A case for defensive medicine

AMNews:

A family sued their infant’s pediatrician, an emergency department physician and an on-call pediatrician at the hospital for not ordering a CT scan. To the doctors, the 11-month-old boy appeared normal and in no need of the test.

But after the infant had more serious injuries resulting from an incident at his babysitter’s home a couple of weeks later, the parents faulted the physicians for not ordering the CT scan they believe would have shown the boy was being abused.

The babysitter originally brought the baby, Jack, to his pediatrician’s office around noon on Nov. 18, 1998. The infant’s mother met the two there. The babysitter told the doctor that the infant hit his head on the floor.

The pediatrician didn’t see any signs of injury — no bleeding, no bruises. The boy appeared alert and neurologically normal. The infant didn’t have a history that would lead the physician to suspect child abuse. The pediatrician sent the infant home with his mother, Robyn Sprague. He told her to keep an eye on the boy and call if there were any concerns.

When her husband John came home from work, he agreed with Robyn that the boy wasn’t his usual energetic self. They phoned the pediatrician who saw Jack earlier in the day; he told them to take the infant to the emergency department.

The Spragues said they believed they were going to the hospital to get the CT scan because their pediatrician wanted it and because their infant was not behaving the way he normally did.

But, the three physicians told jurors there was no reason to order the scan because the infant showed no signs of trauma that would call for the test. According to the physicians’ attorney, Jack’s pediatrician said he would call ahead to let the emergency department know that the family would be arriving and that the infant may need a CT scan so the machine would be ready in the event it was needed. Jack’s pediatrician could not order the CT scan; that would have to be done after the infant was seen by doctors in the ED, according to the physicians’ attorney, A. Gwynn Bowie Jr.

The emergency physician examined Jack and then called the on-call pediatrician to examine the boy. Similar to the boy’s pediatrician, neither of the doctors in the ED saw outward signs of injury, and neurologically the boy seemed healthy, Bowie said.

The emergency physician described the infant as playful, bright and engaging, and the pediatrician described him as alert and active, according to the physicians’ attorney. An ED nurse also described Jack as playful and active.

The CT order that the emergency physician wrote after the infant arrived at the ED was canceled. The boy was discharged, and his parents were advised to follow up with their private pediatrician in a couple of days. When they followed up, the pediatrician found nothing wrong with the boy, Bowie said.

“The medical issue in this case was whether a CT scan was required in a normal child” Bowie said. “The physicians met the standard of care.”

However, the plaintiffs maintained they were expecting a CT scan because the pediatrician called ahead, which led them to believe he wanted the scan. When the Spragues arrived at the ED around 10 p.m., the emergency physician examined Jack and wrote that the infant had postconcussion disorder, according to plaintiff attorney Robert J. Weltchek. A technician talked to the parents about nursing the boy to sleep so that he would not need to be sedated for the scan, Weltchek said. The light in the room was shut off, and the mother began nursing the infant. (There was no testimony during trial from anyone working at the hospital that this took place.)

The pediatrician on call came into the room, turned on the light and woke Jack to examine him, said Weltchek, who also said that from the parents’ perspective, the pediatrician didn’t spend enough time asking questions or evaluating their son.

The pediatrician found that Jack appeared normal and canceled the CT scan, Weltchek said.

“This was an egregious act of malpractice,” Weltchek said. “It was black and white.”

The jury agreed with the plaintiffs that the physicians were negligent in not performing the CT scan and awarded damages to the family.

This is why the physical exam is useless in American medicine – it cannot hold up in court. Clinical evaluation and judgement skills now needs to be supported with objective, and often expensive, tests. Here we have a case of three seperate physicians who, in their clinical opinion, did not feel a CT scan was warranted. They relied on clinical judgement. They were sued and lost. What is the moral of the story? Order an expensive test and save yourself the trouble.

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