A Missed Diagnosis In A Pediatric Patient

Narrator  [00:00]  Every minute someone’s life takes a terrifying detour, not down a dark alley, but into the sterile, bright halls of healing. They walk in seeking care and find themselves plunged into a nightmare. Most malpractice claims in hospitals are related to surgical errors, whereas most claims for outpatient care, which accounts for more than half of the paid malpractice claims, are related to missed or late diagnosis. Now before you raise a pitchfork at every white coat you see, let’s be clear. This isn’t an indictment, it’s a revelation. Because the truth is, any provider, any nurse, any human being capable of brilliance is also capable of a mistake. This is about understanding why and using that knowledge to build a safer future for every patient who walks through those doors. Welcome to FHEA’s Scrubs and Subpoenas, Tales from the Witness Stand, a podcast where we’ll peel back the sterile sheets and delve into the real stories of medical malpractice. Each episode, a cautionary tale of blueprint for change, a reminder that even in the darkest corners of human error, there’s a light. The light of knowledge, the light of empathy, the light of a future where healthcare becomes not a gamble, but a guarantee. So join us as we dissect the mistakes, illuminate the flaws, and ultimately learn to heal not just bodies, but the very system itself.

Dr. Sally Miller  [01:21]  Hello everyone and welcome to Scrubs and Subpoenas, another episode. It’s been a little while, so we have some new cases for you. For those of you that may not have seen Scrubs and Subpoenas before, my name is Sally Miller, and as a nurse practitioner, I do some expert witnessing, along with my colleague, Dr. Wendy Wright. We both do some expert witnessing across the country, and we like to come together and share some of these cases with you. We always want to be really clear in the very beginning, nobody is here to make judgment calls or criticize the care of anyone else. I mean, I know I can go back and look at some of my old notes and think, oh boy, I wish I had said X, why did I say Y, or why did I do or not do the thing that I did or didn’t do back then. We can all go back and do that. The idea here is to learn from it so that we can all pay more attention to documentation and pick up some of these finer points of patient care that maybe just haven’t come up in the past. So today, Dr. Wright is going to tell us about her case. So Dr. Wright, I’ll ask you to introduce yourself, and then we can jump right in and tell us what you got.

Dr. Wendy Wright  [02:25]  All right, Dr. Miller. Hi, good afternoon, everyone. And I am so excited to be back with you, Sally. We’re going to have a really good time producing a few of these. I know when I’m out on social media, I get so many requests for people wanting you and I to be back in the studio taping some of these. You know, every time I look at a case, I say two things. One, oh, but for the grace of God go I, because this could have been me. And I also say, what can I use to translate into a teachable moment? And I think when I do these, and I know you feel the same way, what we’re really hoping to do is for people to learn. Like, I don’t want to be that person. I don’t want to end up there. So is there anything that I can take from this case? And maybe do better so that it doesn’t happen to you or I. So my name is Dr. Wendy Wright. I’m an adult and family nurse practitioner. I own a family practice located in New Hampshire, 11 nurse practitioners, 6,000 patients. And we are about to celebrate our 20th year in practice. So, and this is my 34th year as a nurse practitioner. And somehow I’m going to knock on wood here. I have managed to avoid one of these suits, but you know, I’ve got five more years and I just want to go out on top. I’m just knocking here. But I want to share with you a case, Sally, because I, you know, sometimes when I do these cases, I think you did everything right. Why did you get sued? Or why am I working here on behalf of the plaintiff? Right? So sometimes you can be the best NP and do lots of things right. And sometimes the situation just lends itself that it’s a bad case, if you will. Sally and I aren’t going to tell you who we worked for on these cases. So we’re going to ask you to think about this as we go through. So are you okay with me jumping in? I’m okay.

Dr. Sally Miller  [04:17]  Let’s do it. All right.

