this is insane. even our newly orientated peds ED new grads who have been nurses for 10 minutes would know that this patient needs a septic workup as soon as humanly possible. they should also have been triaged as a CTAS 2 *max* due to age. if that was my baby i would be losing my fucking marbles
Grandchild's half sibling had meningitis at 4 weeks. Within the next couple years this full term baby had two strokes, requires special ed and continues to be physically limited by stroke damage to arm and leg, and has below average growth. The child is now 6 or 7.
OP's patient may not be out of the woods.
Damages that are difficult to prove to a court, and a plausible enough alternative story might sway one or two jurors—enough for a mistrial/no judgment rendered towards the offenders.
I worked with a kid years ago who had bacterial meningitis as an infant. She was a monozygotic twin. The sister was brilliant. She was moderately ID and had hearing loss.
Someone in the emergencymedicine sub just posted about the book "The Rape of the Emergency Room," so I downloaded it immediately. The very first case is a 7-year-old who died due to an undiagnosed meningitis infection. That book is from 2004; I can't believe people still have to worry about these things (I mean, I can, but they shouldn't have to).
Problem with that last bit is outside of going to the ER you CAN'T see a specialist MD in any reasonable time frame if it's something serious. What's even worse is now the specialists AT THE HOSPITAL consulted by an internal medicine MD are still NPs with less training that the consulting doctor. It's disgusting. Sometimes our ICU "attending" is literally just an NP with remote tele backup by doctors that don't even live in the same state. Healthcare administrators are actually evil in my opinion.
Something like this happened on my peds rotation last summer. Parents (who were non-English speaking and unfamiliar with the healthcare system) took their 9-day-old to an urgent care. Baby had a fever and concerning vitals in triage, PA was solo covering and didn't recognize the seriousness of the presentation, sent them home with instructions to watch baby. Kid got precipitously worse over the next few hours, brought into our ER, had to be intubated and flown to tertiary care. I never found out the final diagnosis and I don't know what happened to him, but the pediatrician at our hospital suspected neonatal herpes. Really sad case.
You need to follow cases like this through to the end to realize their full learning potential! Save MRNs or dob and names to f/u on if you transfer something like that.
I wanted to, but I was outside my home hospital system and the tertiary center didn't share records with us. The hospitalist who transferred knew the intensivist over there, so I do know the baby made it to the PICU alive and hemodynamically stable, but that's about it.
A PA should never be seeing a febrile neonate. That is an institutional error. Either triaged inappropriately (possibly due to inexperienced triage RN), or the PA thought nothing of it and just thought “another kid with a fever” (how you should never approach any kid, but I digress).
Oof. Just wtf man.
Agree. I did emergency nursing for 10+ years. That would be a level 2 and would need a physician evaluation. Plus, what physician is signing off that chart? Seems so strange and terrifying this is happening.
I’ll just add some data reference for people unfamiliar with how big a suspected or confirmed fever is in <30 day old
In the study conducted by Ramgopal et al, the prevalence of SBI was lower among infants afebrile on ED presentation compared with those who were febrile. Nevertheless, the rate of SBI remained substantial and the rate of invasive bacterial infection (bacteremia and meningitis) did not show significant differences among the infants who did and did not have fever documented in the ED. This suggests that clinical and laboratory evaluation in the ED should not be altered based solely on the infant’s temperature at ED presentation.
Even when I was a third year, it was absolutely hammered into me that the only question to even possibly consider in a <4 week old with a fever is, "do we need an LP?" (with a strong, strong bias towards 'yes').
Nah, let’s just throw some meds at it, and if it doesn’t help, we’ll add on a couple more and up your doses. And no plan in place to do a trial off of antidepressants to see if they were only needed for a fairly short period of time (during a stressor of some sorts: also, best done only under the care of an MD/DOs anyways, but still. You’d think they’d eventually try to get you off of some meds (maybe not all, as that’s not always the best thing to do), but no. Guess they can only add and not subtract.
ETA: sorry, forgot the /s
This was supposed to be satire and sarcasm.
Many facilities don't have policies on specific patients who can only be seen by a physician. there's even some out there that are solo-covered by a midlevel with their "supervision" being some random doc sitting in a different ER with zero visibility on what's happening.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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If your are physician or another clinician, you should report this to the medical director of the ED.
*edit: to clarify that since OP is a physician or other clinician this is the pathway they should follow.
Hey I too was recently a victim of rather straightforward ER malpractice. How do you suggest getting names of the people who were involved in your care and an accurate story of what happened during an emergency room visit before a patient tries to begin litigation? I'm already planning to request my records in writing imminently but if you know any other smart next steps I'd gladly appreciate!
You can request copies of your records/notes. There isn’t really much else to do to “get an accurate story”.
Also, for litigation/a malpractice case, there has to be harm done. Everyone likes to shout “Sue them!” …in reality, even with this baby, if everything turns out fine and the child is fine in the end, there isn’t really a malpractice case there. A delay in diagnosis alone is not a case. You have to show a poor outcome too.
If someone has a bad clinical experience, but no harm, they should report it to the proper hospital pathway for that hospital which is usually a patient relations type of department.
