Ineffective, delayed treatment of sepsis leads to double amputations and $3.6 million settlement
By Blake J. Delaney, Esq.
Buchanan Ingersoll, Tampa, FL
News: A baby boy in extreme pain was taken by his mother to the doctor, who performed several tests on the child. While the mother and her baby were awaiting the test results, the boy's lips turned purple and he began vomiting. The pediatrician, after some delay, eventually advised the mother to rush the boy to the ED, where doctors diagnosed the child as hypoxic and positive for Streptococcus pneumoniae. Doctors delayed antibiotic therapy, but when such therapy eventually commenced, the boy was given an ineffective type of antibiotic at an ineffective level. The child eventually required multiple surgeries, and both arms and both legs were amputated. Before trial, the parties settled the case for $3.6 million.
Background: The mother of an 11-month-old baby took her son to the pediatrician after he was experiencing temperature spikes up to as high as 105° F over the preceding night. The child had been pulling at his ears, and he had significant nasal congestion. After determining that the boy had a fever, the doctor indicated to the mother that her son could be suffering from sepsis, a severe illness caused by an overwhelming infection of the bloodstream by toxin-producing bacteria. The doctor ordered, on an emergent basis, a complete blood count differential/smear blood culture, a urinalysis, and a urine culture.
The mother and baby then proceeded to a nearby hospital from the doctor's office so that laboratory tests on the infant could be completed. After the testing was concluded, they returned home to await the test results. The pediatrician subsequently called, informing the baby's parents that although he was waiting on the blood culture to fully grow out, the rest of the blood work was normal and they should not be concerned. The parents were advised to keep their son hydrated.
Later that day, the baby boy's lips turned purple. He was acting lethargic and continuing to pull at his ears. The pediatrician instructed the mother to increase her son's intake of fluids, but she could not get him to drink anything. She called the doctor's office again, at which point a second pediatrician similarly instructed her to force fluids into the boy. After another hour of unsuccessful attempts to get her son to drink, the boy began vomiting. The mother called the doctor's office, and she was advised to take the child to the ED.
The ED physician found the boy to have purple ears and a rash around his nose and one of his cheeks. He also was obtunded and suffering from a deficiency in oxygen reaching his bodily tissues. After some delay, an evaluation showed that the baby had a large abscess in his ear. Doctors ordered a spinal tap, which was positive for S. pneumoniae. Nevertheless, doctors again delayed before starting antibiotic therapy. Eventually such therapy was ordered in the form of ampicillin, but nurses initially administered an ineffective dosage level. Had anyone checked the results of the blood culture that had been taken earlier in the day by the baby's pediatrician, they would have realized that ampicillin would not be as effective in treating the boy's condition as vancomycin.
After the antibiotic therapy commenced, another delay occurred before blood gas studies were conducted to detect any impairment in the child's processing of alveolar gas exchange. When the tests finally were performed, doctors failed to respond to the results indicating metabolic acidosis. Hospital personnel eventually decided that the baby should be transferred to another hospital. At the second hospital, doctors realized that the baby should have been treated with vancomycin. The change in antibiotics, however, was too late to save the child from requiring multiple surgeries. He eventually had both arms and both legs amputated.
The baby, through his parents, sued the doctors and first hospital involved in his care. He alleged that the defendants acted negligently in providing treatment. The plaintiff claimed that proper interpretation of the blood culture lab report and an earlier recommendation of going to the ED would have resulted in earlier treatment with vancomycin and no permanent injury. During the pretrial phase, the parties reached a settlement of $3.6 million.
What this means to you: "This case presents the age-old query as to how something this horrific could have occurred given the advancement of modern medical diagnostics and treatment," says Lynn Rosenblatt, CRRN, LHRM, director of quality and risk management at HealthSouth Sea Pines Rehabilitation Hospital in Melbourne, FL. She recognizes several areas of concern associated with the pediatrician's conduct in this case, not the least of which is that he suspected an infection but did not act with a sense of urgency.
