MEDICOLEGAL ISSUES Associate Editor: Steven M. Selbst, MD

Pediatric Emergency Medicine Legal Briefs EDITOR'S COMMENTS

Key Words: lawsuit, legal briefs, malpractice, misdiagnosis (Pediatr Emer Care 2014;30: 749–751)

A

6-year-old boy from Massachusetts experienced chest pain and fainted after running with other children.1 He was evaluated at a local emergency department (ED) and was referred to a cardiologist. The cardiologist performed an electrocardiogram (EKG) and reported to the child's mother and pediatrician that the child's study was normal, and he did not need to modify activities or follow-up. A year later, the child again had chest pain and nearly fainted after running with other children. He was again evaluated in the ED and again referred to a cardiologist. The second cardiologist ordered an echocardiogram and also reported a normal evaluation with no need to modify activities or follow-up. Eight months later, the child suffered a fatal myocardial infarction while running with other children. An autopsy revealed an anomalous coronary artery. The family sued both cardiologists and claimed that the second cardiologist had not actually looked at the echocardiogram at the time the family was told that “everything was normal.” They also claimed that the echocardiogram was actually incomplete and did not comply with the hospital's protocol, which required careful imaging of the origin and course of the coronary arteries. The family argued that the boy's coronary artery abnormality could have been corrected if diagnosed earlier. A settlement was reached for $2.25 million with the second pediatric cardiologist. The case against the other cardiologist is still pending. Unknown Massachusetts venue. From the Division of Emergency Medicine, Nemours/ Alfred I. duPont Hospital for Children, Wilmington, DE; and The Sidney Kimmel Medical College, at Thomas Jefferson University, Philadelphia, PA. Disclosure: The author declares no conflict of interest. Reprints: Steven M. Selbst, MD, Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803 (e‐mail: steven. [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0749-5161

Chest pain in children is generally benign and myocardial infarction is extremely rare in a 6-year-old boy. However, chest pain associated with syncope and chest pain that develops during exercise (he was running when he developed pain) are very concerning. An anomalous coronary artery is usually found at an earlier age. However, the cardiologist should have considered this as a potential cause of his symptoms because some children survive with this abnormality for years. It seems the echocardiogram was not properly read. Failure to arrange further follow-up was another error in this case.

A

19-year-old girl was taken to a Massachusetts ED after waking with severe, stabbing chest pain and difficulty breathing.2 She had symptoms of a gastrointestinal illness for several days. In the ED, chest x-ray and EKG were normal. She was diagnosed with dehydration and gastroenteritis and treated with intravenous (IV) fluids and medication for nausea and reflux. She did not improve over the next several hours, and she was admitted to the hospital. She came under the care of pediatric residents and the attending pediatrician who was not in the hospital. The teenager remained in the ED for 4.5 hours after admission. While in the ED, her vital signs were unstable. The ED nurse allegedly stopped regularly recording her vital signs for several hours before the transfer to a room on the inpatient unit. The medical records and the patient's sister confirm that she continued to have chest pain in the ED. A second EKG read by the emergency physician was abnormal and showed evidence of a pericardial effusion. The admitting team of pediatric residents evaluated the patient in the ED, and the differential diagnosis included pericarditis. When she arrived on the pediatric floor she was in shock and was severely hypotensive. She was given more IV fluids, and the pediatric team decided to transfer her to the intensive care unit (ICU). The ICU residents evaluated her on the pediatric unit, but she was not transferred to the ICU for nearly 2 hours. Her neurologic

Pediatric Emergency Care • Volume 30, Number 10, October 2014

status worsened and she became combative and incontinent of urine. The records indicate that an echocardiogram to rule out myocarditis/pericarditis was planned, but it was not ordered and a cardiologist was not consulted. When the patient arrived in the ICU she could not answer questions appropriately, and she was thrashing about in the bed. She was placed in restraints and given haloperidol and pressors. She developed cardiac arrest about 90 minutes after she arrived in the ICU. A cardiologist drained a substantial amount of pericardial fluid. However, she was pronounced dead about an hour after the cardiologist was called. An autopsy found the cause of death to be viral myocarditis and pericarditis. The family sued and claimed that the patient was given too much IV fluid. The defendant physicians argued that the patient did not show signs of pericarditis and that she did have signs and symptoms of gastroenteritis and dehydration. They also argued that the patient had an overwhelming infection, which would have caused her death regardless of the treatment provided. A settlement was reached with the hospital and emergency physician for $1.6 million. Unknown Massachusetts venue.