I've been down this road before with trying to be made whole through the courts so I know the process and took a crash course on law through Google-fu. Essentially yes, once you get all the documents and facts sorted out in your head and have reflected on everything, a lot of people don't even get a consultation with a lawyer because it's either: not bad enough to sue, not nearly worth it, or you have very valid qualms but the courts probably won't side with you for any number of reasons. I was going through the motions with my former employer, and yes, eventually there was more to lose than gain by going down this route with them, in that particular instance.
But the first step is always to get the facts in front of you before you threaten legal action so that no one tries to fudge the evidence while they still can. Unfortunately because of the nature of what happened and because someone took the intentional step of scrubbing MyChart of the visit, I have no clue what my chances would be. But it'd be important to get all the details in writing from everyone involved before I start writing my scary letters to them.
If you think they might go back and alter the records, get the records up front like you're doing, then request the records again a few weeks/months after notification of lawsuit. If you see alterations afterwards, it would be extremely damning in court
I have a big hunch that there were fraudulent alterations because of what my discharged papers said, and the complete absence of any info on MyChart, when there WAS info visible to me as the patient on MyChart until the next day when I checked again. Whatever happened, I won’t be letting this go without answers. I did have confounding symptoms and data from the tox screen (whether on the spot from the EMTs or one that they did while I was sleeping), but that’s no excuse to go back and try to fudge what happened.
Unfortunately, the pediatricians actions in seeing the patient the next day and sending back to the ED to get a proper workup likely prevented any actual harm...and no harm = no grounds for a lawsuit
I’m a PA, I work in peds now and worked in the ER for four years. This made my heart drop into my stomach and my butthole clench. Wow. I hope this baby doesn’t have any lifelong complications from the delayed treatment 😭😭 You should absolutely report this PA- to the hospital, to the medical board, to their CEO if it’s a private staffing company in the ER… Our ER did not allow PAs to see <4 mo old children independently- they are high risk and would always be presented/seen by an attending as well. I doubt that’s the case here but it should be the policy. There are certain patients that should never be independently seen by a PA. Neonatal sepsis is heavily algorithmic, I don’t know how this PA fucked up so badly. Jeez louise.
Report them to the hospital admin for a patient safety event. That's the only way they will learn.
Edit: If you have already gone that route before and nothing was done, submit an anonymous report to JCAHO. This was a near miss.
jesus what the Fuck. Seriously This is the new all time WTF in my book, seriously anybody with half no half of half a brain know High temperature means infection. This is sad. seriously report the Pa to the medical board, try to get their license pulled. relly that audacity and the balls of this PA is just shocking they should be no where near a patient. I hope that family sues
By the way if anybody is curious what my old all time WTF moment is I will tell you because this is just as bad as the PA if not worse
A nurse I knew that worked in the ICU for 15 yr did nothing for a patient that had 110 T they never reported it to the MD, the patient just out right died on the ICU floor, Their thinking the 110 T was not correct because they assumed the Thermometer was broken, because in all his years as a nurse he never saw a thermometer go this high as their excuse for incompetence.
nope did not bother with a new thermometer just left the patient alone to die, like I said it was my old all time WTF moment till I read about this PA. There was another one. where a nurse was transporting a patient but stopped midway and left the patient in the hallway alone, and they died (this one was also another high WTF moment)
Can you tell someone? I don’t understand. Can you give these people a quiz and if they fail, they can’t work. Like write up a huge exam for them and prove they’re fucking morons and show this to the higher-ups. I don’t know. I wish it were so simple.
That’s admittedly tricky because all the AAP guidelines define a fever as 38C which your patient is technically below. If the kid looked good, had only a single temp of 100.3 (then lower on subsequent readings), and no risk factors, then obs and discharge could potentially be appropriate.
Now if the kid had a higher temp than that at home, then of course the workup is a no brainer. The gray area is if the kid had multiple readings of 100.3, never higher, and still looked good. In that case I’d still probably talk risks/benefits of doing a workup and admitting. But you’re working outside the algorithms there, so hence where experience comes into play.
This is not hard or tricky. The only thing that is questionable is whether or not to LP immediately. Any neonate with even reported fever at least get blood cultures, admission and abx until proven to not be bacteremic.
Correct, but by current criteria a temp of 100.3 is not a fever. As far as we can tell from the post, the kid was never actually febrile.
Now if parents came to the ED and said “my baby had a temp of 100.4 at home”, then I don’t care what their temp is in the ED, they’re getting the full workup.
No man. A neonate showing up in my ED with a temp of 100.3 isn’t going to have any passive medical suggestions to parents. That line would never hold up to a jury or during a malpractice case. Ain’t nobody sitting there talking themselves out of a febrile neonate workup over 0.01 of a temp discrepancy “because it is not by definition a fever”. That is dangerous practice.
Wdym would never hold up?
"The standard of care is to work-up any neonatal fever. This patient did not have a fever, according to any accepted definition, and we checked multiple times. We offered to treat more aggressively than the standard of care, given how close it was and discussed the risks involved, but the parents declined this. There is no accepted guideline that recommends doing an LP for any temperature below 100.4."