"Generally with ear infections and upper respiratory symptoms in infants, physicians will initiate antibiotic therapy even before the final cultures are available because waiting is a greater risk than selecting an inappropriate drug," she says. Perhaps significantly, there was no mention in the scenario of any other prescriptions to dry up the secretions that were causing the child considerable earache and respiratory congestion.
Rosenblatt also is concerned that when the mother contacted the pediatrician and informed him that her child's condition had deteriorated and that he had "purple lips," the physician still did not react to the seriousness of the symptoms. "A child with lethargy and cyanosis of the lips is most likely suffering from respiratory insufficiency and/or metabolic acidosis, both of which are life-threatening conditions," she notes.
Indeed, by the time the mother called back informing the pediatrician of her son's worsening condition, the lab should have provided preliminary results of the blood culture.
Additionally, Rosenblatt recognizes the lack of any reasonable explanation for the advice to force fluids, given that such advice alone would seem totally inadequate under these circumstances. In fact, it is even more baffling that a second physician provided the same advice, apparently without questioning the situation further. "This series of events raises the question as to whom the mother spoke, as it is difficult to believe that a physician would have dismissed the parent's concern in such a blatant manner," she points out.
The narrative indicates that the parents were informed that the lab values were normal, but it does not say that the pediatrician called them himself. Also, since this child had an upper respiratory infection, it is not surprising that the urinalysis was negative, Rosenblatt says. "What is surprising is that the blood was also said to be normal," she says. "A child with fever — particularly a high fever — an ear infection with significant nasal congestion, and a differential diagnosis of sepsis would likely have an abnormally high white count." In her experience, other blood values also could be outside normal ranges, depending on the virulence of the causative organism.
Rosenblatt questions the pediatrician's practice of informing the parents that the child's lab work was normal despite the child's symptoms and his own belief that the patient had a primary blood stream infection. She contends that standard practice would dictate that the physician question the lab results under these circumstances.
Indeed, a related issue of concern for Rosenblatt is who reviewed the lab work before contacting the parents. "If the physician did not review the results himself, could an office worker have called and unknowingly provided the results of another child's lab work? Did the mother speak directly to both physicians when she called back? Were her concerns relayed by the office staff to the physician? Did the office staff actually speak with the physicians when the mother called, or did they just tell her that they had?" she questions. Although the answers to these questions are unclear from the scenario, they show the types of inquiries that risk managers should ask to prevent similar situations.
Clearly, Rosenblatt is concerned with the treatment provided by the pediatricians in this case. In large offices, she notices how physicians rush from one patient to another writing orders, and they leave the follow-up to the office staff (often a nonlicensed medical assistant). Patients who call in with serious issues rarely speak directly to a physician, and phone calls are usually left to the end of the day before messages are relayed. At that point, the physician may not sense the urgency, and he or she may choose to leave it for the next morning.
Furthermore, although labs communicate "panic results" to the office as soon as the information is available, in the real world this information may not be communicated to the physician immediately.
Sometimes, such results can sit on a message board or fax, which causes them to be forgotten until much later. After all, physicians' offices are frequently busy and, depending on the number of physicians and their specialty, can be minefields for potential malpractice claims.
"Getting the right results to the right patient and prescribing the right medications can be daunting under the best of times," Rosenblatt says. "When one adds in the factor that most office help is unlicensed, the formula for a disaster is in place."
Despite the shortcomings of seeing patients in the office setting, physicians are encouraged by managed care to treat in the office rather than send the patient to the hospital. Although the factual scenario does not reveal what the child's insurance was, or if he had any at all, the only plausible explanation for the pediatrician's conduct is a tightly managed HMO, perhaps a Medicaid Managed Care plan, or no insurance at all. Otherwise, it is unclear why a pediatrician examining an 11-month old child with significant respiratory congestion including an obvious middle ear infection and the tentative diagnosis of sepsis did not immediately admit the patient to the hospital for intravenous (IV) antibiotics and hydration, or at the very least admit the child to a 23-hour pediatric observation unit.
Rosenblatt recognizes that another alternative, also costly, would have been to send the mother and child to the ED, where the lab results would have been reviewed and acted upon without undue delay. "It does not make sense that the physician would not have insisted that the mother and child await the results in order to act as quickly as possible on a probable diagnosis," she says.
