Doccantmakeadecisionitis
Posted on 19. Jan, 2010 in Case Reports
Case Synopsis
Christmas Day
For most children, Christmas is suppose to be a fantastic day with gifts, time with the family, music, sweets, and oh more gifts. One can just imagine what it would be like for a young four-year-old girl to become sick on Christmas day.
Natasha was on a family outing on December 25, 1999 when she started complaining of feeling cold. As the family came home, Natasha developed a fever, vomited, and was visibly restless. This seemed a little more than the common cold, so Natasha’s mother took her to the Emergency Room in Hanford, California. It was 9 pm.
First Examination
In the Emergency Room, Natasha vomited again, had a dry cough and was congested. A doctor there examined her. Natasha was cooperative, alert, and appeared well-hydrated. The doctor diagnosed her with “viral infection, nausea/vomiting” and prescribed her Phenergan (which treats nausea and vomiting) and Tylenol. Natasha was sent home. Her mother was given written instructions to call her physician if conditions worsened.
As the night went on, Natasha’s condition indeed worsened. Early the next morning, Natasha and her mother returned to the Emergency Room. Despite telling the receptionist that Natasha was very ill, she had to wait 30 to 45 minutes before being registered by the receptionist at 7:18 am.
At 7:32 am, Natasha was triaged by the Emergency Room nurse. The nurse noted in the records that Natasha appeared ill with a rash on her hands and torso. Vital signs were taken at 7:36. Her heart was pounding away at 193 beats a minute (over 3 beats per second), respiration at 44 breaths a minute, and had a temperature of 102.4 degrees Fahrenheit.
At 7:45 am, Natasha’s blood pressure was markedly low at systolic of only 60 mmHg (below 90 is abnormal). Blood work and blood cultures were obtained and sent to the laboratory.
Second Examination
Finally at 8:17 am, almost an hour since Natasha registered with the Emergency Room, Dr. Punce (not the same doctor who had examined her the night before) came and evaluated Natasha. For some reason, he didn’t note and record the rash on her hands and body, that her heart rate was sky high, and that she was having difficulty breathing. Instead, he noted that her heart was “regular” and gave her some IV fluids.
At 8:31, Dr. Punce called a pediatrician for consultation. During the telephone conversation, Dr. Punce described that Natasha had a purple rash on her extremities. The pediatrician asked if Dr. Punce thinks it might be meningococcemia, an infection caused by the bacterium Neisseria meningitidis. Dr. Punce said he didn’t know because he had never seen meningococcemia before and that he didn’t know what the rash was.
Shortly after the call, two of the Emergency Room nurses approached Dr. Punce and asked him individually about starting antibiotics. Dr. Punce thought about it and decided to continue to observe Natasha in the Emergency Room without starting antibiotics.
Third Examination
At 9:30 am, the pediatrician arrived at the Emergency Room. He noted that there was a rash that covered most of her body, she had a rapid pulse, and was crying. He promptly diagnosed her with meningococcemia and immediately started her on antibiotics.
At 9:45 am, Natasha had developed blood tinged tears, which meant she was having disseminated intravascular coagulopathy (DIC). He canceled her proposed CT scan and emergently arranged for her to be transferred by ambulance to a Children’s Hospital which was better equipped to handle such cases.
At 10:10 am, Natasha, her mother, a paramedic, and the ambulance driver took off for the Children’s Hospital. Unfortunately while en route, Natasha’s condition deteriorated rapidly. The ambulance diverted to the nearest hospital.
Case Outcome
At 11:04 am, the ambulance arrived at another hospital with Natasha in full cardiac arrest. Resuscitation measures ensued for 22 minutes but was unsuccessful. Natasha was pronounced dead at 11:26 a.m.
As the result of the poor management of Natasha, Dr. Punce had his license revoked. However, the revocation was stayed and Dr. Punce was placed on probation for three years instead.
The pediatrician was not cited in any way.
Analysis by Jessie
This story breaks my heart. As a parent myself, I feel for the mother of this child having to watch her child suffer through such an ordeal, only to lose the fight in the end. It must have been very frustrating and angering for her. First, the overly long wait to even be registered, then the doctor’s incompetency.
How did Dr. Punce miss the rash and her heart rate the first time? It sounds like he may have just done a cursory glance and not a thorough examination before making his call. I can’t believe he didn’t check further and see if her rash and symptoms were similar to meningococcemia (after his phone conversation), even if just to reassure himself that it wasn’t. Then again, he seems to have missed all of her symptoms at one point or another. I’m not sure if the antibiotics would’ve helped at the point that the nurses suggested it, but the fact that Natasha’s symptoms had worsened should have been enough for him to double-check.
I see this as a case of just plain neglect. He didn’t notice the rash or (at least record) her irregular heart rate and respiration, but just thought to observe her without taking any proactive measures. How can one doctor miss so much and yet another one only needs to be consulted and can at least come up with an idea of what could be going on? It’s possible that the latter had more experience, but Dr. Punce should have at least noted the multiple symptoms.
