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Legal Review and Commentary
Doctor's failure to monitor possible drug reaction leads to toxicity for child and $600,000 settlement
By Blake J. Delaney, Esq., Buchanan Ingersoll & Rooney, Tampa, FL
News: After receiving treatment at a hospital for an infection of his heel bone, a young boy was discharged with instructions for his mother to administer antibiotics several times a day for the next three weeks. Over the next few weeks, the boy exhibited severe symptoms, including a sustained fever and a rash, prompting her to return to the pediatrician's office several times. Upon each visit, the pediatrician ordered different treatments, but he insisted that the mother continue to administer antibiotics. The boy ultimately was referred to an infectious diseases specialist at the hospital, who concluded that the child had been experiencing an adverse reaction to the antibiotics. The boy underwent kidney and liver biopsies and exploratory laparotomies to address uncontrolled hemorrhaging. The boy's mother sued the pediatrician for negligence, alleging, among other things, that he failed to consider a drug reaction or drug toxicity as her son's symptoms progressed. The parties ultimately settled for $600,000.
Background: After sustaining a puncture wound to his right foot, a 4-year-old boy was sent to the hospital by his pediatrician for an X-ray and a bone scan. The X-ray was negative for a foreign body. But when the bone scan was interpreted as positive for an infection of the heel bone, the child came under the care of an infectious diseases specialist. During the course of the boy's two-day admission at the hospital, a peripherally inserted central-catheter line was inserted so that the mother could provide a three-week course of antibiotic therapy following discharge. Hospital staff instructed the mother on how to administer the drugs every several hours by means of an infusion pump, and she was told her to bring her son in for weekly blood work.
The mother never followed up on the blood work, but she did bring her son to the pediatrician for a follow-up appointment two weeks after his discharge. The doctor ordered another X-ray and told the mother to continue administering antibiotics. Two days later, the boy developed a fever, which the mother was told by the pediatrician to treat with acetaminophen. The fever continued over the next few days, however, and the boy became listless. The mother again called the pediatrician, and he ordered an immediate complete blood count. Although the results of the test were seemingly normal, the pediatrician instructed the mother to take her son back to the hospital because the boy's symptoms were progressing.
A surgeon at the hospital, concerned about a possible central-catheter line infection, replaced the existing line with a peripheral intravenous line. Upon the boy's discharge, the mother again was instructed to continue to administer the antibiotics and call if her son's symptoms lasted more than three days or became worse. The next day, the boy's temperature reached 104°, and the mother returned to the pediatrician. A rash had developed all over the boy's body, and the doctor diagnosed him as suffering from a benign viral infection and mild dehydration. He ordered her to begin forcing fluids.
On the way home, the young child vomited, and the mother rushed him immediately to the emergency department. An infectious diseases consultant visited the boy for the first time since his discharge three weeks earlier and diagnosed him with complete liver and kidney failure, pancreatitis, hepatoxicity, nephrotoxicity, coagulopathies, and retroperitoneal bleeding. Recognizing that the child's liver enzymes and chemistries reflecting kidney function were markedly elevated, the infectious diseases consultant ordered that the antibiotics be immediately suspended.
The child was required to remain in the hospital's pediatric intensive care unit for 10 days, after which time doctors performed kidney and liver biopsies performed in tandem. Two exploratory laparotomies were subsequently performed to address the uncontrolled hemorrhaging that had resulted from clotting disorders caused by his liver failure. The surgeries caused permanent external scarring from the boy's breast bone down to his navel, and he remained at the hospital for four weeks. After discharge, the boy was kept on a special low-fat diet for months until his pancreatitis resolved. Doctors informed his mother that her son has the potential to develop a bowel obstruction secondary to his internal adhesions and scarring.
The boy's mother, on her own and her son's behalf, sued the pediatrician, the hospital, and other entities for medical malpractice. The plaintiff ultimately focused her lawsuit on the pediatrician and alleged that the doctor failed to consider a drug reaction or drug toxicity as his patient's symptoms progressed. The plaintiff also alleged that the doctor failed to properly monitor her son while he was receiving potent antibiotics at home known to have effects on the liver and kidneys, including hepatoxicity and nephrotoxicity, and she maintained that he failed to inquire of her — or anyone else — whether blood work was being performed. The plaintiff sought $73,000 in damages for her medical expenses and unspecified additional damages for pain and suffering.
