Legal Pearls: Missed Meningitis in a Child
Meningitis can be difficult to diagnose, especially in children who may present without some of the more obvious symptoms, such as a stiff neck. In this case, having a pediatrician on call for the emergency department staff might potentially have avoided the tragic consequences of the delayed diagnosis of meningitis.
Clinical Scenario
The patient was a 4-and-a-half-year-old girl. She developed a fever of 105 degrees as well as red, non-blanching skin lesions and vomiting. As it was a weekend, her parents took the girl to an urgent care office where a physician assistant examined her. The physician assistant, fearing that it might be meningitis, referred the parents to a nearby hospital emergency department for evaluation and treatment.
The emergency room physician who was working that evening was not particularly familiar with pediatrics. Luckily, he had found that most of the reasons why parents brought a child in to the emergency department, particularly on a weekend, were common illnesses—the flu, strep throat, ear infections, and the like.
After examining the patient, and speaking to the parents, the physician concluded that the child had acute gastroenteritis. He based his conclusion on the episodes of vomiting and the child’s fever. The physician discharged the girl from the hospital with prescriptions for Tylenol and Phenergan.
The child did not improve, however, and by Monday morning her worried parents called her regular pediatrician and described the symptoms. The pediatrician told the parents to return to the hospital emergency department immediately. On the second visit to the emergency department, another physician diagnosed meningitis, which was confirmed with a lumbar puncture.
The child was given intravenous antibiotics and fluids, and while she showed initial improvement, her condition continued to worsen throughout the evening. At midnight, the girl was flown to another hospital which had a pediatric intensive care unit. However, she developed purpura fulminans and disseminated intravascular coagulation and both arms and legs had to be amputated. The child underwent over 20 surgeries to stabilize her condition.
The Lawsuit
The parents of the girl consulted with a plaintiff’s attorney who advised them to sue the hospital based on the wrong diagnosis of their daughter, which resulted in a delay in treatment. The attorney had physician experts look at the medical records, and all were critical of the initial physician’s treatment of the child. The experts were also critical of the hospital because the hospital had a policy calling for referral of the child to a pediatrician in this situation, however hospital administration had failed to train the physician and the other emergency department physicians about its own policy.
The initial response of the hospital was to try to claim that because the physician was an independent contractor, that it was not responsible for his actions. That claim swiftly failed. Next, the hospital contended that the physician did not fall below the standard of care. This claim was rebutted by all the plaintiff’s experts, and even the defense’s own experts when they were questioned under cross examination. Finally, on advice from the defense attorneys representing the hospital, a structured settlement was reached with the family of the girl, which would provide her with over 10 million dollars over a span of time.
Settlement
By the time the case was approaching trial, the girl’s condition was stabilized, and she was attending regular school where she was an honor student. However, she was confined to a motorized wheelchair. The defense attorneys for the hospital knew that the girl would make a very sympathetic witness for a jury and felt that they did not have a good chance of winning at trial.
Also hindering the hospital from going to trial was the fact that the physician clearly missed a diagnosis he should have considered. The high fever and the child’s rash should have caused the physician to suspect meningitis and start antibiotics at the earliest possible time. However, the physician ignored the rash, and focused on the vomiting—leading to the diagnosis of gastroenteritis.
What’s the Take Home?
Unfortunately, because the symptoms are sometimes slightly different in children, and because very young children may not be able to express something like a headache or stiff neck, there are many cases involving missed diagnoses of meningitis. For example, in another case, a 17-month-old baby who had a high fever for several days was misdiagnosed in the emergency department as having tonsillitis. The delay in proper diagnosis and treatment left the child deaf, and the experts in that case were very critical of the physician’s diagnosis of tonsillitis, which is not typical in that age group.
If you believe a patient may have meningitis, a lumbar puncture should be ordered immediately as well as blood cultures. Meningitis must be treated as swiftly as possible with antibiotics. If you do not believe a child has meningitis, and you are discharging that child from the emergency department, be sure that the patient’s record is well documented on discharge from the hospital. This would include documentation that the child is alert, responsive, taking food or liquids, is not irritable or in pain, etc. Also, be sure to provide very specific follow-up information for parents, instructing them when to return to the hospital, when to call their own physician, and what signs, symptoms, and dangers to be alert for. As with most legal cases, good documentation is often your best bet, both for protecting yourself from lawsuits and for protecting your patients from harm.
Bottom Line—Know when to seek the consultation of a pediatrician. Pediatricians are much more familiar with the ways that a child might present with meningitis. If you have any doubt, seek a consultation.
Ann W. Latner, JD, is a freelance writer and attorney based in New York. She was formerly the director of periodicals at the American Pharmacists Association and editor of Pharmacy Times.