Legal Review & Commentary-Undiagnosed meningitis: $175,000 CA settlement
News: Following a bicycle accident resulting in a head injury, a young man developed meningitis that went undiagnosed for four days and resulted in death. The delay in diagnosis was in part attributable to his alleged use of the drug PCP. The case settled for $175,000.
Background: The 19-year-old fell from his bicycle, hit his head, and was unconscious for a short period of time. He returned home, slept through the night, but awoke the next morning with a headache and nausea severe enough that his mother took him to an emergency room (ER).
He was examined by the ER physician, who ordered a CT scan. The CT revealed a skull fracture line that crossed the roof of the ethmoid and sphenoid sinuses. There was a small subdural hematoma, free air in and around the meninges (the membranes enveloping the brain and spinal cord), and air fluid level in one sinus. His temperature was normal. The ER physician called a neurosurgeon at another hospital, who recommended that the young man be sent home. The ER physician declined to do so and admitted him for overnight observation. The next morning, his headache and nausea were gone, and a follow-up CT showed no enlargement of the subdural hematoma. However, the ER doctor insisted on an evaluated by the neurosurgeon prior to discharge.
The young man was transported to the hospital where the neurosurgeon was; the neurosurgeon saw the young man and discharged him home with Keflex and Tylenol. Even though his white blood count was 15,100, neither physician had been made aware of the test results prior to discharge.
Early the next morning, the headache and nausea returned and were more severe than before. His family took him to the hospital where he had seen the neurosurgeon. At this point, the patient had a fever despite having taken the Tylenol, and he had an elevated white blood count. He was admitted to the hospital.
Three hours later, he had gone from being alert, oriented, and cooperative to being combative, uncooperative, and then lethargic. The neurosurgeon made his rounds eight hours after admission, and seeing the patient's combativeness, he ordered medications to sedate him. The family told the neurosurgeon that he had taken PCP in the past and that it had resulted in similar behavior. After consulting with the hospital's drug and alcohol abuse specialist, the neurosurgeon concluded that the patient's combativeness and lethargy were the result of his use of PCP.
During the night, his temperature and white blood count continued to rise, but the nurses did not inform the neurosurgeon and treated him with ice and Tylenol. By late morning, he had developed severe respiratory problems and was intubated by an anesthesiologist who paralyzed the patient pharmacologically to permit effective ventilation. The results of the PCP test were mixed (positive in the blood, negative in the urine), and a repeat CT scan showed brain swelling. The neurosurgeon performed a ventricular tap to obtain cerebrospinal fluid, which showed bacterial meningitis, and although the patient was aggressively treated with antibiotics, he died.
What this means to you: This case presents some interesting questions from a risk management view, most of which are related to the medical care that allegedly was — and was not — provided. Depending on the arrangements for provision of emergency department medical coverage, a risk manager should be aware of the potential for ostensible agency repercussions for the hospital based on the emergency medicine physician's care during the initial visit.
"In addition, one might question why the emergency department physician called a neurosurgeon at another hospital; was it because the hospital where the patient was did not provide neurosurgical care, or because the neurosurgeon on call wouldn't come into the hospital to examine the patient, which may be considered a potential COBRA violation?" asks Leilani Kicklighter, RN, ARM, MBA, DASHRM, assistant administrator for safety and risk management with the North Broward (FL) Hospital District and a past president of the American Society for Healthcare Risk Management.
A lab test was ordered and run showing an elevated white count; however, the results were not seen by the discharging nor the ordering physician by the time of discharge. "The physician who ordered the test should have reviewed all results before making the final decision to discharge. While it is not clear if the results were available on the unit, it seems that a call could have been made to obtain the results. Assuming the results could have been gotten, they may have altered the discharging physician's decision. The scenario presents a potential compliance issue given that the test was ordered and seemingly not used," says Kicklighter.
The facts in this case indicate that upon readmission the next day, the patient's neuro status changed, but the surgeon was not made aware of the changes until eight hours after admission, apparently five hours after the changes occurred. In view of the patient's prior history and X-ray results, this may have been significant. It appears there was a discussion with the drug and alcohol specialist, but no tox screen was done at the time of the consult. During the night, the patient's condition and white count continued to change, but the nurses didn't communicate these changes to the surgeon. "In each instance, there seems to have been a delay in communicating critical information to the attending physician, and these delays seemed to hinder the making of delivery-of-care decisions that ultimately delayed appropriate care. The series of delays raises questions as to the lines of communication between physician and allied health professionals," says Kicklighter.
"From a risk management view, in addition to the potential for a COBRA violation and a compliance issue, this case should probably be referred for medical peer review. From a nursing view, the lack of timely communication of the patient's change[s] in condition needs to be addressed through human resources and nursing administration," she says.
Reference
Anonymous v. Anonymous, Los Angeles County (CA) Superior Court. n
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