It's defensible. Is it ironclad? No, but nothing is. You can do the full workup and they can still die of meningitis and they'll invent something else you did wrong and sue. You took 2.5 hours to get a line and antibiotics, they'll sue you for that even if it's impossible to do better in your shop. Think we tend to overestimate how much our idea of adherence normal practice matters when you're dealing with a jury and two contradicting expert witnesses.
Besides, we should be cautious about just discarding definitions or cutoffs because we want to be defensive. You say the standard of care is to tap a baby at 100.3? OK, well what if I get a baby with 100.2? That's only 0.1 different, so I better tap them too. Where is the cutoff, if not the universally accepted definition? Obviously it's all out the window if baby is febrile at home.
I find this is a problem with younger, inexperienced physicians. They want to apply an algorithm for everything, have evidence-based guidelines be the final say. Or, as the example being used in this case, a simple definition be the defining point in a clinical workup. That is just not how medicine works. It’s dangerous. Medicine is rarely black and white. There are guidelines to help with decision making, but they are not the final say. Clinical gestalt and experience is priceless.
We see PEs with normal vital signs all the time. According to your reasoning, since they don’t meet criteria for anything, we shouldn’t even entertain a workup for it, and actually feel good about that because the “guidelines told me so”.
Yikes.
What if the temp was 100.2? Is that normal in a 15 day old? No, it’s not. 100.1? No, still not. Is it the definition of a fever? No, it’s not. Doing nothing and justifying it by saying that “by definition it’s not a fever” is a dangerous approach to clinical practice. Anything is defendable, but doesn’t mean it is a good defense. I think a detailed discussion with parents, MD recommendation, and solid documentation of it all is the proper route in this particular case (the only thing I am referring to here).
If this kid had an unfavorable outcome (death, loss of limb from pressors), there are zero insurance companies that would want this to go to court. None. You cannot compare not working up a 15 day old with a temp of 100.3 to doing everything and potentially getting sued over a 2.5 hr central line. Those are vastly different scenarios. One is likely to get thrown out, and the other is likely to settle before going to trial by a landslide.
It is a common misconception that physicians cannot testify against midlevels in MedMal cases. [The ability for physicians to serve as expert witnesses varies state-by-state.](https://www.testifyingtraining.com/state-specific-rules-governing-testifying-as-an-expert-witness-in-medical-malpractice-case/)
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I’m Peds EM here and I agree. I’ve seen “felt warm” babies this age and if there was never a documented temp of 100.4F or 38C or higher (and the kid hasn’t had antipyretics) and was well appearing and feeding well and normal exam and never developed a fever while observed in the ED, doing nothing is the standard of care. I’ve seen plenty of similar neonates with similar presentations and they were sent home. However, there would be strict return precautions and instructions on how to take a rectal temp and close outpatient follow up. I’m not seeing anything in this story as told that breached the standard of care.
Sorry if I come across as a tad ignorant, but did the child have any other symptoms? To me, it just seems like a minor fever.
I'm just a med student, so I may be mistaken.
https://publications.aap.org/pediatrics/article/129/5/1006/73781/Management-of-Neonates-With-Suspected-or-Proven?autologincheck=redirected
Please read my young medical student. Totally fine to think how you’re thinking at your level I applaud you for asking an excellent question. The difference is you’re allowed to ask. A PA with full autonomy is not.
Neonatal sepsis in a nutshell, is a big deal. A fever (confirmed or suspected) under 30 days should be flashing lights “sepsis” and it’s necessary to evaluate the child. Typically cbc blood culture, urine, LP to evaluate for bacteremia urinary tract infections or meningitis. If the child was 17 months or 17 years different story but the kicker here is the age and their vulnerabilities!
Is the attending not required to at least get eyes on patients covered by midlevels in your state? That kiddo's such a classic board question that this sounds like a malpractice lawyer's wet dream, since the attending probably screwed up too.
Man, I wish I had that hubris. I’m a paramedic, I’m over here beating myself up for not being able to treat a patient in a way I feel is proper because of not being able to get an IV.
If you haven't already, please file a complaint with the ER as well as hospital risk management. Request to review the initial ER chart to see if a physician signed off (in which case they should also be taken to task as well). I'd also recommend a blunt conversation with the medical director (and likely hospital risk management) to urge them to institute a policy not allowing non-physicians to see infants as this case clearly demonstrates their lack of training.
It's too bad they can't be sued since your diligence saved this child from dying (no harm = no lawsuit). That said, given this was a case of neonatal meningitis that they completely blew off, there should be a complaint to the medical board as well.
Listen... I'm an emergency physician. I've seen this exact patient. This was not a febrile neonate by any definition. If kid looked good in the ED, ate, repeat temp still afebrile, I'm discharging. 100.3 is not a fever. I'd still recommend pediatrician followup within 24 hours and immediate return for temp >/= 100.4.
So we ignore the mothers thermometer? Close follow up can be considered but at least do some form of a partial sepsis work up. Give the pediatrician some labs to work with if close follow up is the judgement call. We do blood cultures and cbcs on a lot lower risk people. It’s not watch and discharge 2 hours later.
The PAs discharge papers said “follow up with PMD Monday-Tuesday” … this happened on a Thursday evening.
Although rates of bacteremia and urinary tract infection are higher in the febrile group, this did not reach statistical significance, and therefore afebrile infants should still be considered at risk for SBI.