Dr. Wendy Wright  [04:18]  I do have to tell you a very interesting story. And I want to tell you all this before we even jump into the case. One of my Scrubs and Subpoenas episodes was just shown to me while I was on the stand testifying in a trial. So these are public domain and I’ll tell you, attorneys are using these in not always in a good way to kind of show you, oh, are you saying this? Good thing what I said on the stand was absolutely in concert with what I had said on one of these Scrubs and Subpoenas. But I know, right? I know. It’s always scary when they bring up pictures. And all I could think was, oh, my gosh, my hair was so awful that day. I should have been worried about something else I suspect, but I was worried about my hair. All right, everyone. Here we go. Ten-year-old boy. Always kids, kids stuff is really hard. But ten-year-old boy comes in to see his established PCP family has been taken, been taken care of by this PCP in a small community for since the child was born. All the kids come and this child comes in for abdominal pain. And it was right upper quadrant abdominal pain, but was really more generalized. And there was nothing else accompanying this pain. It was kind of in the location of his right rib cage. But there was no vomiting, no nausea, no fevers, no changes in stooling, no diarrhea. He was walking, talking, laughing with the examiner, absolutely nothing other than a few days of right upper abdominal pain. And so he sees a physician during that visit and is diagnosed with right upper abdominal pain slash myalgias thought to just really be something musculoskeletal. Really couldn’t even reproduce the pain on examination and just said, let’s treat this with heat. Let’s treat this with ibuprofen, etc. Because really the entire exam, including the review of systems was benign, except for just that right upper quadrant pain. This was a relatively healthy young man, past medical history of asthma, past medical history of short stature. And multiple medicines in terms of vitamins and inhaler for his asthma and had been started on growth hormone, approximately a month or two by an endocrinology NP outside of this clinic, but had been started on it, but it was doing well, no new issues. So physician sends the patient home, the patient comes back three days later, still the same complaints, nothing has changed, but mom’s really alarmed. Again, another exam is done, kind of a myalgia diagnosis, no workup. And then two days later, mom calls and says his pain is really bad. And this came in in a call and it’s severe. So triage nurse instructs the patient to go off to the ER, which they did. Mom takes him to the ER and he’s or a CT is ordered an abdominal CT with contrast. And he has his abdominal CT with contrast and develops anaphylaxis in the middle of the contrast infusion survives. They treat him. They treat him with epi. And needless to say, there’s nothing identified on the CT scan. So his next appointment is actually with a nurse practitioner in a follow up for an ER and comes back in. NP this time, really good history, really good physical exam. But again, there’s nothing brewing that they can find. NP does dip a urine, nothing. Does order… no, we’ve got a CT. So we know that the gallbladder, the liver, you know, everything really looked benign. And this kid is pooping, he’s peeing, and she orders a CBC as well, even though it had been done in the ER, and CBC is unremarkable. And so now, eight more times over the next 21 days, this kid is back into the clinic. And things are now evolving. The next time he comes in and sees the physician, he’s got neck pain. And the neck pain is so severe, he’s having a difficult time moving his neck. But again, afebrile. So if you’re thinking at home, is this a meningitis? You know, this kid has no rashes. He’s afebrile. He’s walking, talking, but he’s diagnosed with torticollis. Little unusual, I think. I don’t know, Sally, what do you think about a 10-year-old?

Dr. Sally Miller  [09:05]  I mean, the whole thing is unusual, though.