In his defense, the doctor pointed out that he referred the boy to infectious diseases specialists at the outset because treatment of osteomyelitis and antibiotic toxicity were outside of his area of expertise. He also maintained that he was under no duty to monitor the child as an outpatient and that he had no knowledge of the discharge plan effectuated by the hospital. The doctor lastly argued that the boy's symptoms of rash, fever, and listlessness were more typical of a viral presentation rather than of any drug reaction or drug-toxicity reaction. After a jury trial, a verdict was returned in favor of the plaintiff for $1.073 million. The parties ultimately settled, however, for $600,000.
What this means to you: This case illustrates that when a child is the injured party, someone likely will bear the larger share of the blame, even if that individual had less than full liability in the grand scheme of the entire incident. "Juries are generally more sympathetic to child plaintiffs, as they see a child as more vulnerable and dependent on the professional accountability of the health care delivery system," notes Lynn Rosenblatt, CRRN, LHRM, risk manager at HealthSouth Sea Pines Rehabilitation Hospital in Melbourne, FL. "In this case, the pediatrician was the target of the jury's obvious disgust that such an egregious situation had occurred."
The pediatrician was the first provider that the child had contact with. "Once the pediatrician determined that the situation was beyond his expertise, he did the right thing in referring the case to an infectious diseases specialist. And from there, the treatment seemed appropriate," says Rosenblatt. In fact, it was at this juncture that the mother failed to follow instructions to return for blood monitoring, which prompts Rosenblatt to question what exactly the mother was told about the necessity of doing so. From a risk management perspective, there should have been some follow-up at this point by the infectious disease group to ensure the lab draws occurred as necessary to monitor the patient.
At the two-week interval, the pediatrician again was involved in the boy's care when he was consulted by the mother regarding the change in her son's condition. "The pediatrician should have collaborated with the specialist. The pediatrician was most likely aware that the child was on powerful antibiotics and, given the boy's age, there were certain risks to long-term treatment," says Rosenblatt. Rosenblatt notes that the pediatrician did not involve the infectious diseases team either because he did not question the mother sufficiently to know exactly what the course of treatment and follow-up had been or because he did not anticipate the possible signs of drug toxicity.
In his argument at trial, the pediatrician used the defense that he had no knowledge of the care provided by the hospital and the infectious diseases specialist. He also contended that he had no obligation to monitor the child while receiving treatment from another professional. But Rosenblatt believes an argument can be made that the pediatrician had an obligation to follow up on the treatment that the infectious disease expert ordered. "The child remained his patient and was obviously under his care," she notes.
Rosenblatt thinks the pediatrician's argument completely disregards the concepts of "primary care provider" and "consulting physician." "While the consultant is managing a specific disease process according to his specialty training," she says, "the pediatrician still remains the primary attending following the patient." The pediatrician therefore is responsible for maintaining awareness of the patient's treatment by other providers and how that treatment affects the care the pediatrician is providing on an ongoing basis.
But Rosenblatt is quick to point out that this premise does not negate the obligation of the other providers to appropriately follow the patient and initiate appropriate interventions based on timely assessment and information from a coordinated network of care. Rosenblatt far too often has seen complex case management become segregated among specialties when no one identifies the role of case coordinator from the beginning. She thinks that this responsibility likely should have fallen by default to the pediatrician, as he was the primary practitioner and the others were brought in at his bequest. Because there was apparently no discussion between the various players as to the nature of the treatment, the appropriate follow-up, the effectiveness of the treatment over time, and the ongoing issues with the child, the obvious potential drug toxicity was overlooked until the child was in an advanced state of system failure. "All providers have some obligation to intervene at some point and come to this conclusion," she says. "Unfortunately, because they each were acting independent of the other providers, the child's condition went undetected until it was far advanced and life-threatening."