Neonatology and Pediatrics

CHAPTER 32 Neonatology and Pediatrics



Jonathan Fanaroff, M.D., J.D., F.C.L.M. , Robert Turbow, M.D., J.D., F.C.L.M.




GOLDEN RULES



1. Stay current by reading journals and textbooks and by attending CME conferences.

2. Maintain professional ties with a large medical center.

3. If facing a difficult situation, consider consulting with a colleague.

4. Maintain open communication with parents and families.

5. Ensure timely documentation of procedures, communication, complications, who was present.

6. Document telephone advice.

7. If unsure, do not diagnose over the phone.

8. Be aware of state laws that affect your practice.

This chapter will focus on medical malpractice issues in pediatrics and in perinatal/neonatal medicine that can affect the daily professional lives of those who work with infants, children, and adolescents. Note that most of the neonatal issues are common issues and apply to pediatricians who care for newborns and attend deliveries as well as neonatologists. Practicing clinicians must understand their rights, duties, and liabilities as physicians.




CASE PRESENTATION


In their pediatric malpractice lawsuit, Mr. and Mrs. Smith claimed that on July 27, 2005, Mrs. Smith called Dr. Case for advice regarding their 15-month-old daughter Samantha. Samantha had been well until July 25, when she developed a low-grade fever. At that time Mrs. Smith talked to Dr. Case’s partner, who recommended acetaminophen. By the next day (July 26), in addition to the fever, Samantha had developed a significant cough. Dr. Case recommended Robitussin and also thought that she may be dehydrated and stated that Pedialyte should be given to see if she would produce a wet diaper by 2:00 p.m., which she did. Mrs. Smith called back to inform Dr. Case of this, and also that Samantha seemed abnormally drowsy and sluggish and still had a fever despite the acetaminophen. Mrs. Smith also allegedly asked whether she should take Samantha to the Emergency Department, but was told by Dr. Case that this was not necessary and that Samantha could be given ibuprofen and to see if she produced six wet diapers by that evening. Samantha produced five by that evening, so the Smiths thought everything was fine and went to bed.


The next morning on July 27, at about 9:00 a.m., Mrs. Smith had a hard time waking Samantha and called Dr. Case again about taking her to the Emergency Department, but he told her to “give it half an hour” to see if she improves. The Smiths were unsatisfied with this advice and took her to the ED at the Main Street Hospital where they waited half an hour before being seen by the triage nurse. At that time she was immediately taken to a treatment room where a spinal tap was performed and she was diagnosed with bacterial meningitis. Antibiotics were started but by that time she was severely brain-damaged.


When Dr. Case visited the family he told them that antibiotics seemed unnecessary because their baby would be better off dead. He also argued with the family over whether he should have diagnosed the meningitis earlier, stating that “over the phone it sounded like dehydration.”


While not admitting to any negligence or responsibility, the suit was settled for $9 million.



ISSUES



Introduction


As the above case illustrates, pediatric malpractice claims can result in very large money damages. Pediatric patients are often treated with enormous sympathy by juries. Also, many of the most common errors in diagnosis, such as meningitis and brain-damaged infants, lead to severe and permanent injuries. Furthermore, children are at the beginning of their lives, so that the lifetime cost of care for a permanently injured child can easily run in the millions of dollars.


Because of the factors mentioned above, the average closed pediatric malpractice claim in 2004 was approximately $468,000 according to the Physician Insurers Association of America (PIAA). This is 43% higher than the overall average for all physician specialties. Indeed, the PIAA ranks pediatrics fourth in highest average indemnity from 1985 to 2004, behind neurology, neurosurgery, and obstetrics/gynecology.


The relatively high malpractice risks are due in part to the tremendous clinical and ethical challenges surrounding pediatric and neonatal medicine. In both fields, there are some unique challenges and issues that differ somewhat from adult medicine. First, parents or guardians have a moral and legal responsibility to care for and protect their children and thus become an additional and essential party in the doctor–patient relationship. Second, infants and young children are unable to create or express their own preferences and thus the physician has their own legal and moral obligation to ensure that the parents are acting in the best interests of the child. Third, as children get older, they generally can communicate their own preferences. Therefore, their assent to treatment becomes increasingly important.


