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A call for help

01 May 2007

Miss P was a 45-year-old secretary who had had type 1 diabetes since she was 13 years old. She developed an abscess on her left buttock so visited her GP, Dr S. He prescribed a course of flucloxacillin and gave her an appointment to return in five days if things did not improve.

Miss P took the antibiotics but over the weekend the skin around the abscess became red and inflamed. She felt feverish and generally under the weather. On the Sunday, she called the out-of-hours service and spoke to Dr J, telling him that the abscess kept bursting.

Dr J did not see her but instead gave advice over the telephone. During his telephone triage he did not ask her about fever and did not take a past medical history so was unaware that she was diabetic. He organised a prescription of erythromycin for her.

Miss P did not get any better and went to A&E a week later where examination of the abscess revealed hot, red, tender skin with haemorrhagic bullae. There was necrosis and sloughing of the skin. Group A streptococci were later detected in blood cultures and from the abscess exudates. She was diagnosed with necrotising fasciitis. She needed a large area of debridement and subsequent grafts.

Expert opinion

GP experts were critical of Dr J for not arranging for Miss P to be seen, either on a home visit or at the out-of-hours centre. Dr J should have considered the fact that Miss P was now developing systemic symptoms.

Necrotising fasciitis is a necrotising process of the deep fascia and the vessels within it. Its diagnosis is clinical and thus the patient needed to be seen. If caught late, there is secondary death of the overlying skin and spread to the deep muscle. Eventually toxaemia and death can ensue.

The case was settled for a moderate amount.

Learning points

  • Always ask about past medical history and medication – it would have helped in the assessment of risk for this diabetic woman with an infection.
  • “Safety-net” in the consultation.1 Safety-netting refers to providing patients with information on what to expect and what to do if they don’t improve. General practice has been described as the art of managing the uncertain and provision needs to be made within the consultation for this. Miss P would have felt more secure if she had had a clear outline of what to expect from her treatment and under what circumstances to re-consult.
  • Have a low threshold for seeing the patient. Necrotising fasciitis has a clinical diagnosis and the patient needed to be seen.
  • Careful documentation is always necessary, in the surgery as well as for out-of-hours telephone triage.2

References

  1. Neighbour R, The Inner Consultation: How to Develop an Effective and Intuitive Consulting Style, Lancaster: MTP Press (1987).
  2. General Medical Council, Good Medical Practice (2006) www.gmc-uk.org