I’m not pleased with the probation for three years. I’d be interested in knowing if there were other stipulations to this. It seems like such a light punishment when you look at the loss of life and his lack of knowledge and interest.
| Score |
|---|
| 8.8 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 10 | 10 | 10 | 9 | 5 |
Response by Lyssa
What makes this more tragic is that meningococcemia is a known condition and, if diagnosed early, is very treatable. In Natasha’s case, it could have been diagnosed in time to provide adequate treatment. For some reason, the competent doctor was not on hand. When he showed up, it was too late.
This case illustrates how important it is to have a second opinion on medical issues. Unfortunately, it’s not always possible in an emergency situation. Many hospitals cannot afford to consistently have enough doctors for a second opinion. Especially in busy ERs, it can take quite a long time to receive care from a physician at all. Unless you report difficulty breathing or if you collapse on the floor (actually, after King’s County Hospital, that’s not even for certain anymore), you might be made to wait for possibly hours.
In the end, I think the only advice I can give is for parents to not take chances and fight for at least a second opinion when you have any reason to mistrust the initial diagnosis (or lack thereof).
| Score |
|---|
| 7.2 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 10 | 8 | 10 | 5 | 3 |
Response by Marc
When it comes to a death of a child, it’s very difficult to look at the bird’s eye view of things. However, approaching it from another angle, mistakes do happen. I am not defending Dr. Punce’s lack of action, but doctors are not perfect and never will be. We can’t be constantly expect doctors to be right 100% of the time! Medicine is an applied art, especially in non-surgical cases.
Yes, yes, this further reinforces the obvious notion that second opinions are important. However, most readers will probably feel that 3 year’s probation is very little discipline. However, keep in mind that there was likely no malice involved. It was a genuine mistake, and we can’t be heavily punishing every doctor that makes a mistake just because it resulted in death.
| Score |
|---|
| 5.8 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 10 | 7 | 8 | 2 | 2 |
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What_The_Heck
Jan 19th, 2010
Oh wow, poor child. My heart goes out to the family. The name chosen for the doc in this story was well chosen. If I had come up with the name though I assure you it would have been censured.
RachLv
Jan 19th, 2010
That’s really tough. I’d have say that although it’s very frustrating, it’s true that we can’t just go around punishing the doctor as they mess up. Many doctors try very hard and still have patients die on them. It’s not an easy job.
Donald
Jan 20th, 2010
Are you kidding? Give the doctor a break? Then who are they supposed to be accountable to? They were doing their jobs by punishing him. I don’t know why they keep “staying” instead of revoking as they should.
Tiff
Jan 20th, 2010
Most ER protocols are that 2 sets of blood cultures and a lumbar puncture are ordered with basic labs. Broad spectrum antibiotics are also standard protocol until the culture and sensitivity reports are back. More than anything, this seems like a simple case of poor documentation and assessment skills. ERs are so overcrowded with babies with fevers, and people that have had a stomach ache for 2 weeks. The doctors probably assumed that this was just another overly dramatic mother that didn’t have the sense to give her child some tylenol because that is much more commonly seen than meningococcemia. They were quick and dirty to get her in and out so they could move on to the next “emergency”. 3 years doesn’t seem like much but if it’s any consolation, it will haunt him forever. But what about the nurse’s? They can’t make major decisions but they can offer opinions and they have an ethical responsibilty to document the accurate vital signs.This just sounds like a case of incompetency from parking lot to funeral and my heart goes out to these poor parents.
Kuddle
Jan 20th, 2010
STRONGLY disagree with Marc! It doesn’t take a doctor to recognize increased respirations. I consider this doctor incompetent for not noticing the OBVIOUS signs and symptons, not researching meningococcemia and not listening to his co-workers. Nor did he examine this child or he would have heard the irregular heart rate. His actions were neglect. Doctors can be licensed killers and receive nothing but a smack on the back of the hand, move to another state and start all over every time he/she is repremended. I am curious as to why the pediatrician didn’t suggest antibiotics. Could it be because the E.R. doctor didn’t present her signs and symptons appropriately to the pediatrician? Afterall, he himself didn’t even know what her vital signs were…how could he give a good description of her illness in a verbal conversation when he didn’t know the obvious facts?
Kuddle
Jan 20th, 2010
Tiff, the first lesson learned in medicine is NEVER assume, it makes an ASS of U and ME and kills the innocent. The nurses DID document at 0736 a HR of 193 and respirations of 44. They also suggested antibiotics not once but TWICE. You are correct about one thing, they can not diagnose or prescribe medications or treatments…if they could…this family may not have had to suffer this horrible tragedy.
Fay
Jan 20th, 2010
@Tiff: No offense to your opinion but it’s ridiculous to think that we’d be better off if nurses could prescribe meds without doctors (we’re obviously not talking about NPs). If we’re questioning a doctor who took four more years of medical school beyond college not counting residency etc., how can we go and say nurses (many without even a 4-year) know better? Maybe in THIS case but not in most cases.
