Opinion ID: 1597354
Heading Depth: 2
Heading Rank: 2

Heading: Dr. Zeiger's Treatment

Text: 1. Upon Reagan's arrival at the UAB Hospital emergency room at 4:50 p.m. on April 25, Dr. Zeiger noted that Reagan had been released from Children's Hospital earlier that day, after suffering from fever, vomiting, and diarrhea. She presented to the UAB emergency room with a rigid neck and a low fever. 2. Dr. Zeiger's initial admitting diagnosis for Reagan was meningitis, and he ordered that she be treated with the antibiotic Mefoxin; however, the hospital staff did not administer it at that time. Dr. Zeiger was also concerned that Reagan's shunt might be malfunctioning; a shunt malfunction is a common problem for children with shunts. 3. A tap of Reagan's shunt yielded cerebrospinal fluid, indicating that fluid was moving through the shunt and that the shunt was functioning properly. 4. Once a shunt malfunction was ruled out, Dr. Zeiger's next concern was the possibility of a shunt infection without a concurrent malfunction of the shunt. 5. Dr. Zeiger examined the fluid drawn from Reagan's shunt and found that the levels of protein and white blood cells were normal; the normal levels indicated that there was no infection of the cerebrospinal fluid in her brain. 6. Dr. Zeiger and Dr. Kendrick reviewed the other possible causes of Reagan's illness, which was still symptomatic of meningitis. 7. Dr. Zeiger eventually theorized that the Arnold-Chiari malformation of Reagan's brain, extending into the spinal canal, may have developed to such an extent as to create a separate compartment of spinal fluid that did not circulate completely with the other areas of her spinal canal and her brain, as would normally occur. He believed that it was possible that so much of Reagan's brain may have protruded into her upper spinal canal as to create a compartment that spinal fluid could enter through what would effectively be a one-way valve, but could not thereafter circulate through the rest of Reagan's spinal column and her brain. 8. Dr. Zeiger decided that it was necessary to do a spinal tap to obtain a sample of Reagan's cerebrospinal fluid from a point other than her shunt tube. However, a normal spinal tap was not possible, because the myelomeningocele deformation in Reagan's lower spinal column caused her to not have the fluid sack at the base of her spinal column where such taps are normally performed. 9. Before the spinal tap was done, a CAT scan of Reagan's brain was performed. The CAT scan was normal for a child with Reagan's abnormalities and revealed no any sign of infection affecting brain tissue. 10. Dr. Kendrick performed the spinal tap at 10:30 p.m. on April 25. Examination of the spinal fluid sampled by Dr. Kendrick's spinal tap showed that Reagan did have an infection in an area of cerebrospinal fluid that was not in circulation with the cerebrospinal fluid being drawn from her brain by the shunt. 11. Based on his knowledge that 96% of all shunt-related meningitis infections are caused by Staphylococcus bacteria, Dr. Zeiger ordered that Reagan be admitted and treated with the antibiotic Mefoxin. Dr. Zeiger continued with his diagnosis that the meningitis infection was related to Reagan's shunt, even though the spinal fluid drawn from the shunt itself was not infected. Dr. Zeiger chose not to put Reagan on the antibiotic ampicillin. 12. The antibiotic Mefoxin was not actually administered to Reagan until 3:00 a.m. on April 26, more than 4 hours after her spinal tap and 10 hours after she had been come into the emergency room with an initial diagnosis of meningitis. Mefoxin was again administered to Reagan at 6:00 a.m. 13. Laboratory testing of Reagan's infected spinal fluid later revealed that it was infected by Hemophilus influenza, the most common cause of meningitis in young children, and not Staphylococcus bacteria as Dr. Zeiger had assumed. Because of the laboratory results, the medication for Reagan's meningitis was changed from Mefoxin to a combination of ampicillin and chloramphenicol, antibiotics that are more specific for Hemophilus influenza meningitis and that are the standard treatment for that particular illness. 14. Reagan was transferred to Children's Hospital after 9:00 a.m. on the morning of April 26, and she finally underwent treatment with ampicillin and chloramphenicol, more than 16 hours after she was first seen by Dr. Zeiger at the UAB Hospital emergency room with symptoms of meningitis. 15. Reagan's condition deteriorated greatly and she was near death before she recovered and was able to be discharged. She remained in Children's Hospital until May 15, 1982.