Dr. Wendy Wright  [09:08]  I know, right? That is something I think we should talk about. And then he keeps coming back. And eventually he comes back when a mom calls up and says, my kid is now having right eye pain. And he’s got a headache. And his neck pain is terrible. So the physician brings him in, he’s going to order an ultrasound, evaluates the kid, doesn’t really find anything. And the next day, mom calls back and says, now he’s saying he’s seeing lights in his vision field. So they send him off to the ER. ER looks at his retina and he’s got increased, he’s got papilledema. And so they see some swelling. And so they see to the brain. They also get him evaluated immediately by an ophthalmologist and he has he has pseudotumor cerebri. And so he has so much fluid noted that a shunt is placed within the next 24 hours. But unfortunately, this child lost vision and now has a shunt draining the fluid. So about three years later, two, actually two years later, a notice appears that the entire practice, there were actually nine defendants in this case. One of them was the nurse practitioner who did that one visit follow-up there, which is why I’m talking about it today. But you know, it was certainly the physician who saw him six or seven times. And then it was the ER times two, it was, you know, a group, it was the prescriber of the growth hormone, which I want to chat with you about. And so there is where it went. And so they sued. And so let’s talk about what are some of the learnings that I think from this case. First of all, they say the less specific the pain or discomfort and the more frequently people come in, the more aggressive you’ve got to be in your work up. Because for a mom to bring a child in, I think I counted up something like 12 or 13 times over the course of 21 days, there’s something going on that someone isn’t putting together. But truly, I guess I would say in those first six, seven, eight days, actually, I saw on the note, it was something like 19 days in before he developed the torticollis and the vision changes and all of those things going. Most of it was right over quadrant abdominal pain. So it kind of makes sense to search the belly, right? But this all came down to pseudotumor cerebri and linked with growth hormone.

Dr. Sally Miller  [11:52]  And so that’s the thing that so like I’ve had maybe three patients with with that and, you know, idiopathic intracranial hypertension. But they had the diagnosis coming to me. So when you started talking about the headache and the eye and the vision, okay. But I’ve never never had to pick it up and never seen in a 10 year old. So yeah, the growth hormone thing is kind of interesting.

Dr. Wendy Wright  [12:19]  So interestingly enough, because I don’t prescribe growth hormone, and I think I’ve probably in 34 years had two or three kids on growth hormone that I didn’t start but was obviously being prescribed elsewhere. I did not know until this case came up that it is a well known adverse event from growth hormone. In fact, I had to go out and do some research because I just would have never known that or didn’t know it because I just don’t see it enough. Is that something you have seen?

Dr. Sally Miller  [12:50]  No, I didn’t know that. And so, you know, that one of those teaching points is the standard of care being the benchmark. Would any nurse practitioner in a more general setting be expected to know? Is that consistent with what your average nurse practitioner would be expected to know or differentiate?

Dr. Wendy Wright  [13:12]  Yeah, well, obviously, and I guess obviously the pediatricians didn’t even pick it up either after multiple, multiple visits. And I guess I would think pediatricians are probably seeing these are higher risk kids, you know, these are tend to be sicker in a lot of practices. Those are the kids that go to pediatricians. So I guess there are a couple of things that I think are really important. One is when you see a drug on someone’s chart that you’re not necessarily familiar with, probably not a bad idea to look it up. Although I will tell you that I did some research throughout this case and abdominal pain is a really unusual finding for idiopathic intracranial hypertension. Now, I have read in some of the literature that it can occur because of an increase in cerebral spinal fluid, it can cause some congestion in the liver, but his transaminases weren’t even elevated. So it’s easy to kind of go down that abdominal road and kind of get hung up there until things started to escalate. But I always ask people when I’m seeing people like, is there something different that started or that you did before this all happened? I don’t see that that question was asked. And so I do wonder if mom had said, listen, my kid was just started two months ago on injections of growth hormone, would that have kind of changed a little bit? But it was clearly mentioned in the medication list. It was listed there.

Dr. Sally Miller  [14:49]  Even if you don’t know that potential adverse effect, it is when you have a new persistent complaint and any new thing, and you can’t figure out any other reason for the new persistent complaint, you have to consider that the new thing might have something to do with the new complaint.

Dr. Wendy Wright  [15:14]  Absolutely. And that’s why I love that reasoning. Tell me anything changed, any drug been added on, you know, in the world of older adults, we often say we’ve got this list of drugs that can cause delirium. But anytime you change a dose or anytime you modify a dose, right, you are at risk for that mental status change. And so what we have now is a 10 year old who for the rest of their lives now has a shunt placed. I don’t know what that future looks like. I’m just not well versed enough to know will that kid ever be able to get that shunt out or not. But because of the increased intracranial pressure, it impacts the optic nerve. And so you’ve got a decline in visual acuity. And that’s permanent. That is the most serious sequelae of an idiopathic… intracranial hypertension. But the other one is persistent cognitive changes. Now this child is 10 and we’re only about three years into this now or four years. What does that future look like? I don’t think anyone knows.