EDITOR'S COMMENTS There are clearly many details of this case that are missing. However, it seems the emergency physician and the inpatient resident teams did not appreciate how ill this teenager was until it was too late. Things seemed to move slowly on all units. As happens occasionally, once a patient is admitted, but does not leave the ED, the patient is left in ‘limbo’ and may not get needed treatments or careful observation.

A

young Mississippi man came to a local ED in November 2009 with abdominal pain and recent vomiting.3 He was evaluated by an emergency physician who noted the patient had normal bowel sounds and a soft abdomen. Blood tests were obtained and were reportedly normal. A computed tomography (CT) scan of the abdomen was read by a radiologist as showing a normal appendix. The emergency physician then ruled out appendicitis and the patient was www.pec-online.com

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

749

Pediatric Emergency Care • Volume 30, Number 10, October 2014

Selbst

discharged with a diagnosis of acute gastritis and instructions to return if his condition changed. Two days later, the patient was diagnosed with a ruptured appendix. He had a complicated and difficult recovery, which included several surgeries. The patient sued the physicians initially involved with his care and claimed negligence in the failure to diagnose appendicitis at the first presentation. The patient claimed that the radiologist had misread the CT scan and argued it showed an abnormal appendix, which was double its normal size. The emergency physician argued that he had reasonably relied on the radiologist's report and that there was nothing else in his examination or other test results to indicate that the patient had appendicitis. The emergency physician also claimed that the patient should have returned to the ED earlier when his condition worsened. The radiologist settled the case for an undisclosed amount prior to trial. A jury then found in favor of the emergency physician. Harrison County, MS Circuit Court, Case No. 11–73.

EDITOR'S COMMENTS It seems the emergency physician acted reasonably in this case, and it is reassuring that the jury agreed that he was not negligent. If the patient had a worrisome examination, one could argue the emergency physician should have questioned the reading of the CT scan, but if the evaluation was otherwise unconcerning, it was reasonable to discharge the patient and have him return if needed.

A

20-month-old baby was admitted to a pediatric ICU in Washington in August 2011 for management of a febrile seizure following a vaccination.4 It was difficult to get an IV started in the child's arm, so the pediatric intensivist inserted a central line in his neck. No serious medical issues were noted, the fever resolved and the baby was discharged to home the next day. For the next 6 months, the child was noted to walk with a wide-based gait and complained of neck pain and a headache. Visits to doctors did not find a cause for these symptoms. In February 2012, the parents noticed a “bump” on the child's neck. The size and location of the bump seemed to move and change, so x-rays were obtained, which revealed two long metal wires in the child's neck. Emergency surgery was performed and two metal guide wires were removed. The heath care providers who initially saw the wires on x-ray, suspected child abuse and involved Child Protective Services. The parents were eventually able to convince that agency that the wires were from a

750

www.pec-online.com

medical procedure when the baby was in the ICU. The child initially showed some minor developmental regression, but otherwise recovered well. The family sued the hospital and the ICU physician who treated the boy. They argued the hospital was at fault because it did not have any checklist for its physicians to use when placing central lines. The family also noted the intensivist performed the procedure when he was 41 hours into his 48-hour weekend shift, and he may have been fatigued. The defendants claimed that the guide wire had malfunctioned in that a piece broke and the outer coil became separated from the inner wire and there was no way the intensivist could have realized that the wire was left in the child's body. The hospital also claimed that the child had suffered no injury from the retained wire. A jury found in favor of the patient and awarded him $1 million. King County, WA Superior Court, Case N. 12-2-15607-7 SEA.

