No tests ordered, despite baby's yellowing skin ... Amputation blamed on tardy Dx of compartment syndrome

No tests ordered, despite baby’s yellowing skin

Many studies suggest that our ability to judge bilirubin levels on the basis of skin color is rather limited.

A 5-DAY-OLD INFANT’S YELLOW COMPLEXION led his worried mother to take him to a family practice. The physician assistant (PA) who examined the child noted yellowing of his face and chest. When the baby’s doctor arrived at the office unexpectedly, the PA consulted with her. The mother was given standard infant care instructions; no orders for diagnostic testing were issued.

Two days later the baby’s skin became yellower and he appeared lethargic. His mother brought him to a clinic, where she was told to take him to the hospital immediately. Testing at the hospital revealed an elevated bilirubin level. The infant developed kernicterus and suffered brain damage, resulting in developmental delays and cerebral palsy.

PLAINTIFF’S CLAIM The physician was negligent in failing to test and treat the infant promptly. The mother claimed that the physician had treated her older son for jaundice, as well. The mother also claimed that the physician noted the infant’s skin color but did nothing.

THE DEFENSE The infant’s sclera were white and he was alert and active when examined. The mother didn’t follow the instructions given to her.

VERDICT $6.25 million Delaware verdict.

COMMENT Many studies suggest that our ability to judge bilirubin levels on the basis of skin color is rather limited. It’s hard to imagine not doing a simple test in this situation.

Amputation blamed on tardy Dx of compartment syndrome

PAIN IN HER RIGHT LEG AND KNEE prompted a woman in her 60s to go to the emergency department (ED). She couldn’t remember any specific event or trauma that might have triggered the pain. Her history included deep vein thrombosis, pulmonary embolism, diabetes, hypertension, placement of a Green-field filter, and right knee replacement. She was taking warfarin; her international normalized ratio (INR) in the ED was 5.0. A physician diagnosed joint effusion and sent the patient home on pain killers.

Two days later, the patient returned to the ED complaining of numbness in her leg and excruciating pain in her right calf. She was seen by a different physician, who ordered a surgical consultation. Evaluation revealed a lack of sensation in her right foot, a dorsalis pedis pulse undetectable by Doppler ultrasound, and inability to dorsiflex or plantarflex the right foot.

Compartment syndrome was diagnosed and an emergent fasciotomy performed. The patient suffered extensive muscle and tissue death and became septic, necessitating an above-knee amputation. While recuperating and waiting for a prosthesis, the patient fell from her wheelchair, fracturing her dominant arm and shoulder in several places.

PLAINTIFF’S CLAIM No information about the plaintiff‘s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $890,000 Virginia settlement.

COMMENT When the diagnosis is ambiguous, close follow-up and reevaluation is key to avoiding a hefty settlement.

Abnormal labs go unnoted, patient goes into septic shock

A 52-YEAR-OLD WOMAN went to the ED because of vomiting and weakness. Her fingers and toes were blue; she was tachycardic and hypotensive. A pacemaker/defibrillator had been implanted 3 weeks earlier. The woman’s history included cardiomyopathy, eczema, renal failure, and lumbar fusion requiring maintenance narcotic medication. When initial blood tests showed hypokalemia, she was given potassium and general fluid resuscitation.

The ED physician also ordered a complete blood count, which automatically included differential and band counts. The patient’s bands were high and her platelets low, but these results weren’t noted.

The patient improved after receiving fluids; her longtime physician admitted her to the hospital with a diagnosis of hypokalemia and narcotic withdrawal. He ordered repeat blood work for the following morning.

That evening, another doctor, who was covering for the patient’s physician, received calls from nurses reporting that the patient was complaining of increased pain in her extremities. He diagnosed Raynaud’s syndrome and ordered medication. The patient’s physician also diagnosed Raynaud’s syndrome when he saw her the next morning; he noted that she was improving and ordered her diet to resume. The results from the second CBC, performed that morning, weren’t noted in the patient’s chart.

The covering doctor was on duty again in the evening and again received calls reporting that the patient was in pain. The following morning the patient went into septic shock. She was diagnosed with a staph infection and transferred to the ICU, where she died of sepsis and multi-organ failure a few days later.

PLAINTIFF’S CLAIM The doctors and nurses were negligent in failing to note the abnormal band and platelet counts for 44 hours. The physicians should have recognized signs and symptoms of infection and administered antibiotics. The hospital should have reported the laboratory results and findings of infection to the physicians.

