Presentation
On January 29, a 20-month-old boy was brought by his mother to his pediatrician’s office. The patient had a one-day history of fever — up to 104 degrees. He was also tugging at his ears and had a decreased appetite. That morning, he vomited phlegm.
Physician action
Pediatrician A — who was not the patient’s usual treating physician — noted that the patient was crying but consolable. His temperature was 100.5 degrees; his throat was red; and his neck was supple with full range of motion. A rapid strep test was positive.
Pediatrician A diagnosed strep throat and fever. She prescribed cephalexin; recommended increased fluids; and discussed fever protocol with the mother. The specifics of this conversation were not documented.
The evening of January 30, the mother called the pediatric practice and told the nurse her son was not improving. He was not eating, still had fever, and was sleeping a lot. The mother later claimed the nurse told her to wait for the antibiotics to work, and if the patient did not improve by the next day, to call back or bring the patient to the office. There is no record of this phone call in the patient’s records, but phone records indicate a call was placed to the pediatric practice.
The patient’s mother called the office at 9:35 a.m. on January 31. She told the nurse that the patient was lethargic with a temperature of 102.9 degrees. She also reported that when she called his name, he would open his eyes, but not move his head. The patient had a pink tinge in his diaper the previous night.
The nurse told the mother to take the patient to the emergency department (ED) at the children’s hospital. The mother replied that she wanted her son to see Pediatrician B (his usual treating physician) first. An appointment was made for 2 p.m., but the nurse called back and told the mother to bring the patient in immediately.
The parents brought the patient to the office, and he was seen by Pediatricians A and B. His temperature was 100.4, and he was noted to be lethargic and dehydrated. His neck was stiff with flexion, and he had negative Brudzinski and Kernig meningeal signs. Pediatrician A questioned possible meningitis and administered ceftriaxone. She told the parents to take him to the children’s hospital ED immediately.
When they arrived at the ED at 12:30 p.m., the patient’s temperature was 102.3 degrees. His neck was stiff, and he appeared ill. The patient’s mother reported that he had shaking and chills and that he had an episode of “stiffening” that morning.
A lumbar puncture revealed a white blood count of 576 and was positive for bacteria. A CT scan showed sinus opacification. While in the ED, the patient had a seizure and was treated with lorazepam. He was also given IV fluids, acetaminophen, vancomycin, and cefotaxime. He was transferred to the ICU at 4:30 p.m.
While in the ICU, the patient was treated by a pediatric neurologist and two pediatric intensive care specialists. His diagnosis was bacterial and pneumococcal meningitis complicated by cerebral infarcts. He continued to experience seizures and was placed on ventilator support. He never regained consciousness and died on February 4.
An autopsy was performed, and the cause of death was listed as “streptococcus, pneumoniae meningitis, as well as stress related changes due to infection, including thymus, acute splenitis, and bone marrow myeloid predominance with left-shifted myelopoiesis and megakaryocyte hyperplasia.”
Allegations
Lawsuits were filed against Pediatrician A, Pediatrician B, and their pediatric group. The allegations were failure to timely diagnose and treat meningitis.
Legal implications
The plaintiff’s expert criticized Pediatrician A for failing to perform an adequate evaluation of the patient on January 29; misdiagnosing him with strep throat; and prescribing the wrong antibiotic. This expert also claimed that Pediatrician A failed to give appropriate follow-up instructions and failed to warn the patient’s mother of the significance of a worsening condition. He argued that the patient would have survived, if he had been diagnosed with meningitis on January 29 or 30.
Physicians who reviewed this case for the defense were supportive of Pediatrician A. At the January 29 visit, there was a positive strep test and the patient did not appear toxic. There was no indication for further lab work such as a CBC, blood culture, or lumbar puncture, and it was reasonable to treat with antibiotics and monitor.
Documentation was a weakness in this case. Pediatrician A documented that she discussed “fever protocol” with the mother. Pediatrician A later testified that this discussion included supportive care; avoidance of sick contacts; and signs and symptoms of a worsening condition that require an urgent return for re-evaluation. The patient’s mother testified that she did not recall having this conversation.
The after-hours phone call of January 30 was also an issue. The mother claimed that a nurse told her to continue watching her son and to call the next day if there was no improvement. There was no documentation of this phone call, though phone records show it took place.
Disposition
This case was settled on behalf of Pediatrician A.
Risk management considerations
The lack of communication and follow-up documentation was a challenge in this case.
At the first visit, Pediatrician A documented that she discussed “fever protocol” with the mother but did not document specifics. Physicians should document when providing a patient with specific signs and symptoms to look for worsening conditions, along with instructions for when to return to the clinic or ED.
Providing follow-up instructions may help defend against allegations of failure to diagnose and treat. If the information discussed is not documented, the case is harder to defend.
One expert testified that the standard of care includes emphasizing that the child should have returned to the office or been taken to the ED if the condition worsened, as exhibited by changes in mental status, increased sleepiness, listlessness, lack of energy, decreased oral intake, and/or decreased urine output. He stated that had the physician provided the patient’s mother with these instructions, the patient’s condition may have been recognized in time to save his life.
Another weakness in this case was the lack of documentation of the after-hours phone call on January 30. It is recommended that after-hours phone calls be documented and details communicated to the treating physician. Staff members should be trained in telephone protocols and provided with telephone decision guidelines, including when to contact the physician after hours.
