.  The fractures were recognized and the patient was admitted.  The specialist in bone diseases (orthopedist) should be responsible for more in depth work up.  I’m sure the EP was seeing many more patients at the time and can’t research every case he sees in real time.
—LeeAnne Lee
Not sure why ED doc is always the scapegoat. The ED doc made a correct call to admit.  Then it’s the duty of the admitting physicians to reassess and render appropriate treatments accordingly. If the patient is worse, then treat the patient. However, once the patient is out of ED and onto the floor, then the on-duty physician should get to work. Not sure since when we as ED doctors have to hold every admitting doctor’s hand and make sure he is doing his job.  As if the chef has to get out of the kitchen to make sure the waiter is serving the customers politely. Unbelieveable!
—J. Ting, DO, CFII-MEI
AOBEM certified ED doc
There were some mistakes made, but I feel that the most serious ones were made by the admitting specialists. If they had attended to the patient in a timely fashion, they would have recognized the issues and been able to deal with them. I would fault the ED physician for no spinal precautions. If the pt had arrived on the floor in full spinal precautions, he likely would have been seen sooner by the admitting MD. Also, in emergency medicine, unfortunately, “if you don’t put your finger in, you are putting your foot in” is true—so yes, a rectal exam might have changed the index of suspicion. In the end, however, we emergency physicians rely on our back-up specialists once the patient has been presented and admitted. The spine specialist could have insisted on spine precautions on his admitting orders, and, most importantly, seen the patient in a timely fashion. Where does our responsibility stop when we have turned over care to a “specialist”?
—Joanna Weinberg, MD
I have never learned any of the information that the expert witness states is taught in every medical school. I never knew that a fracture in a patient with a history of ankylosing spondylitis could have such consequences. So I disregard his remarks about that.
However, I do have concerns about disregarding a neurological sign, and no rectal exam, especially in light of the fracture with retropulsed fragments. But we don’t know that there would have been any difference even with the rectal exam. And isn’t it the responsibility of the admitting physican and consulting physician to do their job? Docs in the E/R can’t be watchdogs for everyone. So, in the end, did this doctor meet the standard of care? I would say yes.
—Leilani LaBianco
Certainly Flaherty’s comments involve such over-the-top embellishment that he should be subject to a peer review.
Spinal fractures complicating ankylosing spondylitis. A long-term followup study.
—Hunter T
Dubo, HI
Twenty-two spinal fractures in 20 patients with chronic ankylosing spondylitis are reported. Nineteen fractures occurred in the cervical region. Fourteen of the fractures were caused by minor falls, 3 by falls down steps, 4 by motor vehicle accidents, and 1 by cardiopulmonary resuscitation. Long-term followup (mean 3.2 years) of 9 fractures diagnosed early and managed conservatively showed bony union of all fractures. No patient deteriorated neurologically and 3 patients made major recovery. Long-term followup is also reported on 6 patients in whom the diagnosis was delayed. The difficulties in diagnosis and management are discussed. I have been practicing EM for 24 years now and remain well-read. I have never read an article stating that fractures of the spine in ankylosing spondylitis should be treated emergently like a Myocardial Infraction. Does the expert witness actually practice EM? Obviously not. Trying to get a spine specialist to see a spinal fracture in the ED without neurologic deficits is almost impossible.                                       
—Robert Brock Allen, MD
The entire situation is a fiasco. NO, I do not believe ANY ER Doc has ever diagnosed A.S. in the ED—almost by definition one cannot. Additionally, we do not see it very often and I would DOUBT VERY MUCH if the expert has seen as many as he claimed (unless he worked in an AS clinic prior to his current job)….
The ED doc did everything right and nothing wrong…I have seen a few pts with the Dx. of AS (they presented with this diagnosis) and I have never seen any of them go on to become quads. It is a chronic disease and one that is managed appropriately, most often, as an outpatient. This case is outrageous, as is the expert testimony.
—Ron Elfenbein
Basically, the “expert witness” is full of crap.  If you look at the national incidence of ankylosing spondylitis (about 1:775 people in the U.S.  according to Mayo), he would have had to treat (conservatively)  approximately 387,500 patients in his 21 year career, or remarkably, 18,425 patients a year all by himself.  Boy, I wish he worked for me if he is THAT good. Secondly, I don’t think ANY emergency physician would be recognized as an “expert” on ankylosing spondylitis. Basically, the care of the emergency physician was what would be considered the norm. The care of physicians that did not see the patient for 24 hours was not.