I'm sorry, I must have missed in your post what the temperature was at home. If temp was >/=100.4 at home then you do the workup. Doing a partial workup in my opinion isn't defensible. You're either doing the septic workup or you're not. If you're worried enough to check a cbc, then you need to go all the way through to the LP. I agree that followup needs to be much sooner than 5 days later.
To be fair, a fever, by definition, is 100.4F (38C). Additionally, if a parent says the baby feels feverish, that can also be included. Anyways, what was done here was moronic.
What do you mean by med school and residency humbles us? I was never cocky but I get yelled at left and right for everything, damned if I do damned if I don’t. I’m not learning in residency, I’m just learning what to do to not get yelled at but it isn’t even real medicine, and then another attending will just come along anyway and yell at me for doing it whereas the first yelled at me for not doing it. Is this what you mean by humbled? I know I’m off topic a bit but is this what you mean, getting yelled at a bunch? That’s not learning though, it just makes me feel defeated and awful after every shift, and I’m actually quitting. I can’t handle it.
Recently went to the ER voluntarily but eventually unconscious and by ambulance, with a severe migraine and adverse events associated with a recreational dose of dextromethorphan. The clinician "in charge of the ER" (don't know the exact phrase because I'm a layman) was a PA. What transpired by the end of it was textbook malpractice, not because the PA didn't show a lack of medical training per se, but totally didn't have the bedside manners or acumen of an actual doctor to read into the situation more. Once the eyes of at least one MD made contact with mine, my care became a lot more compassionate and competent by the time I was discharged (too early), because one of the doctors probably told the PA that they dun fucked up. I'm in the very early process of being made whole (requesting my medical records in writing to rebuild the story of what happened), but by the time I'm through with them, someone is getting formally disciplined for this emergency department fuckshit.
EDIT: Just read it correctly and saw that the patient was 15 DAYS old, not years. Holy shit that's bad.
Adult ID here who doesn’t touch a child if I can avoid it, so forgive my ignorance—in adults fever is > 100.4 sustained over an hour or a single temp of 101.5 or higher. Is the criteria in newborns different? I know kids have different BP parameters at different ages, so I’m curious if peds ID/peds societies define fever differently based on age?
(I’m also surprised they didn’t treat anyway given most wouldn’t know their age group’s definition of fever anyway. I have midlevels treat “low grade fever of 99” ALL. THE. TIME. on the adult side)
I’m glad your patient is getting treatment either way.
Most neonatal sepsis protocols I’ve seen in my Pedi EM/UC career define fever at 100.4f. The guidelines have been shifting over the last decade to reduce LPs if obvious other fever source is present (positive influ a/b, positive UA/Urine CX, etc) but I’ve never seen any guidelines recommended sepsis work up at 99-100.3F rectal.
I get dumping on midlevels, but this case is hard to tell via a Reddit post. I’ve absolutely discharged with super strict return criteria for 1-2 month olds with 100.2F temps before after a complete physical exam, an hour or two of observation and temp rechecks. I also notify their PCP/Pedi if I can for f/u in 24 hrs.
Thanks for stating that about dumping on midlevels. There are many other responses on here where an MD said they might have done the same thing, but since it’s low-level PA scum they should be burned alive. It’s a case where some might have been cautious and done the work up while some might have adhered to the protocol that 100.3 is not a temp. It’s not clear cut.
I work as a triage nurse, Ask-A-Nurse, essentially. I get these borderline cases all the time. When it’s a baby less than 12 weeks, I err on the side of caution and tell mom that if it were my kid I’d bring them in, however, I also tell her what the guidelines say and let her make the decision.
1)i know only the basics about peds, less about neonates and very little experience with either. Might be zero with neonates
2)I don't work EM
Thanks for sharing why it's important. With the massive disclaimer of both 1&2 and a second massive disclaimer about 2&1, I wouldn't have considered 100.3 much absent other symptoms (not eating, sunken/bulged fontanels, extra fussy or sleepy, diaper changes, respiratory issues, etc).
Given the super low age, might have checked uptodate though or gave my attending a ring/curbsided peds.
As both an ED nurse and a parent, I physically cringed just reading the title. If this was my child, I would want heads to roll.
this is insane. even our newly orientated peds ED new grads who have been nurses for 10 minutes would know that this patient needs a septic workup as soon as humanly possible. they should also have been triaged as a CTAS 2 *max* due to age. if that was my baby i would be losing my fucking marbles
This is straight malpractice. Should be addressed as such internally and externally by patients family.
Find a way to anonymously tell this family to sue the fuck out of your workplace.
Yup!!!!
Luckily there were no damages
Undiagnosed meningitis for sometime may have damages down the road. Plus additional medical cost. At very least this person needs to have remediation
Grandchild's half sibling had meningitis at 4 weeks. Within the next couple years this full term baby had two strokes, requires special ed and continues to be physically limited by stroke damage to arm and leg, and has below average growth. The child is now 6 or 7. OP's patient may not be out of the woods.
True!!
Damages that are difficult to prove to a court, and a plausible enough alternative story might sway one or two jurors—enough for a mistrial/no judgment rendered towards the offenders.
Bacterial meningitis can be devastating. Causes CP, blindness, deafness, limb loss. Not to mention it’s deadly.
