Tuesday, December 11, 2007

Law and Medicine Rounds

By Dainius A. Drukteinis, M.D., J.D.

“The only real mistake is the one from which we learn nothing.”
- John Powell

The Cyanotic Child
Systems Failures in the Emergency Department

In MacDonald v. Chestnut Hill Hospital, 903 A.2d 61, 2006 Pa. Super. LEXIS 2061 (Pa Super. Ct. June 1, 2006), a family alleged multiple systems failures in the treatment of their newborn baby girl.

On October 25, 2000, Erin MacDonald was born without complication at Chestnut Hill Hospital. The parties dispute whether the baby was feeding properly and whether she was overly sleepy, but everyone agreed she appeared outwardly healthy. She was discharged two days later from the hospital. While at home, Erin had a brief cyanotic episode. Mom called 911 and Erin was transported back to the hospital’s Emergency Department. Ambulance workers noted that Erin’s color was normal and she appeared stable. In the Emergency Department, Erin’s temperature, blood pressure, and respirations were normal, and her condition also appeared stable to the attending physician. Due to her cyanotic episode, however, the attending physician felt that Erin should be admitted.

Arrangements were made with Erin’s pediatrician to transfer her to another hospital with a pediatric floor. Erin’s temperature at the new hospital was 100.9 degrees on arrival. The physicians were concerned that Erin was septic. Labs drawn at the new hospital revealed that Erin was in fact hypoglycemic. A “heel stick” confirmed hypoglycemia and a dextrose infusion was begun. During treatment, she had multiple seizures and suffered permanent brain damage. Erin was eventually diagnosed with congenital hyperinsulinism.

One of the many allegations of the MacDonald family was that if a “heel stick” had been initially performed in the Emergency Department, Erin’s glucose would have been controlled more quickly, thus preventing subsequent seizures and brain damage. An expert witness testified that the hospital had protocols for obtaining a “heel stick” which were not followed by the medical staff. In the end, however, the jury found in favor of the physicians despite evidence of negligence, because the negligence was not the cause of the harm suffered.

If Erin did not have congenital hyperinsulinism, the jury could have easily found in favor of the MacDonalds. In such a circumstance, the jury may have agreed that Erin’s hypoglycemia could have been more quickly diagnosed and more easily controlled, thus avoiding brain damage from seizures.

A fingerstick is often thought of as the sixth vital sign. It is well-recognized that altered mental status or neurologic deficits are often the result of hypoglycemia, and can be completely reversed with prompt administration of dextrose. It is for this reason that the hospital had protocols in place for performing “heel sticks,” and the staff, if speaking candidly, would probably agree that a “heel stick” would have been appropriate even in the above case. Furthermore, obtaining one drop of blood from a “heelstick” has almost no risk of an adverse consequence.
So why did the system fail? Was there a lack of automaticity to the system? Did the system rely on the staff to make a decision for a simple diagnostic intervention that should have been thoughtless?
It is hard to believe that a physician or nurse would have actively decided that Erin did not require a fingerstick for her cyanotic episode. It was most likely a simple failure to think of the intervention.

Whatever the source of error, systems should be designed not to eliminate human error, but embrace it. A system should anticipate human error, as in the above case, and insure implementation of simple interventions in well-defined situations. For instance, checking vital signs on every patient entering the Emergency Department, regardless of chief complaint, is one of our most basic systems for preventing patients with serious illness from being missed. At times, the system should cast a larger net than the individual medical decision-maker to prevent missing common diagnoses. The system cannot make all of the decisions for medical staff, but perhaps the true decision-making component of medical care should be left to those problems that are more difficult to solve.

Dainius A. Drukteinis, M.D., J.D. is a fourth year Emergency Medicine Resident at NYU/Bellevue Hospital and author of Law and Medicine Rounds. He may be contacted at ddrukteinis@gmail.com


Anonymous said...

Just one question: how does hypoglycemia cause cyanosis?
I mean, if she came in with apnea, that's something different, but I don't think that cyanosis is enough of a reason to suspect hypoglycemia. A glucose level would be, say, my eigth vital sign, after a pH and PCO2 from an ABG (assuming we have the pulse ox sat already to substitute for the PO2). So no, I disagree with the point of this article, I don't think we should base our medical methods on the legal system, all that does is cause fluff in the medical system. However minimal they may seem, "baseline" tests stack up fast and completing them all is often not possible in an emergency setting. But we're the USA, we can sue anyone at anytime for anything! So lets sue for not checking fingersticks! Heck lets do a class-action lawsuit, it makes it seem more, ya know, substantial.


Dainius said...

It is often difficult for a physician to hear that their medical management was inappropriate when the determination is made by a non-medical body such as a judge or jury in the legal system. The legal system forces us to look at our medical management in a way that we are often not used to when we are saturated with medicine in our hospital bubble. The legal system and the medical system communicate in different ways. For this reason, it is no mystery why patients often complain that they did not understand the physician who was explaining the management of their illness. On the flip side, perhaps we are frustrated when the legal system fails to explain to us our failures in the "medical speak" we are familiar with.

In this case, whether you approach it from a medical or legal perspective, a quick determination of glucose concentration should have been made. There are many signs and symptoms of hypoglycemia. One recognized sign of hypoglycemia is cyanosis, and it should be taken very seriously. Chan W, Neonatal Hypoglycemia, uptodate.com (2007). While cyanosis may be more likely a primary cardiac or pulmonary etiology, metabolic dysfunction must be considered. In the first week of life, neonates undergo profound metabolic changes in an effort to establish proper glucose control. When a newborn's glucose supply is suddenly cut off from the mother, the baby must learn how to break down glycogen to glucose, as well as learn to eat properly to maintain adequate levels of glucose in the body. An inability to maintain adequate levels of glucose affects all organ systems including cardiac, pulmonary, and hematologic. Cyanosis may develop from a failure of any one of these systems as a result of inadequate glucose concentration.

While obtaining a pH and PCO2 from an ABG may be warranted, it would take longer than a glucose heelstick. A heelstick is done at the bedside in less than one minute. An ABG, on the other hand, would take a minimum of 20 minutes by the time the lab finishes the result, and that assumes the sample was easy to obtain from the baby which it often is not. Technology has not reached the point that ABGs can be resulted at the bedside. Until then, the heelstick in a cyanotic child should be the sixth vital sign.

AtYourCervix said...

Granted, I work as an L&D RN, but we have a list of s/s, maternal issues, SGA and LGA weight ranges, etc, of when to check a blood sugar on a neonate. A blood glucose is one of the quickest tests, and easiest to help treat. I would think that it would be one of the first things to check on any neonate in any type of distress (after the ABC's, of course). This neonate appeared to be WNL for vitals and assessment, but did have an episode of cyanosis. That one episode alone is enough to warrent a blood glucose. It can be a delicate balancing system in a neonate to maintain normal blood glucose levels, and almost any stress can alter the glucose level.

ArkieRN said...

I agree with anonymous. I consider a pulse oximetry reading to be the sixth vital sign. I do not agree with the subsequent ABG. Vital signs are quick and relatively non-invasive. The Fingerstick should be seventh.
Paramedics now use a special nasal cannula to measure end tidal CO2 - If desired, that could be added as is non-invasive.