Failure to diagnose rhabdomyolysis

Presentation
At 3:20 p.m., a 3-year-old girl was brought to the emergency department (ED) with complaints of fever, lethargy, sore throat, severe leg pain bilaterally with decreased sensation, absent reflexes, weakness, and inability to walk. Similar symptoms existed in her arms, but were not as pronounced. She was noted to have a non-raised rash on her palms and erythema of her pharynx with a white exudate and possible blisters on her tonsils.

Physical examination revealed temperature of 102.7 degrees; heart rate at 152 bpm; respirations at 28; O2 saturation 97 percent; and intact cranial nerves without meningeal signs or facial palsy. Labwork revealed a white blood count of 17.8 with a left shift and bandemia with normal hemoglobin, hematocrit, and platelet count. Electrolytes and renal function study results were reported as normal. Her mother noted the patient’s urine was amber and slightly cloudy.

A lumbar puncture was performed to rule out meningitis and ceftriaxone was administered. She was also given an initial bolus of 300 ml NS and started on D5 one-half NS at 60 ml/hr because of dehydration. Acetaminophen 240 mg and ibuprofen 120 mg were given for fever. At 4:20 p.m., the emergency medicine physician contacted the on-call pediatrician, one of the defendants in this case, and reported the child’s condition.


Physician action
The on-call pediatrician elected not to come to the ED. Instead, she gave a telephone order to obtain a urinalysis via catheterization. She then had follow-up conversations with the ED physician at 5:23 p.m. and the ED nurse at 6 p.m. and again at 7:45 p.m., concerning the pending urinalysis.

Later in the evening, the child’s condition worsened and the pediatrician was contacted again. The pediatrician arrived at 9 p.m., 5.5 hours after the child came to the ED. She found the patient to have temperature of 98.3 degrees; heart rate of 120 bpm;  respirations at 24;  good capillary refill; and warm extremities with no meningeal signs. Neurological exam revealed no deep tendon reflexes or muscle tone of the lower extremities and 1+ deep tendon reflexes on the upper extremities. The child complained of extreme pain in her legs. The physician’s impression was viral myalgia or myositis process versus possible Guillian-Barre’ syndrome. Her documentation noted the most likely diagnosis being viral illness, but also mentioned Bornholm and Coxsackie virus as possibilities. The pediatrician did not communicate directly with the child’s mother.

The urinalysis revealed a large amount of blood with a few RBCs. It was reported to the pediatrician that only a 6 cc urine specimen was obtained for analysis. No order for a second urinalysis was written; however, an order to continue IV fluids was given. The child did not void while in the ED, despite being given the IV bolus of 300 ml and a continuous IV fluid drip at 60 ml/hr. The child’s mother expressed concern to the nurses that the patient had not voided since 1 p.m., and the nurses encouraged the child to do so. The child denied the need.

At 12:50 a.m., the pediatrician wrote orders to admit the child to the adult ICU, and then left the hospital. The admission orders included telemetry and O2 monitoring, strict I & O, IV D5 one-half NS at 60 ml/hr and to call the patient’s regular pediatrician in the morning. On admission to the ICU, vital signs were: temperature 96.2 degrees; blood pressure, 119/78 mm Hg; respirations 45; O2 saturation 100 percent. Because the child had still not voided by 4:03 a.m., the pediatrician was paged and returned the call at 4:06 a.m. She gave orders to encourage voiding again and to catheterize if unsuccessful.

At 4:09 a.m., the mother placed the child on the bedpan and noticed that the child felt “heavy.” At 4:15 a.m., the child was catheterized returning only 31 cc of “dark brown coffee colored urine.”

At 4:18 a.m. vital signs showed changes and the ED physician ordered a stat EKG. The ED physician arrived in the ICU to see the child at 4:30 a.m. Her blood pressure was 92/48 mm Hg and her heart rate was 86. The patient coded. The pediatrician was paged at 4:35 a.m., and arrived at 4:55 a.m. She participated in and then conducted the code. The child was pronounced dead at 6:15 a.m. An autopsy was performed and concluded the cause of death to be from rhabdomyolysis.


Allegations
A lawsuit was filed against the pediatrician, alleging failure to timely report to the ED to evaluate the child; failure to properly evaluate; failure to diagnose and treat rhabdomyolysis; and failure to transfer the patient to an appropriate facility. The hospital and the ED physician were also named in this suit.


Legal implications
No experts reviewing this claim were fully supportive of the defendant’s treatment. Defense consultants had concerns in the following areas:

  • delay in arrival to the hospital — 5.5 hours after the child came to the ED;
  • failure to recognize clinical signs that would have led to appropriate treatment and transfer of patient for dialysis — including anuria since 1 p.m., abnormal lab results, elevated T-wave;
  • failure to order appropriate testing even after receiving abnormal results — repeat UA, CPK, electrolytes; and
  • failure to properly handle a code — monitor strips clearly showed a severe electrolyte problem that was not recognized. 

The damages of this case centered on the untimely death of a 3-year-old child. Consultants who reviewed this case agreed that the patient’s death could have been prevented had the appropriate care been delivered. Chances of a successful defense were further marred by the negative depositions of the nurses at the hospital regarding the defendant.


Disposition
This case was settled on behalf of all defendants.


Risk management considerations
For optimal patient outcomes, it is necessary to carefully and comprehensively communicate, evaluate, monitor, and follow up on a patient’s condition. All of these factors played key roles in this case.

Physicians may face additional liability exposure when on call in the ED. In many instances, the patient is not an established patient presenting additional challenges to the on-call physician. The pediatrician on call in this claim fell below the standard of care in her failure to come to the ED in a timely manner to examine and evaluate the child. Availability and a commitment to respond quickly are vital characteristics of a conscientious physician, as is the ability to recognize when emergency transfer is the best course of action, especially when treatment choices such as pediatric ICU or dialysis are unavailable in the hospital.

Pediatricians have an obligation to communicate with the child’s parents. Effective physician/patient/parent communication is the foundation of a sound relationship and medical management. In hospitals where physician specialists are not staffed 24 hours a day other than the ED, the obligation for on-call physicians rises concurrently.

Reviewing claims against physicians retrospectively allows conjecture and opinions by all concerned. In this case, however, the on-call pediatrician’s medical management was not supported by either defendant or plaintiff expert reviews.

 


These closed claim studies are based on an actual malpractice claims from TMLT. These cases illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. These studies have been modified to protect the privacy of the physicians and patients.

 
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