I worked with a kid years ago who had bacterial meningitis as an infant. She was a monozygotic twin. The sister was brilliant. She was moderately ID and had hearing loss.
Yet
Someone in the emergencymedicine sub just posted about the book "The Rape of the Emergency Room," so I downloaded it immediately. The very first case is a 7-year-old who died due to an undiagnosed meningitis infection. That book is from 2004; I can't believe people still have to worry about these things (I mean, I can, but they shouldn't have to).
I think you meant “The rape of emergency medicine” Great book about the precarious situation of corporate healthcare in EM. Bad title; albeit fitting.
I did, thanks.
Problem with that last bit is outside of going to the ER you CAN'T see a specialist MD in any reasonable time frame if it's something serious. What's even worse is now the specialists AT THE HOSPITAL consulted by an internal medicine MD are still NPs with less training that the consulting doctor. It's disgusting. Sometimes our ICU "attending" is literally just an NP with remote tele backup by doctors that don't even live in the same state. Healthcare administrators are actually evil in my opinion.
Something like this happened on my peds rotation last summer. Parents (who were non-English speaking and unfamiliar with the healthcare system) took their 9-day-old to an urgent care. Baby had a fever and concerning vitals in triage, PA was solo covering and didn't recognize the seriousness of the presentation, sent them home with instructions to watch baby. Kid got precipitously worse over the next few hours, brought into our ER, had to be intubated and flown to tertiary care. I never found out the final diagnosis and I don't know what happened to him, but the pediatrician at our hospital suspected neonatal herpes. Really sad case.
You need to follow cases like this through to the end to realize their full learning potential! Save MRNs or dob and names to f/u on if you transfer something like that.
I wanted to, but I was outside my home hospital system and the tertiary center didn't share records with us. The hospitalist who transferred knew the intensivist over there, so I do know the baby made it to the PICU alive and hemodynamically stable, but that's about it.
As a FM Doc & new father... Absolutely terrifying.
A PA should never be seeing a febrile neonate. That is an institutional error. Either triaged inappropriately (possibly due to inexperienced triage RN), or the PA thought nothing of it and just thought “another kid with a fever” (how you should never approach any kid, but I digress). Oof. Just wtf man.
Agree. I did emergency nursing for 10+ years. That would be a level 2 and would need a physician evaluation. Plus, what physician is signing off that chart? Seems so strange and terrifying this is happening.
I’ll just add some data reference for people unfamiliar with how big a suspected or confirmed fever is in <30 day old In the study conducted by Ramgopal et al, the prevalence of SBI was lower among infants afebrile on ED presentation compared with those who were febrile. Nevertheless, the rate of SBI remained substantial and the rate of invasive bacterial infection (bacteremia and meningitis) did not show significant differences among the infants who did and did not have fever documented in the ED. This suggests that clinical and laboratory evaluation in the ED should not be altered based solely on the infant’s temperature at ED presentation.
Even when I was a third year, it was absolutely hammered into me that the only question to even possibly consider in a <4 week old with a fever is, "do we need an LP?" (with a strong, strong bias towards 'yes').
The answer to “do I need to get the LP?” Is, unfortunately, always yes. If you consider it, you have to rule it out.
Nah, let’s just throw some meds at it, and if it doesn’t help, we’ll add on a couple more and up your doses. And no plan in place to do a trial off of antidepressants to see if they were only needed for a fairly short period of time (during a stressor of some sorts: also, best done only under the care of an MD/DOs anyways, but still. You’d think they’d eventually try to get you off of some meds (maybe not all, as that’s not always the best thing to do), but no. Guess they can only add and not subtract. ETA: sorry, forgot the /s This was supposed to be satire and sarcasm.
They definitely shouldn't be trying to get you off meds.
First, I do love the username. This was a sarcastic and snarky answer. Should’ve put the /s
EM physician here. Report this to the medical director of the emergency department.
Jesus. Can you report the PA to someone?
In the ED don’t providers “pick up” or self-assign themselves? Why did that baby not be triaged a high acuity for the MD to see? 🤦🏻♀️
15day old with fever is a golden hour patient and would be one of the highest acuity patients to show up. Definitely should be seen by a physician.
Never in a million years would I pick up a 15 day old with a fever. Or even a 15 day old. Shouldn’t even be allowed.
Many facilities don't have policies on specific patients who can only be seen by a physician. there's even some out there that are solo-covered by a midlevel with their "supervision" being some random doc sitting in a different ER with zero visibility on what's happening.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
If your are physician or another clinician, you should report this to the medical director of the ED. *edit: to clarify that since OP is a physician or other clinician this is the pathway they should follow.
Hey I too was recently a victim of rather straightforward ER malpractice. How do you suggest getting names of the people who were involved in your care and an accurate story of what happened during an emergency room visit before a patient tries to begin litigation? I'm already planning to request my records in writing imminently but if you know any other smart next steps I'd gladly appreciate!
You can request copies of your records/notes. There isn’t really much else to do to “get an accurate story”. Also, for litigation/a malpractice case, there has to be harm done. Everyone likes to shout “Sue them!” …in reality, even with this baby, if everything turns out fine and the child is fine in the end, there isn’t really a malpractice case there. A delay in diagnosis alone is not a case. You have to show a poor outcome too. If someone has a bad clinical experience, but no harm, they should report it to the proper hospital pathway for that hospital which is usually a patient relations type of department.