Neonatologists, like pediatricians, face multiple challenges, especially surrounding the care of premature infants at the limits of viability. Does the physician have to honor whatever the parents request? What if the parents do not want resuscitation and the medical team disagrees? What if there is conflict between the parents’ wishes and hospital policy or national guidelines? These questions are not just academic. A recently overturned $60 million verdict (HCA, Inc. v. Miller ex rel. Miller) accentuates the importance of knowing the multitude of cases and legislation that affect clinical practice. These areas remain contentious and ill-defined in many states. Physicians are often caught in the middle with potential liability for either resuscitating or not resuscitating, although certainly good communication can minimize this risk.



Common Malpractice Suits in Pediatrics


Malpractice suits in pediatrics most commonly arise from:


image Meningitis

image Appendicitis

image Specified nonteratogenic anomalies

image Pneumonia

image Brain-damaged infants

image Telephone triage—failure to treat/delayed treatment.

The most prevalent causes of malpractice suits against pediatricians involve errors in diagnosis. Part of the reason for this lies with the nature of pediatrics; obtaining a history from a child is very different from that of an adult. Does the 8-year-old with abdominal pain have a surgical emergency such as appendicitis, or are they trying to avoid confronting the school bully on the playground? Additionally, the pediatrician is often trying to provide medical care and advice over the telephone, without the advantage of having the patient in front of them.


One theme that arises repeatedly in pediatric malpractice cases, however, is a failure of the physician to heed the concerns of the parent. In general, no one knows their child better than the parents, and their concerns should always be taken seriously. Furthermore, while parents may not be able to explain their exact concern, they are often able to correctly intuit that something is wrong. Much of the advice in this book applies to pediatric patients. In the following paragraphs we will examine some specific issues in pediatrics.



Meningitis


As the case illustrates, pediatric meningitis malpractice cases lead to some of the highest average indemnities paid and also have among the highest payout ratios. Often these cases involve children too young to verbalize their symptoms, with the median age of patients being 2 years old in the PIAA Meningitis Claims Study undertaken in 2000. Many of these cases, almost 25% in the PIAA study, claim a delay in diagnosis, and, as in the case noted above, often the first contact is over the phone. Symptoms are often generalized and can include fever, nausea and vomiting, lethargy, change in mental status, and neck stiffness. Furthermore, it is important to maintain a low threshold to work up (including lumbar puncture) and treat possible meningitis, especially in infants and toddlers. Finally, a prudent physician will note if a parent states that a child is lethargic or not acting normally.



Appendicitis


Abdominal pain is an extremely common presenting complaint for pediatric patients. Approximately 15% of school-aged children are brought to a physician because of abdominal pain, of which the most common serious disorder is appendicitis. Misdiagnosing appendicitis or other causes of abdominal pain, such as constipation, gas pain, or gastroenteritis, can lead to a lawsuit. In the PIAA Data Sharing System Report from 1985 to 2003, failure to diagnose appendicitis was the second most frequent patient condition missed. One important problem in many of these cases was poor documentation. If a child presents with symptoms that may represent a “surgical abdomen,” it would seem prudent for the pediatrician to document the presence or absence of pain in each quadrant, distension, guarding, rebound, tenderness, and bowel sounds. It is also important to recognize that the diagnosis of gastroenteritis is generally associated with vomiting and diarrhea. Finally, the parents need to be educated as to their most appropriate course of action should the child’s condition worsen. Parents should be instructed that prompt reevaluation may stave off a serious medical/surgical problem, and the physician’s instructions to the parents should be documented in the child’s chart.



Telephone Triage


Pediatricians regularly offer medical advice over the telephone. Indeed, it has been estimated that up to 30% of all ambulatory pediatric care is delivered via the phone. This care led to almost 100 malpractice claims and over $11 million to plaintiffs during the period 1985–2004. In the case presented at the beginning of the chapter, it is certainly possible that the outcome would have been different had Samantha been seen and examined in the office rather than over the phone. Thorough documentation is important, as is accessibility, when setting up a phone triage system. It is particularly important to recognize that the parent or caregiver who has made the call is not a trained health care professional and cannot be expected to know exactly what to look for and what to tell you. If the telephone triage personnel determine that the parents seem to be overly nervous or the parents are insisting that their child be evaluated in person, then the prudent practitioner will strongly consider accommodating the family or referring the family to an acute care center or emergency department. The American Academy of Pediatrics Section on Telephone Care has developed a comprehensive set of management guidelines. When followed appropriately, these guidelines can mitigate the considerable legal risk associated with telephone care.

Related posts:

  1. Professional Liability Insurance
  2. Medical Malpractice Stress Syndrome
  3. Improper Disclosure of Confidential Information
  4. Neurology and Neurosurgery

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Mar 25, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Neonatology and Pediatrics

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