Dr. Sally Miller  [16:20]  And the growth hormone. Does anybody know how growth hormone elevates?

Dr. Wendy Wright  [16:26]  So I did some reading as I was getting ready and prepping for the case and they say it increases the production of cerebral spinal fluid. Oh, you said that. Yeah. I mean, I don’t understand. You are the pathophysiology queen. I would defer to you.

Dr. Sally Miller  [16:47]  And I don’t know. So I mean, I well, that’ll be a new one. Hey, something interesting to show you we can all we can all learn something new no matter how many decades in.

Dr. Wendy Wright  [16:59]  And I know that this is probably a case like maybe we’ll never see anything like this again. But I think there’s some teaching moments here. And one is rapidly escalating frequent repeated phone calls. When I do telephone triage lectures, I always say when someone keeps calling you and persistently saying, this isn’t good. I’m not getting better. It’s it’s time to get them in. It’s time to take them seriously and and really kind of try to harness that in because repeated calls are often for many people kind of a desperate attempt. Particularly for the same thing. Right. Particularly for the same thing. And then not to be able to find anything but to continue to have that discomfort present. The nurse practitioner had written in her notes that if it persisted, consider a GI evaluation, but there was just really nothing. She, I, if you will, other than the complaint was right upper quadrant rib cage kind of pain.

Dr. Sally Miller  [17:55]  Man, those abdomens. I don’t like abdomen. There’s just too much that goes on in there. When you open a book and it says, oh, right upper quadrant think this left lower quadrant think that you know, epigastric think X and then patients just never have the good grace to recite. A textbook series of signs and symptoms.

Dr. Wendy Wright  [18:13]  So I’m going to tell you that I worked on the defense on this case, and I will tell you that that nurse practitioner, you could tell took that visit seriously. She took the history tried to pull it all together. Did a comprehensive really good exam. She was actually alone. It happened on a weekend that she works on the weekend shifts in this pediatric practice and she consulted with a physician, even though that physician wasn’t readily available. She made sure to talk with that physician just to say, what am I missing here? And they both agreed that it was likely something musculoskeletal. But she did the urine, did the CBC and then never saw that patient again. So one could argue like, why would that NP be named? I know why she is named. Because it’s easier to name everyone at the beginning and everyone is a pocketbook and the more people you name, the more the potential to recover that money, right? Because we’re each worth about a million. And so if you’ve got nine defendants, conceivably, the plaintiffs attorney can get 9 million and maybe more if there’s punitive damages. I don’t believe that there was anything in this case that warranted punitive damages. It wasn’t like they were blowing this mother and child off. I mean, every time this child was reevaluated, I just don’t think anyone puts the belly stuff together with the head. And honestly, I’m not sure that I would have until the headaches, the torticollis, the vision changes, the light, you know, seeing the light in their eye, things started to appear.

Dr. Sally Miller  [19:56]  Well, that’s why that’s why the old saying hindsight is 2020. It’s certainly easy to go back and look. But so can we, we can ask how this came out? Sure.

Dr. Wendy Wright  [20:06]  Every provider settled except for the nurse practitioner. She was left standing alone. Oh, this is why I wanted to talk with this about this as well, because she was on her own policy. So, so there was one attorney defending her. And they reached out to me actually, because I really felt like we had a good defense. There was nothing on that exam at that time that would have ever made you get a CT scan of the kids head, right? And so, but they made the decision that the NP needed to settle because she was now holding and everyone else had already paid out. And because what they were going to be able to get in a settlement was going to be a lot less than she was potentially at risk for, for if she held out, this went to trial. That could have been much higher if he’s got a jury who really believes that this child was harmed by that NP. And so in talking with the attorney, he said to me, it’s really sad when we have to settle these things out when we know we’ve really got a well defense, a really good defensible case. But she was standing alone absorbing all of the cost potentially of what these families were and plaintiff’s attorney wanted to get.