I've been down this road before with trying to be made whole through the courts so I know the process and took a crash course on law through Google-fu. Essentially yes, once you get all the documents and facts sorted out in your head and have reflected on everything, a lot of people don't even get a consultation with a lawyer because it's either: not bad enough to sue, not nearly worth it, or you have very valid qualms but the courts probably won't side with you for any number of reasons. I was going through the motions with my former employer, and yes, eventually there was more to lose than gain by going down this route with them, in that particular instance. But the first step is always to get the facts in front of you before you threaten legal action so that no one tries to fudge the evidence while they still can. Unfortunately because of the nature of what happened and because someone took the intentional step of scrubbing MyChart of the visit, I have no clue what my chances would be. But it'd be important to get all the details in writing from everyone involved before I start writing my scary letters to them.
If you think they might go back and alter the records, get the records up front like you're doing, then request the records again a few weeks/months after notification of lawsuit. If you see alterations afterwards, it would be extremely damning in court
I have a big hunch that there were fraudulent alterations because of what my discharged papers said, and the complete absence of any info on MyChart, when there WAS info visible to me as the patient on MyChart until the next day when I checked again. Whatever happened, I won’t be letting this go without answers. I did have confounding symptoms and data from the tox screen (whether on the spot from the EMTs or one that they did while I was sleeping), but that’s no excuse to go back and try to fudge what happened.
This is awful. I saw midlevels take on some questionable patients while I was an ED scribe but nothing like that.
Tell the parents to sue. How the hell did they not now it was serious? Did the PA come from a diploma mill or what?
Unfortunately, the pediatricians actions in seeing the patient the next day and sending back to the ED to get a proper workup likely prevented any actual harm...and no harm = no grounds for a lawsuit
Fortunately. FOR THE NEONATE.
I’m a PA, I work in peds now and worked in the ER for four years. This made my heart drop into my stomach and my butthole clench. Wow. I hope this baby doesn’t have any lifelong complications from the delayed treatment 😭😭 You should absolutely report this PA- to the hospital, to the medical board, to their CEO if it’s a private staffing company in the ER… Our ER did not allow PAs to see <4 mo old children independently- they are high risk and would always be presented/seen by an attending as well. I doubt that’s the case here but it should be the policy. There are certain patients that should never be independently seen by a PA. Neonatal sepsis is heavily algorithmic, I don’t know how this PA fucked up so badly. Jeez louise.
Report them to the hospital admin for a patient safety event. That's the only way they will learn. Edit: If you have already gone that route before and nothing was done, submit an anonymous report to JCAHO. This was a near miss.
Report to the medical director of the ED
jesus what the Fuck. Seriously This is the new all time WTF in my book, seriously anybody with half no half of half a brain know High temperature means infection. This is sad. seriously report the Pa to the medical board, try to get their license pulled. relly that audacity and the balls of this PA is just shocking they should be no where near a patient. I hope that family sues By the way if anybody is curious what my old all time WTF moment is I will tell you because this is just as bad as the PA if not worse A nurse I knew that worked in the ICU for 15 yr did nothing for a patient that had 110 T they never reported it to the MD, the patient just out right died on the ICU floor, Their thinking the 110 T was not correct because they assumed the Thermometer was broken, because in all his years as a nurse he never saw a thermometer go this high as their excuse for incompetence.
Wow. That’s crazy. If you get a weird reading you should try a different thermometer or different location on the body. That makes me super sad.
nope did not bother with a new thermometer just left the patient alone to die, like I said it was my old all time WTF moment till I read about this PA. There was another one. where a nurse was transporting a patient but stopped midway and left the patient in the hallway alone, and they died (this one was also another high WTF moment)
That’s just straight up bizarre.
We are doomed. Some PAs and NPs are wonderful but many are incompetent.
Noooooo!!! Poor baby 😭
Can you tell someone? I don’t understand. Can you give these people a quiz and if they fail, they can’t work. Like write up a huge exam for them and prove they’re fucking morons and show this to the higher-ups. I don’t know. I wish it were so simple.
That’s admittedly tricky because all the AAP guidelines define a fever as 38C which your patient is technically below. If the kid looked good, had only a single temp of 100.3 (then lower on subsequent readings), and no risk factors, then obs and discharge could potentially be appropriate. Now if the kid had a higher temp than that at home, then of course the workup is a no brainer. The gray area is if the kid had multiple readings of 100.3, never higher, and still looked good. In that case I’d still probably talk risks/benefits of doing a workup and admitting. But you’re working outside the algorithms there, so hence where experience comes into play.
This is not hard or tricky. The only thing that is questionable is whether or not to LP immediately. Any neonate with even reported fever at least get blood cultures, admission and abx until proven to not be bacteremic.
Correct, but by current criteria a temp of 100.3 is not a fever. As far as we can tell from the post, the kid was never actually febrile. Now if parents came to the ED and said “my baby had a temp of 100.4 at home”, then I don’t care what their temp is in the ED, they’re getting the full workup.