—Tom Richardson, MD, F.A.C.E.P.
Some of the expert testimony is a bit over the top.  The items that would have aroused my interest in regards to the EP’s standard of care would have been the assurance that spinal precautions were maintained, performing the rectal exam, and assuming any weakness was related to cord injury until proven otherwise.  It’s not clear from the record provided whether the EP conveyed a potentially evolving neurologic exam to the admitting physicians.  Although details are lacking, the vast majority of the questionable management which may have contributed to this patient’s morbidity seems to have occurred after admission.  My interpretation of the provided record is that the EP certainly left himself vulnerable on some issues, but not nearly to the extent the expert testimony would suggest.
This case certainly re-opens that can of worms regarding who writes the admission orders. Unless the patient was recently seen by his primary physician, for this same problem, I feel that the ED physician has a better handle on the patient than anyone else, and therefore should write the admission orders IF the admitting physician is not going to come in and see the patient in the ED (which would be the ideal situation.) This case demonstrates the biggest argument against the ED physician writing those orders! As far as the accusations against the ED physician: He did not demonstrate a failure to understand the pathophysiology—he saw the problem and admitted the patient to an appropriate service. He tried to get the patient seen—we do not know what information he was told by the accepting physician. If he was told that the accepting physician would not be in for a few days and he still admitted the patient to that physician, that’s a different story. I suspect that there is a provision in the rules of the hospital specifying what interval (usually up to 4 hours) can pass between admission and the patient being seen by the attending.
Most ICU’s would have no idea what to do for a spinal cord patient, and most orthopods wouldn’t have ICU privileges. If he called Medicine to admit the patient to the ICU, he would be told that it isn’t a medicine case (until he developed DT’s). It isn’t clear in the case study who the primary physician was.
The rectal exam may have been abnormal, which may have prompted the orthopod to either come in sooner, or ask for a transfer, but if the orthopod doesn’t believe that this condition represents “one of the few emergencies that we have,” which he apparently didn’t, a rectal wouldn’t have made much difference.
The increasing weakness is questionable—the ED physician says his neuro status was intact and his neuro exam on the floor was normal. When was there increasing weakness?
As far as the expert diagnosing 150 to 200 cases of ankylosing spondylitis, this seems to me to be analogous to making the diagnosis of diabetes on everyone with a fasting sugar of 112!—the Ivory Tower Diabetologists would probably agree, but who cares!  With elderly patients (and the age of this patient is not mentioned) it would seem a more significant finding if signs of ankylosing spondylitis were NOT present on x-ray studies.
Overall, it seems to me that the ED physician did his job and did it well—he met the standard of care up to the point he wrote the admission orders. Spinal precautions were not ordered. However, if this was an orthopedic unit and spine specialists were part of the program, the nursing staff should know to follow spinal precautions whether the order was written or not.  I’ll bet he didn’t write “Universal precautions” either. Does that make it his fault when the patient develops MRSA or the nurse gets hepatitis?
A guy gets drunk and falls; somebody has to pay. The bartender doesn’t have a deep pocket, so he’s off the hook for serving the drinks. The internist and orthopod contend that the ED physician didn’t paint a clear enough picture or they would have done what they should have done in the first place and seen the patient before he left the ED. The poor ED guy does his job, does it well and still takes the fall. It just isn’t right!
—Karl E Harnish, DO
Board Certified Emergency Physician
Chiefly, “one of the first things you learn in medical school”.  I’d like to see him present a single first YEAR syllabus from a med school that lists any of the seronegative spondyloarthropathies as a testable subject.  Would also like to see the reference that delineates the factor by which spine instablility and cord impingement increases for spinal fractures (and which kind of spinal fractures) with this condition.
The EM physician acted within the standard of care. He diagnosed the injuries, ordered appropriate imagin studies, consulted in a timely manner the appropriate specialist, and had the patient admitted.  Failure to perform a rectal exam and attributing weakness to pain are legitimate but minor faults.  It is reasonable to assume that disposition—floor vs ICU—was arrived at jointly by the orthopedist, EM physician, and internist.  The fact that the orthopedist and internist were willing to admit this patient versus transfer was amazing.  There is no discussion regarding MRI or steroids in the information provided.