EDITOR'S COMMENTS Anyone who has placed a central line using the Seldinger technique knows this is your nightmare. One could argue that getting an x-ray after placing the central line would have been a reasonable test that was not performed. Still, it may be true that the patient suffered no long-term consequences from the retained guide wire and thus the award seems quite excessive.

A

13-year-old boy was brought to an Illinois ED in September 2007 with complaints of left knee pain and fever.5 He was diagnosed with a quadriceps strain and discharged. The next morning, the teenager was seen at a local health center with persistent knee pain. His temperature was normal at that visit, and the physician diagnosed a sprained knee. Three days later, the patient was taken to another hospital with a high fever, severe knee pain and inability to walk. Laboratory studies revealed an elevated white blood cell count and elevated liver enzymes. A blood culture revealed a methicillin-resistant staphylococcus aureus infection in the knee. The patient was transferred to another medical center for treatment. The infection spread, and he was hospitalized until early December 2007. He required 17 surgeries. The patient sued the emergency physician who initially treated him and claimed he was negligent in failing to order blood work and failing to recognize signs of infection. He also claimed that the staph infection had been present at least four days

prior to diagnosis. The defendant physician claimed that the patient did not have a clinically diagnosable infection on the day he was seen and that his condition progressed over the next 3 days. The emergency physician settled for $765,000 before trial. Cook County, IL Circuit Court, Case No. 09L-8164.

EDITOR'S COMMENTS Many details of this case are missing. It seems the emergency physician may have ignored or was unaware that the patient had fever when he was diagnosed with a knee strain. It is likely he received analgesic medication which may have been why he had no fever when he was seen at the health center the next day.

A

2-year-old boy was brought to an Alabama ED in October 2006 after 2 days of vomiting.6 The emergency physician examined the child and diagnosed gastroenteritis. Medication for nausea was prescribed, and the child was discharged to home. Instructions were given to have the child seen by his primary care physician if he did not improve. The next day the child returned to the hospital by ambulance. He had been listless all day and vomited again. He also stopped breathing for a period of time. The same emergency physician evaluated him and again diagnosed gastroenteritis. He ordered a chest x-ray and after consultation with a pediatrician, the baby was admitted to the hospital. Several hours later, a nurse noted that the child's heart rate was dropping, his eye movements seemed abnormal, and his pupils were unequal. The pediatrician was called to the bedside, and the child was examined. The pediatrician continued to believe the child's problems were related to gastroenteritis. Shortly after the doctor left the bedside, the nurse noted that the child was posturing and he was bradycardic. Another physician arrived and ordered a stat CT scan of the brain. This showed a mass in the brain and a possible hemorrhage. The child developed breathing problems, and he was intubated. He was then transferred to another hospital where surgery was performed to remove the mass in his brain. He never regained consciousness and died the next day. The baby's family sued the treating physicians and argued that the emergency physician and the pediatrician had been negligent in erroneously diagnosing gastroenteritis instead of an intracranial mass. The defendant physicians denied any negligence. © 2014 Lippincott Williams & Wilkins

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Pediatric Emergency Care • Volume 30, Number 10, October 2014

A mistrial was declared when the case was first tried. In a second trial, a jury found in favor of the physicians. Mobile County, AL Circuit Court, Case No. 08-901174.

EDITOR'S COMMENTS Although details are missing, this case again reminds us that vomiting is not always related to a gastrointestinal problem. Although it may have been reasonable for the emergency physician to initially assume a benign condition when the child was first seen, other diagnoses should have been considered when the child returned by ambulance to the ED the next day. It is unclear why the pediatrician ignored the nurse's concerns about bradycardia and abnormal eye movements when he was called to the bedside. The physicians were fortunate that a jury found in their favor. Perhaps they believed the outcome would not have changed had the diagnosis been made a day earlier.