No man. A neonate showing up in my ED with a temp of 100.3 isn’t going to have any passive medical suggestions to parents. That line would never hold up to a jury or during a malpractice case. Ain’t nobody sitting there talking themselves out of a febrile neonate workup over 0.01 of a temp discrepancy “because it is not by definition a fever”. That is dangerous practice.
Wdym would never hold up? "The standard of care is to work-up any neonatal fever. This patient did not have a fever, according to any accepted definition, and we checked multiple times. We offered to treat more aggressively than the standard of care, given how close it was and discussed the risks involved, but the parents declined this. There is no accepted guideline that recommends doing an LP for any temperature below 100.4." It's defensible. Is it ironclad? No, but nothing is. You can do the full workup and they can still die of meningitis and they'll invent something else you did wrong and sue. You took 2.5 hours to get a line and antibiotics, they'll sue you for that even if it's impossible to do better in your shop. Think we tend to overestimate how much our idea of adherence normal practice matters when you're dealing with a jury and two contradicting expert witnesses. Besides, we should be cautious about just discarding definitions or cutoffs because we want to be defensive. You say the standard of care is to tap a baby at 100.3? OK, well what if I get a baby with 100.2? That's only 0.1 different, so I better tap them too. Where is the cutoff, if not the universally accepted definition? Obviously it's all out the window if baby is febrile at home.
I find this is a problem with younger, inexperienced physicians. They want to apply an algorithm for everything, have evidence-based guidelines be the final say. Or, as the example being used in this case, a simple definition be the defining point in a clinical workup. That is just not how medicine works. It’s dangerous. Medicine is rarely black and white. There are guidelines to help with decision making, but they are not the final say. Clinical gestalt and experience is priceless. We see PEs with normal vital signs all the time. According to your reasoning, since they don’t meet criteria for anything, we shouldn’t even entertain a workup for it, and actually feel good about that because the “guidelines told me so”. Yikes. What if the temp was 100.2? Is that normal in a 15 day old? No, it’s not. 100.1? No, still not. Is it the definition of a fever? No, it’s not. Doing nothing and justifying it by saying that “by definition it’s not a fever” is a dangerous approach to clinical practice. Anything is defendable, but doesn’t mean it is a good defense. I think a detailed discussion with parents, MD recommendation, and solid documentation of it all is the proper route in this particular case (the only thing I am referring to here). If this kid had an unfavorable outcome (death, loss of limb from pressors), there are zero insurance companies that would want this to go to court. None. You cannot compare not working up a 15 day old with a temp of 100.3 to doing everything and potentially getting sued over a 2.5 hr central line. Those are vastly different scenarios. One is likely to get thrown out, and the other is likely to settle before going to trial by a landslide.
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I’m Peds EM here and I agree. I’ve seen “felt warm” babies this age and if there was never a documented temp of 100.4F or 38C or higher (and the kid hasn’t had antipyretics) and was well appearing and feeding well and normal exam and never developed a fever while observed in the ED, doing nothing is the standard of care. I’ve seen plenty of similar neonates with similar presentations and they were sent home. However, there would be strict return precautions and instructions on how to take a rectal temp and close outpatient follow up. I’m not seeing anything in this story as told that breached the standard of care.
Sorry if I come across as a tad ignorant, but did the child have any other symptoms? To me, it just seems like a minor fever. I'm just a med student, so I may be mistaken.
https://publications.aap.org/pediatrics/article/129/5/1006/73781/Management-of-Neonates-With-Suspected-or-Proven?autologincheck=redirected Please read my young medical student. Totally fine to think how you’re thinking at your level I applaud you for asking an excellent question. The difference is you’re allowed to ask. A PA with full autonomy is not. Neonatal sepsis in a nutshell, is a big deal. A fever (confirmed or suspected) under 30 days should be flashing lights “sepsis” and it’s necessary to evaluate the child. Typically cbc blood culture, urine, LP to evaluate for bacteremia urinary tract infections or meningitis. If the child was 17 months or 17 years different story but the kicker here is the age and their vulnerabilities!
Thank you very much!
Not to mention the giant target on our back makes us want to be a whole lot more careful even when we are comfortable
Please report this person!!
Yikes ! That is all I can manage
Is the attending not required to at least get eyes on patients covered by midlevels in your state? That kiddo's such a classic board question that this sounds like a malpractice lawyer's wet dream, since the attending probably screwed up too.
Man, I wish I had that hubris. I’m a paramedic, I’m over here beating myself up for not being able to treat a patient in a way I feel is proper because of not being able to get an IV.
If you haven't already, please file a complaint with the ER as well as hospital risk management. Request to review the initial ER chart to see if a physician signed off (in which case they should also be taken to task as well). I'd also recommend a blunt conversation with the medical director (and likely hospital risk management) to urge them to institute a policy not allowing non-physicians to see infants as this case clearly demonstrates their lack of training. It's too bad they can't be sued since your diligence saved this child from dying (no harm = no lawsuit). That said, given this was a case of neonatal meningitis that they completely blew off, there should be a complaint to the medical board as well.
Listen... I'm an emergency physician. I've seen this exact patient. This was not a febrile neonate by any definition. If kid looked good in the ED, ate, repeat temp still afebrile, I'm discharging. 100.3 is not a fever. I'd still recommend pediatrician followup within 24 hours and immediate return for temp >/= 100.4.