Fay
Jan 21st, 2010
Correction sorry, I meant my last comment @Kuddle, not @Tiff.
cupid
Jan 21st, 2010
This is very sad, but….people die. Doctor’s are not God, they are human beings. This doc. obviously was a jerk because ER nurses are the eyes and ears for the doc. while he is seeing other patients. Nurses have to assess and re-assess, over and over and report any abnormal findings to the doc. If the doc won’t listen and the nurse feels strongly that the child is sick…really sick, then he/she should make a stand and force the issue, call the nursing supervisor call the kids doc., call the on call peds doc. it’s a child’s life we are talking about here. The nurse is the patient’s advocate. This wouldn’t have happened with more secure nurses.
cat
Jan 21st, 2010
@cupid: The nurses suggested twice that antibiotics be administered. He’s the one who kept CHOOSING to ignore all suggestions given to him. From the pediatrician right on down to the nurses. Yes people die, but this is one death that had the possibility of being prevented if he would have let’s say, asked someone to look up the disease, maybe actually have assessed the child and noted all her symptoms, or even taken a moment when he was asked a second time if they should start antibiotics. Every one is swamped in an ER setting and to me it sounds like the nurses were trying to do what they could. Honestly, any time I’ve been to an ER the nurses are the ones picking up the slack as much as they can. I don’t see that this was any nurses fault in any way.
mjfan
Jan 21st, 2010
Patient is sick,…time to get to work. Fingers, dial that phone! Expert is on his way! Job well done!
What_The_Heck
Jan 22nd, 2010
@mjfan What the heck???
Kris
Jan 29th, 2010
As a nursing student I’ve dealt with great doctors and horrible doctors. From what I read the nurses were doing what they could. A nurses hands are tied very effectively by the doctors. If the Dr doesn’t want to listen they won’t and if you call another Dr, you are treated like a whistle-blower usually. As unfair as that is, it is what happens. This is a heart-breaking story. Dr Punce didn’t check the nurses notes or the exam, obviously, as he didn’t note it, he also did NOT do a through exam. No matter how busy the ER is a general prelim exam takes 5 min, and as this story demonstrates, saves lives. I am more surprised at the Dr saying he didn’t know what meningitis is. This illness has been in the news for months now and a good portion of the general public knows of this illness and at least some of the symptoms, so for a Dr who STUDIED this illness to miss it is more than incompetence, it’s negligence.
Cat
Feb 1st, 2010
This is a case of negligence of a high magnitude. First, ER’s are supposed to “fast-track” patients returning for worsening of the same illness. Second, the child was clearly in cardiac and respiratory distress when vital signs were first taken and should have IMMEDIATELY seen a physician. This is standard triage procedure worldwide. An on call pediatrician should have been brought in from the outset, just from the information gained in triage. Either the hospital is equally at fault for not instituting policies in keeping with accepted triage protocols or the staff is fault for not following them. This is the whole reason for triage so that the most serious case are seen immediately and appropriate specialists are called in from the outset. That child should have had a team working on her, not a single doctor. A critical care transport to the nearest facility with a PICU should have been arranged from the outset. Such transportation, if not by helicopter, involves a team usually including a PA, respiratory therapist, PICU nurse or others depending on the condition – not just a lone paramedic in the back with such a critically ill child. This was FUBAR from the moment that child returned to the ER.
Pat
Feb 1st, 2010
Obviously, doctors are not perfect, but if they don’t know the answer they are obliged to find out. The Pediatrician gave him his cue, probably based on incomplete information. It was up to him to find out. It’s not that hard. The nurses tryed to push him, but he ignored them. Going over a doctor’s head is tough and potentially dangerous to their career. I would have at least reported to the Nursing Supervisor and let them take it further.
barb2828
Feb 1st, 2010
I think the doctor is like alot of them I, they don’t examine their pt. properly, they go on nurse’s assessments. The doctor should be held responible for what happened, the child was in critical condition and something more should have been done. Also the nurses are the first line of defense for pt. and they should have spoken up and done more. If one doctor does not do something, you go to another. Doctors are not perfect, they do make mistakes, yes, but this child’s case should have been handled completely different! The nurses that took care of this little girl are just as much in fault!! Very sad case, and things like this happen every day. When these drs and nurses become to “busy” or that uncaring, it is time they find a new job!
Pat
Feb 3rd, 2010
I disagree that the nurses were equally guilty. They cared enough to advocate for the patient multiple times. Yes, they should have taken it further. However, the Doctor failed on multiple levels and was derelict in performing his duties.
LPN2RN2010
Mar 3rd, 2010
I would have continued pursuing antibiotics, to the point of nag, and notified the house supervisor, who have made the on call pediatrician come in.Dr. Punce was a putz, and so was the triage nurse the second time around!
Spanky McShee
May 25th, 2010
I had an uncle who died basically because the doctor couldnt make up her mind about what he had. I dont get why they cant just ask another doctor. Why do they feel they need to come up with it on their own?