Due to the pressures of managed care, national, state, and local governments are looking hard at HMOs and the emphasis on the bottom line. Rosenblatt comments that the message is clear that the HMO has an obligation to provide the same quality of care and access to needed treatment to enrolled beneficiaries as any prudent health care provider would provide in a freedom of choice situation. "The push is on in many states for large physician practices to assume more of an affirmative duty to ensure quality and acceptable standards of care," she says. "Quality and risk professionals see physician practice patterns as the best opportunity at a basic level to correct many serious mistakes that occur as a direct result of a poorly organized practice environment."
From the facts presented, it appears the second facility was better equipped to handle complicated pediatric cases. Therefore, Rosenblatt advises, the pediatrician should have instructed the mother to go there rather than the smaller hospital that clearly was lacking the expertise for a case of this magnitude. "Again, one can surmise that if this was an HMO case, the first smaller hospital was in-network, while the second may not have been," she says.
Much of this is speculation, as there is insufficient information in the narrative to say conclusively if this analysis has basis in fact, Rosenblatt says. "Nevertheless, if these conclusions are correct, it speaks to the commonly held belief that physicians in managed care networks are often so overworked and intimidated by the managed care organization that they fail to provide a full and accurate assessment of a patient's symptoms followed by appropriate treatment," she says.
Hospitals employ quality and risk experts to assist in developing best practices so that this type of catastrophic situation can be avoided. In this case, says Rosenblatt, the ED missed all the clues, and it could have benefited from a critical practice pathway.
"Such tools provide step-by-step guidance to physicians, nurses, and other clinicians as to their role in managing the case and the point at which intervention is required," she says. "This allows for consistency and provides a framework for a quality level of care."
Unfortunately, the treatment received by the patient did not improve after his parents were directed to take him to the ED. "The pediatrician should have called ahead and informed the [ED] physician of the child's condition and what preliminary treatment had transpired," Rosenblatt says. She advises that pass through of patient information from one care setting to another is one of the National Patient Safety Goals endorsed by the Joint Commission on the Accreditation of Healthcare Organizations and supported by the American Medical Association and other health care quality organizations.
"Had that occurred in this case, the [ED] physician would have had more information and an accurate timeline of the child's illness," Rosenblatt says. "Some of the delays that occurred may have been avoided." For example, the ED would have been aware that blood had been drawn in the hospital lab earlier that day and that the results were merely a phone call away. Furthermore, speaking directly with the pediatrician of record would have provided the ED physician with sufficient information to arrive at a differential diagnosis of possible septic shock, respiratory insufficiency, and metabolic acidosis.
The importance of this preliminary communication cannot be underestimated. "Early recognition of this child's situation may have prompted the emergency room staff to respond in more aggressive manner, a course which was certainly warranted given the child's rapidly declining condition," Rosenblatt says.
The fact that the boy had an ear infection was fairly obvious, but there also was every indication that he had bacteremia. "Given the fact that streptococcus is a common organism in children and extremely dangerous in one so young, the [ED] physician was remiss in not ordering a reasonably broad-spectrum antibiotic immediately," she says, noting that vancomycin generally is the drug of choice in a situation such as this.
Finally, "although this case screams urgent care, apparently there was no sense of an emergency," says Rosenblatt. For example, given the child's respiratory difficulty and the fact that he was obtunded, blood gases should have been ordered without delay on arrival. Supplemental oxygen also should have been a consideration, an IV for hydration and delivery of continuous antibiotic therapy should have commenced upon arrival, a simple chest X-ray may have been appropriate to rule out pneumonia, and, given that the spinal fluid was positive for bacteria, a simple Gram stain could have provided some indication of the sensitivity even if the specific organism had not been identified, she advises.
All in all, the series of events that transpired at the first hospital seems to indicate either an ED staff that was not properly trained to deal with sick children (as opposed to injured ones) or a staff that was so rushed that they failed to properly triage this case and provide the appropriate care in a timely manner, she says. "Both situations are entirely possible given the delays, the ineptitude of the physician in properly diagnosing a very ill child, and the medication calculation error made by the nurses," Rosenblatt concludes.