THE DEFENSE The patient’s physician maintained that the patient’s signs and symptoms weren’t consistent with infection. He didn’t order a differential blood test and wasn’t aware that the hospital performed it automatically. He claimed that the results weren’t available to him on the first 2 days; the hospital and nurses claimed that the results were available.

The covering doctor argued that he was only the on-call physician, never actually saw the patient, and had no duty to follow up on the blood tests. The hospital maintained that the nurses had no duty to look at the laboratory results unless requested to do so and that the physicians hadn’t asked them to do so.

VERDICT $500,000 Illinois verdict against the patient’s physician; high/low agreement of $3 million/$150,000 between plaintiff and hospital ($150,000 to be set off from the verdict against the physician).

COMMENT If a test is ordered, review it promptly. Ignorance is unlikely to be an adequate defense in a malpractice allegation.

Infection, then rapid death

HIGH FEVER, DIARRHEA, LETHARGY, SPREADING RASH, and other symptoms in a 16-month-old boy led to an ED visit. The child died about 3 hours later from meningococcemia and sepsis caused by Neisseria meningitidis (Waterhouse-Friderichsen syndrome).

PLAINTIFFS’ CLAIM The ED physician failed to properly monitor and treat the child’s deteriorating condition from meningococcemia and septic shock.

THE DEFENSE The child received proper treatment, but his condition was too far advanced to prevent his death.

VERDICT Illinois defense verdict.

COMMENT Urgent evaluation and treatment—even today—can be imperative to help prevent the sequelae of meningococcemia.

No tests ordered, despite baby’s yellowing skin

Many studies suggest that our ability to judge bilirubin levels on the basis of skin color is rather limited.

A 5-DAY-OLD INFANT’S YELLOW COMPLEXION led his worried mother to take him to a family practice. The physician assistant (PA) who examined the child noted yellowing of his face and chest. When the baby’s doctor arrived at the office unexpectedly, the PA consulted with her. The mother was given standard infant care instructions; no orders for diagnostic testing were issued.

Two days later the baby’s skin became yellower and he appeared lethargic. His mother brought him to a clinic, where she was told to take him to the hospital immediately. Testing at the hospital revealed an elevated bilirubin level. The infant developed kernicterus and suffered brain damage, resulting in developmental delays and cerebral palsy.

PLAINTIFF’S CLAIM The physician was negligent in failing to test and treat the infant promptly. The mother claimed that the physician had treated her older son for jaundice, as well. The mother also claimed that the physician noted the infant’s skin color but did nothing.

THE DEFENSE The infant’s sclera were white and he was alert and active when examined. The mother didn’t follow the instructions given to her.

VERDICT $6.25 million Delaware verdict.

COMMENT Many studies suggest that our ability to judge bilirubin levels on the basis of skin color is rather limited. It’s hard to imagine not doing a simple test in this situation.

Amputation blamed on tardy Dx of compartment syndrome

PAIN IN HER RIGHT LEG AND KNEE prompted a woman in her 60s to go to the emergency department (ED). She couldn’t remember any specific event or trauma that might have triggered the pain. Her history included deep vein thrombosis, pulmonary embolism, diabetes, hypertension, placement of a Green-field filter, and right knee replacement. She was taking warfarin; her international normalized ratio (INR) in the ED was 5.0. A physician diagnosed joint effusion and sent the patient home on pain killers.

Two days later, the patient returned to the ED complaining of numbness in her leg and excruciating pain in her right calf. She was seen by a different physician, who ordered a surgical consultation. Evaluation revealed a lack of sensation in her right foot, a dorsalis pedis pulse undetectable by Doppler ultrasound, and inability to dorsiflex or plantarflex the right foot.

Compartment syndrome was diagnosed and an emergent fasciotomy performed. The patient suffered extensive muscle and tissue death and became septic, necessitating an above-knee amputation. While recuperating and waiting for a prosthesis, the patient fell from her wheelchair, fracturing her dominant arm and shoulder in several places.

PLAINTIFF’S CLAIM No information about the plaintiff‘s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $890,000 Virginia settlement.

COMMENT When the diagnosis is ambiguous, close follow-up and reevaluation is key to avoiding a hefty settlement.

