Malpractice

Field: Medicine (Health Sciences)

Figure: Darkening of the skin caused by Addison's disease.FigureA teenager dies when a rare disease escapes diagnosis The parents of a 13-year-old girl with fatigue, weight loss, and an upper respiratory infection for three weeks took her to two EDs, two urgent care centers, and a pediatrician. All but one urgent care center shared the same medical record. Medical professionals asked about her tan, inquired about use of tanning salons, but didn't address her skin color in their notes. Tests for mononucleosis, streptococcus, and anemia were negative. Her white blood cell count was 18,000/mm3, sodium was 130 mmol/L, and potassium was 4.9 mmol/L. She was diagnosed with mono-spot negative mononucleosis and culture-negative and ASO-negative strep throat. The family was told that it sometimes takes months to recover from viral infections and they needed to wait it out. Her symptoms continued, and she stopped going to school because she was sleeping up to 20 hours a day. Several months later, she developed another significant respiratory infection, and was taken to an ED where she had a sudden cardiac arrest. She was resuscitated and airlifted to a tertiary hospital where the ED team quickly assessed her problem as a likely adrenal crisis, later confirmed to be autoimmune Addison's disease. She was placed on ECMO, developed massive brain hemorrhages, and was withdrawn from life support four days later. Her parents filed a lawsuit against the hospital system and five members of the care team. (AHRQ PSNet. March 29, 2023; https://bit.ly/3CiwNJq.) The Plaintiff's Case The parents said their daughter's death was a completely preventable tragedy. She was seriously ill for several months with multisystem complaints, terrible fatigue, and significant weight loss. Everyone seeing her could look at her previous records, but if they did, they never thought beyond viral infection, mono, or strep throat, even though tests for the latter were negative. None broadened the differential; all simply rubber-stamped her prior diagnosis without documenting their medical decision-making. The pediatrician even called his exam a well-child visit, and told the parents to return in a month for a weight check. All the doctors mentioned her bronzed skin but didn't document it or see her classic “tan” as a sign of Addison's disease. The girl was very sick, yet no one recognized it or referred her for further evaluation until it was too late. Any of them could have saved her life. The Defense's Case Addison's disease is rare. You can't expect EPs and urgent care providers to diagnose it on a single visit. The defense counsel said the staff was busy treating emergencies and couldn't be expected to diagnose chronic, serious, systemic diseases. The medical professionals said the parents shopped around to multiple providers rather than sticking with a single source of care, calling that contributory negligence, and stressing that continuity of care is important. The defense counsel said the parents never brought her back for the weight check, giving the pediatrician another chance to make the diagnosis. Even though the parents claimed that all the providers commented on her hyperpigmentation, none ever documented it, so how do we know it was there? The photos they showed of her bronzed skin weren't really accurate. The Verdict The case went to trial despite several pretrial motions against the plaintiffs. During jury selection, the discouraged parents settled for a low amount. Takeaways Try your best to avoid anchoring and confirmation biases, especially diagnosis momentum, which clearly affected the providers in this case when they accepted a previous diagnosis without sufficient skepticism. Another example would be thinking a pregnancy test at a referring hospital was positive, eliminating the need to worry about appendicitis. Remember Hickam's dictum. (Wikipedia. https://bit.ly/42uMvvB.) The medical professionals' depositions revealed significant knowledge deficits regarding adrenal insufficiency and the significance of the hyperpigmentation. Emergency physicians should do their best to avoid such knowledge deficits, like Addison's disease. (J Emerg Med. 2022;63[2]:212.) Always keep in mind that you may not know what you don't know (metacognition). Keep an open mind in your diagnostic decision-making. Listen to that quiet voice in the back of your head asking, “Could this be something else besides what I'm thinking?” All of us have heard some version of the horses vs. zebras cliché. Could a case like this be your zebra? Dealing with uncertainty is a valuable skill, especially for emergency physicians. The longer we can stay in a place of uncertainty, the better we do at getting the right diagnosis. (Ann Emerg Med. 2020;75[6]:715; https://bit.ly/3MVDjuj.) Your diagnosis is less important than the way you arrived at it. In other words, document your MDM. (Chicoine N. Medical Malpractice Insights. November 2022; https://bit.ly/3Cf7h7N.) Blaming the plaintiff is a last-ditch defense. If you're a patient, always give the first doctor you saw a second chance. Good doctors will try harder the second time. Doctor shopping or embarking on a diagnostic odyssey only slows the process. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].