A

2-week-old baby girl was brought to a Maryland ED in December 2005 after she had missed several feedings and appeared to be short of breath.7 The infant was examined by a nurse and an emergency physician, and blood tests were ordered. The on-call pediatrician was consulted. The baby was subsequently discharged from the ED with instructions to follow-up with the infant's pediatrician. The blood test results were still pending at the time of discharge. A blood culture grew group B streptococcus, and the baby was called back for admission to the hospital. By the time treatment was begun, the infant had developed meningitis. She suffered a brain injury and was later diagnosed with cerebral palsy. The family sued the employer of the nurse and emergency physician and claimed that the infection was not timely diagnosed and treated and that information regarding the results of the blood tests was not timely communicated. The parents claimed that the blood test result showing bacterial infection became available on the morning

© 2014 Lippincott Williams & Wilkins

after discharge, but instead of notifying the parents at that time, an additional blood culture was ordered to determine the type of bacteria present. The parents claimed that they were not contacted until 6 hours after the bacteria was identified as group B streptococcus. The defendants denied any negligence, and the nurse specifically claimed that she had no control over the test results and had expressed concerns about the decision to discharge the infant. A jury found in favor of the family and the patient and awarded them $9.5 million. The award was reduced to $7.15 million in compliance with the state cap on noneconomic damages. A posttrial motion was pending. Prince George's County, MD Circuit Court, Case No. CAL11-08836.

Legal Briefs

and also used an IV pump intended for use with adults. The infusion went at that rate for 46 minutes before another nurse noticed the newborn looked “puffy.” The infant's blood volume increased by 250% and her weight increased by 20% in less than 1 hour. A physician called to treat the baby was able to lower the infant's glucose levels while bringing up her sodium levels. She was subsequently diagnosed with brain damage, having a low IQ and difficulties with cognitive function. The parents believed that the child would improve with time, but a lawsuit was filed in 2011. A settlement was reached for $7 million. DuPage County, IL Circuit Court, Case No. unknown.

EDITOR'S COMMENTS

EDITOR'S COMMENTS

It is not clear how the child looked in the ED or which blood tests were pending at the time of discharge from the ED. If the 2-week-old baby truly had difficulty feeding or breathing problems, discharge would be unwise. Was a complete blood count obtained and did this indicate a bacterial infection? Regardless of the recommendations of the pediatrician who provided phone advice, the ED staff still has most responsibility for the baby. The parents have a reasonable argument if the baby was not admitted and treated immediately after the initial blood culture results were known. To delay treatment while a repeat blood culture is pending would not be appropriate. Also, when the nurse who cared for the baby testifies that she had expressed concerns about discharge of the infant from the ED, defending the case is clearly more difficult.

This is not a case from the ED. However, this type of error could happen in any ED. It seems the nurse who cared for this infant had little to no experience with newborns, and there were no checks in place to prevent an incredible amount of fluid given. It was wise to settle this case as defending such an obvious error as occurred here would be very difficult.

A

n Illinois baby, one of triplets, was born in January 2003.8 Soon after birth, she was prescribed IV fluids D10W to be infused at the rate of 4.5 ml per hour. She received the fluids at that rate for 2 hours. When a nurse hung a new bag, she set the IV pump to dispense 405 mL per hour,

REFERENCES 1. Laska LL. Medical Malpractice Verdicts, Settlements and Experts. 2014;30:4. 2. Laska LL. Medical Malpractice Verdicts, Settlements and Experts. 2014;30:12–13. 3. Laska LL. Medical Malpractice Verdicts, Settlements and Experts. 2014;30:13. 4. Laska LL. Medical Malpractice Verdicts, Settlements and Experts. 2014;30:17. 5. Laska LL. Medical Malpractice Verdicts, Settlements and Experts. 2014;30:6. 6. Laska LL. Medical Malpractice Verdicts, Settlements and Experts. 2014;30:7–8. 7. Laska LL. Medical Malpractice Verdicts, Settlements and Experts. 2014;30:8. 8. Laska LL. Medical Malpractice Verdicts, Settlements and Experts. 2014;30:19.

www.pec-online.com

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

751

Pediatric emergency medicine legal briefs.

Pediatric emergency medicine legal briefs. - PDF Download Free
95KB Sizes 4 Downloads 5 Views