Abnormal labs go unnoted, patient goes into septic shock

A 52-YEAR-OLD WOMAN went to the ED because of vomiting and weakness. Her fingers and toes were blue; she was tachycardic and hypotensive. A pacemaker/defibrillator had been implanted 3 weeks earlier. The woman’s history included cardiomyopathy, eczema, renal failure, and lumbar fusion requiring maintenance narcotic medication. When initial blood tests showed hypokalemia, she was given potassium and general fluid resuscitation.

The ED physician also ordered a complete blood count, which automatically included differential and band counts. The patient’s bands were high and her platelets low, but these results weren’t noted.

The patient improved after receiving fluids; her longtime physician admitted her to the hospital with a diagnosis of hypokalemia and narcotic withdrawal. He ordered repeat blood work for the following morning.

That evening, another doctor, who was covering for the patient’s physician, received calls from nurses reporting that the patient was complaining of increased pain in her extremities. He diagnosed Raynaud’s syndrome and ordered medication. The patient’s physician also diagnosed Raynaud’s syndrome when he saw her the next morning; he noted that she was improving and ordered her diet to resume. The results from the second CBC, performed that morning, weren’t noted in the patient’s chart.

The covering doctor was on duty again in the evening and again received calls reporting that the patient was in pain. The following morning the patient went into septic shock. She was diagnosed with a staph infection and transferred to the ICU, where she died of sepsis and multi-organ failure a few days later.

PLAINTIFF’S CLAIM The doctors and nurses were negligent in failing to note the abnormal band and platelet counts for 44 hours. The physicians should have recognized signs and symptoms of infection and administered antibiotics. The hospital should have reported the laboratory results and findings of infection to the physicians.

THE DEFENSE The patient’s physician maintained that the patient’s signs and symptoms weren’t consistent with infection. He didn’t order a differential blood test and wasn’t aware that the hospital performed it automatically. He claimed that the results weren’t available to him on the first 2 days; the hospital and nurses claimed that the results were available.

The covering doctor argued that he was only the on-call physician, never actually saw the patient, and had no duty to follow up on the blood tests. The hospital maintained that the nurses had no duty to look at the laboratory results unless requested to do so and that the physicians hadn’t asked them to do so.

VERDICT $500,000 Illinois verdict against the patient’s physician; high/low agreement of $3 million/$150,000 between plaintiff and hospital ($150,000 to be set off from the verdict against the physician).

COMMENT If a test is ordered, review it promptly. Ignorance is unlikely to be an adequate defense in a malpractice allegation.

Infection, then rapid death

HIGH FEVER, DIARRHEA, LETHARGY, SPREADING RASH, and other symptoms in a 16-month-old boy led to an ED visit. The child died about 3 hours later from meningococcemia and sepsis caused by Neisseria meningitidis (Waterhouse-Friderichsen syndrome).

PLAINTIFFS’ CLAIM The ED physician failed to properly monitor and treat the child’s deteriorating condition from meningococcemia and septic shock.

THE DEFENSE The child received proper treatment, but his condition was too far advanced to prevent his death.

VERDICT Illinois defense verdict.

COMMENT Urgent evaluation and treatment—even today—can be imperative to help prevent the sequelae of meningococcemia.

No tests ordered, despite baby’s yellowing skin

Many studies suggest that our ability to judge bilirubin levels on the basis of skin color is rather limited.

A 5-DAY-OLD INFANT’S YELLOW COMPLEXION led his worried mother to take him to a family practice. The physician assistant (PA) who examined the child noted yellowing of his face and chest. When the baby’s doctor arrived at the office unexpectedly, the PA consulted with her. The mother was given standard infant care instructions; no orders for diagnostic testing were issued.

Two days later the baby’s skin became yellower and he appeared lethargic. His mother brought him to a clinic, where she was told to take him to the hospital immediately. Testing at the hospital revealed an elevated bilirubin level. The infant developed kernicterus and suffered brain damage, resulting in developmental delays and cerebral palsy.

PLAINTIFF’S CLAIM The physician was negligent in failing to test and treat the infant promptly. The mother claimed that the physician had treated her older son for jaundice, as well. The mother also claimed that the physician noted the infant’s skin color but did nothing.

THE DEFENSE The infant’s sclera were white and he was alert and active when examined. The mother didn’t follow the instructions given to her.

VERDICT $6.25 million Delaware verdict.

COMMENT Many studies suggest that our ability to judge bilirubin levels on the basis of skin color is rather limited. It’s hard to imagine not doing a simple test in this situation.