The neurologic deterioration occurred between 24-48 hours after the patient was seen by the EM physician and after he was transferred to a telemtery bed. Even if the EM physician wrote the initial admitting orders (and the patient arrived there stable), someone responsible for inpatient care had to give orders for that inpatient transfer.  Only the internist and orthopedist can answer why they didn’t see this patient.
With all due respect to Dr. Flaherty, emergency physicians don’t see on average 20 patients a year with ankyosing spondylitis. Is Dr. Flaherty boarded and practicing EM, or is he in yet another specialty trying to dictate my standard of care? I hadn’t heard of his claims regarding injury instability associated with AS.  I’m wondering which  textbooks/medical literature he is looking at. I had to do a  literature/abstract search on the particular topic, since the most recent edition of Tintinalli I have gives a whopping one paragraph in discussing AS, and that’s a textbook that isn’t “slimming down” with each new edition.  The majority of abstracts I saw on PubMed were case reports/series that talked about the association of AS with cervical fractures, not the injuries described above.  If it were comparable to MI, I would have expected to learn about it more in residency and recall questions from my initial and recertifying boards on this topic.  Guess I got those ones wrong.
—Jim Mensching, DO, FACEP
Regarding this case, it would seem that both the ED Physician and the on-call orthopedist who admitted the patient were remiss in not protecting him from further deterioration.
—Michael F. McCormack, MD
Since the ED doc made the appropriate diagnosis, admitted the patient with appropriate neuro checks, made the proper consultations, and the patient arrived to the floor neurologically intact, he is not responsible for subsequent errors and lack of timely treatment by the admitting physicians. The bad neurologic outcome was due to the nature of the fracture and the lack of prompt attention and care by the orthopedist.  The orthopedist who was consulted, having heard the words spine fracture and posterior elements and moderate distraction, should have called his spine specialist colleague right away and attended to the patient right away.  Had this been done the patient would have had a good outcome.
As for the expert witness, his testimony is a lot of nonsense. AS just increases the likelihood of fracture.  The past history of AS is meaningless since the diagnosis of fracture was appropriately made.  I doubt his testimony that he has seen 500-600 cases.  I have worked 20 years and have only seen a few true bamboo spines on x-ray.  There is no difference if the orthopedist sees the patient in an ED bed or a bed located on the floor, as long as he sees him quickly.  Similarly an ICU bed is not essential to the man’s care.  A rectal exam would be appropriate but wouldn’t change the treatment at all because the CT scan points to operative care regardless.  Since the patient is documented to be neurologically intact on arrival to the floor, and he went 24 hours with q 2 hour neuro checks before a deficit was discovered, the weakness in the ED may not have been significant.  Even if he were weak in the ED, the treatment would still be surgery.  The expert witness is criticizing the wrong physician.
—Dwayne Bernard, MD    
I have several questions. First, the diagnosis of ankylosing spondylitis (AS) was made presumptively by x-rays when the patient was first seen. Normally, it is a progressive slowly deteriorating disease. The diagnosis of AS is usually made by serology plus clinical history, NOT on the initial visit.
I think the standard of care was appropriate and met. As for performing the rectal exam…if the patient did not have any GU complaints and the neurologic exam is completely normal, a rectal exam is not necessary.
—Dr. Ma
In this case, I believe the standard of care was met. The emergency physician contacted the appropriate consultants and documented the neurologic status as intact. If the patient had documented leg weakness, then I believe an emergent MRI should have been ordered and based upon those results, the neurosurgeon on-call may have been contacted emergently. Once the patient was transferred to the floor, it was the responsibility of the admitting physician to re-examine the patient, document any neurologic changes, and contact the consultants. In this case, the admitting physician failed to examine the patient more than 24 hours after admission. I agree with Dr. Flaherty that a rectal exam should have been performed in this patient and ankylosing spondylitis patients may be at higher risk for spinal cord compression but I disagree that these cases are “almost always unstable.” Furthermore, I find it difficult to believe that a full-time emergency medicine physician has diagnosed “150 to 200 cases of ankylosing spondylitis” in the ED. According to Harrison’s Principles of Internal medicine, the incidence of ankylosing spondylitis is 0.1%, making it an extremely rare disease in the United States.
—Tony Kanluen, MD

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