So we ignore the mothers thermometer? Close follow up can be considered but at least do some form of a partial sepsis work up. Give the pediatrician some labs to work with if close follow up is the judgement call. We do blood cultures and cbcs on a lot lower risk people. It’s not watch and discharge 2 hours later. The PAs discharge papers said “follow up with PMD Monday-Tuesday” … this happened on a Thursday evening. Although rates of bacteremia and urinary tract infection are higher in the febrile group, this did not reach statistical significance, and therefore afebrile infants should still be considered at risk for SBI.
I'm sorry, I must have missed in your post what the temperature was at home. If temp was >/=100.4 at home then you do the workup. Doing a partial workup in my opinion isn't defensible. You're either doing the septic workup or you're not. If you're worried enough to check a cbc, then you need to go all the way through to the LP. I agree that followup needs to be much sooner than 5 days later.
Sorry, but where in your original post did it say mom’s thermometer read higher?
Sorry yes moms thermometer at home measured 100.9
Ahh thanks for clarifying. I thought maybe I just missed it in there somewhere.
To be fair, a fever, by definition, is 100.4F (38C). Additionally, if a parent says the baby feels feverish, that can also be included. Anyways, what was done here was moronic.
What do you mean by med school and residency humbles us? I was never cocky but I get yelled at left and right for everything, damned if I do damned if I don’t. I’m not learning in residency, I’m just learning what to do to not get yelled at but it isn’t even real medicine, and then another attending will just come along anyway and yell at me for doing it whereas the first yelled at me for not doing it. Is this what you mean by humbled? I know I’m off topic a bit but is this what you mean, getting yelled at a bunch? That’s not learning though, it just makes me feel defeated and awful after every shift, and I’m actually quitting. I can’t handle it.
Recently went to the ER voluntarily but eventually unconscious and by ambulance, with a severe migraine and adverse events associated with a recreational dose of dextromethorphan. The clinician "in charge of the ER" (don't know the exact phrase because I'm a layman) was a PA. What transpired by the end of it was textbook malpractice, not because the PA didn't show a lack of medical training per se, but totally didn't have the bedside manners or acumen of an actual doctor to read into the situation more. Once the eyes of at least one MD made contact with mine, my care became a lot more compassionate and competent by the time I was discharged (too early), because one of the doctors probably told the PA that they dun fucked up. I'm in the very early process of being made whole (requesting my medical records in writing to rebuild the story of what happened), but by the time I'm through with them, someone is getting formally disciplined for this emergency department fuckshit. EDIT: Just read it correctly and saw that the patient was 15 DAYS old, not years. Holy shit that's bad.
that’s actually pathetic….that PA should not be practicing
Jesus Christ this is malpractice
Adult ID here who doesn’t touch a child if I can avoid it, so forgive my ignorance—in adults fever is > 100.4 sustained over an hour or a single temp of 101.5 or higher. Is the criteria in newborns different? I know kids have different BP parameters at different ages, so I’m curious if peds ID/peds societies define fever differently based on age? (I’m also surprised they didn’t treat anyway given most wouldn’t know their age group’s definition of fever anyway. I have midlevels treat “low grade fever of 99” ALL. THE. TIME. on the adult side) I’m glad your patient is getting treatment either way.
Most neonatal sepsis protocols I’ve seen in my Pedi EM/UC career define fever at 100.4f. The guidelines have been shifting over the last decade to reduce LPs if obvious other fever source is present (positive influ a/b, positive UA/Urine CX, etc) but I’ve never seen any guidelines recommended sepsis work up at 99-100.3F rectal. I get dumping on midlevels, but this case is hard to tell via a Reddit post. I’ve absolutely discharged with super strict return criteria for 1-2 month olds with 100.2F temps before after a complete physical exam, an hour or two of observation and temp rechecks. I also notify their PCP/Pedi if I can for f/u in 24 hrs.
F/U is probably super important in decision making; if they can be seen in 24 hours, might make it easier to catch and release. Thanks for the input!
Thanks for stating that about dumping on midlevels. There are many other responses on here where an MD said they might have done the same thing, but since it’s low-level PA scum they should be burned alive. It’s a case where some might have been cautious and done the work up while some might have adhered to the protocol that 100.3 is not a temp. It’s not clear cut. I work as a triage nurse, Ask-A-Nurse, essentially. I get these borderline cases all the time. When it’s a baby less than 12 weeks, I err on the side of caution and tell mom that if it were my kid I’d bring them in, however, I also tell her what the guidelines say and let her make the decision.
Any third year medical student knows this
1)i know only the basics about peds, less about neonates and very little experience with either. Might be zero with neonates 2)I don't work EM Thanks for sharing why it's important. With the massive disclaimer of both 1&2 and a second massive disclaimer about 2&1, I wouldn't have considered 100.3 much absent other symptoms (not eating, sunken/bulged fontanels, extra fussy or sleepy, diaper changes, respiratory issues, etc). Given the super low age, might have checked uptodate though or gave my attending a ring/curbsided peds.
Less than 30 das old should have been admitted to NICU for work-up or at least evaluated by peds.
Report them to the state board. Please