Amputation blamed on tardy Dx of compartment syndrome

PAIN IN HER RIGHT LEG AND KNEE prompted a woman in her 60s to go to the emergency department (ED). She couldn’t remember any specific event or trauma that might have triggered the pain. Her history included deep vein thrombosis, pulmonary embolism, diabetes, hypertension, placement of a Green-field filter, and right knee replacement. She was taking warfarin; her international normalized ratio (INR) in the ED was 5.0. A physician diagnosed joint effusion and sent the patient home on pain killers.

Two days later, the patient returned to the ED complaining of numbness in her leg and excruciating pain in her right calf. She was seen by a different physician, who ordered a surgical consultation. Evaluation revealed a lack of sensation in her right foot, a dorsalis pedis pulse undetectable by Doppler ultrasound, and inability to dorsiflex or plantarflex the right foot.

Compartment syndrome was diagnosed and an emergent fasciotomy performed. The patient suffered extensive muscle and tissue death and became septic, necessitating an above-knee amputation. While recuperating and waiting for a prosthesis, the patient fell from her wheelchair, fracturing her dominant arm and shoulder in several places.

PLAINTIFF’S CLAIM No information about the plaintiff‘s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $890,000 Virginia settlement.

COMMENT When the diagnosis is ambiguous, close follow-up and reevaluation is key to avoiding a hefty settlement.

Abnormal labs go unnoted, patient goes into septic shock

A 52-YEAR-OLD WOMAN went to the ED because of vomiting and weakness. Her fingers and toes were blue; she was tachycardic and hypotensive. A pacemaker/defibrillator had been implanted 3 weeks earlier. The woman’s history included cardiomyopathy, eczema, renal failure, and lumbar fusion requiring maintenance narcotic medication. When initial blood tests showed hypokalemia, she was given potassium and general fluid resuscitation.

The ED physician also ordered a complete blood count, which automatically included differential and band counts. The patient’s bands were high and her platelets low, but these results weren’t noted.

The patient improved after receiving fluids; her longtime physician admitted her to the hospital with a diagnosis of hypokalemia and narcotic withdrawal. He ordered repeat blood work for the following morning.

That evening, another doctor, who was covering for the patient’s physician, received calls from nurses reporting that the patient was complaining of increased pain in her extremities. He diagnosed Raynaud’s syndrome and ordered medication. The patient’s physician also diagnosed Raynaud’s syndrome when he saw her the next morning; he noted that she was improving and ordered her diet to resume. The results from the second CBC, performed that morning, weren’t noted in the patient’s chart.

The covering doctor was on duty again in the evening and again received calls reporting that the patient was in pain. The following morning the patient went into septic shock. She was diagnosed with a staph infection and transferred to the ICU, where she died of sepsis and multi-organ failure a few days later.

PLAINTIFF’S CLAIM The doctors and nurses were negligent in failing to note the abnormal band and platelet counts for 44 hours. The physicians should have recognized signs and symptoms of infection and administered antibiotics. The hospital should have reported the laboratory results and findings of infection to the physicians.

THE DEFENSE The patient’s physician maintained that the patient’s signs and symptoms weren’t consistent with infection. He didn’t order a differential blood test and wasn’t aware that the hospital performed it automatically. He claimed that the results weren’t available to him on the first 2 days; the hospital and nurses claimed that the results were available.

The covering doctor argued that he was only the on-call physician, never actually saw the patient, and had no duty to follow up on the blood tests. The hospital maintained that the nurses had no duty to look at the laboratory results unless requested to do so and that the physicians hadn’t asked them to do so.

VERDICT $500,000 Illinois verdict against the patient’s physician; high/low agreement of $3 million/$150,000 between plaintiff and hospital ($150,000 to be set off from the verdict against the physician).

COMMENT If a test is ordered, review it promptly. Ignorance is unlikely to be an adequate defense in a malpractice allegation.

Infection, then rapid death

HIGH FEVER, DIARRHEA, LETHARGY, SPREADING RASH, and other symptoms in a 16-month-old boy led to an ED visit. The child died about 3 hours later from meningococcemia and sepsis caused by Neisseria meningitidis (Waterhouse-Friderichsen syndrome).

PLAINTIFFS’ CLAIM The ED physician failed to properly monitor and treat the child’s deteriorating condition from meningococcemia and septic shock.

THE DEFENSE The child received proper treatment, but his condition was too far advanced to prevent his death.

VERDICT Illinois defense verdict.

COMMENT Urgent evaluation and treatment—even today—can be imperative to help prevent the sequelae of meningococcemia.