Dr. Sally Miller  [21:30]  And I think a lot of people watching actually don’t realize the considerations. It’s not just about, did you do anything wrong? In fact, you and I, Dr. Wright, were talking about this the other day, about all of the behind the scenes things that go on to determine whether a case actually is brought and the decision making behind whether or not it settles. And it rarely seems to have to do with what’s actually right, you know, what’s, what’s actually done correctly. And I mean, it’s a very sympathetic case.

Dr. Wendy Wright  [22:06]  And I think when you have a 10 year old, and I don’t mean to sound callous, but it’s one thing if you’ve got a 95 year old who’s lived their entire lives, right? But now you’ve got a 10 year old who’s got a shunt, who’s got vision impairment, may have some cognitive stuff that often is very sympathetic in front of the jury. And so it’s kind of like a really bad baby delivery case. I mean, those things garner millions and millions of dollars. So sometimes what people don’t realize, because you and I have actually sat in the courtroom and done courtroom work and testified in a trial, so much of what should be said never makes its way in. Because of the way the question is asked by an attorney or because they’ve already filed that this information is going to be omitted and the jury can’t hear it. And it’s really disheartening when you work these cases to see how much goes on behind the scenes that none of us have any control over.

Dr. Sally Miller  [23:07]  It is and the relative unimportance of whether or not the nurse practitioner deviated from the standard of care, which is what it’s supposed to be about. Right.

Dr. Wendy Wright  [23:21]  And what it really comes down to is liability and who’s on the hook for so much money. And I don’t know if everyone realizes as well, punitive damages, because a lot of times they ask for that, because that’s above and beyond what the states often cap these fees on. And if that goes above malpractice companies don’t pay punitive damages. The organization is on the hook for them. And some of them are millions and millions of dollars. So, so much goes beyond behind the scenes. But I don’t know if you’ve ever talked to anyone you’ve ever worked on a case for, and you were trying to defend a case. But I have a couple of colleagues who have requested me to work on their cases and to help defend them. And they’ve said to me after their insurance company decide to settle, they said, I had no say in it whatsoever. And I know I didn’t because I would have said I want to defend this. I think we have a really good case. It’s heartbreaking. And it makes a lot of NPs really angry. And I get it. I get it.

Dr. Sally Miller  [24:25]  And it drives it drives some really, really talented people out of practice.

Dr. Wendy Wright  [24:30]  Absolutely. And then when you are when you do settle or when there’s been a claim against you. This is something you have to report every time you renew your nursing license every time you renew your malpractice. Have you ever had a case filed against you? I mean, this haunts you for a long time, which is heartbreaking.

Dr. Sally Miller  [24:52]  On that happy note, I mean, remember, I was an investigator for the Nevada Board of Nursing for three years. And that was routinely one of the things would come across my desk is for a renewal. If you answer yes to having having a judgment or even an open case pending, then virtually always you had to upload information about the case and then the investigator reviews it. And sometimes we review it and realize that it’s not a barrier to practice. And then that’s the end of it right there. And other times it has to go to a hearing before the board trying to find a way to make this uplifting for our new and these

Dr. Wendy Wright  [25:31]  that are listening that there are cases I guess for me, number one, repeated calls repeated visits, start really thinking there’s something bad going on. We’re just not figuring it out and keep pushing it. And you know, none of us want to send people to the emergency room. But I’ve worked enough cases where if they if the NP had said, go to the ER, they may have been off the hook. So always document when it’s escalating like this, go to the ER, anything changes, anything worsens, make sure you put that in your note because that can be protective as well. And sometimes the saddest thing is you can be a really good NP, you could have done everything right, but you just got caught up in a really bad sequential of that, you know, a sequence of activities that happened that you really did not do anything wrong.

Dr. Sally Miller  [26:28]  The other thing that just jumps out at me and I always tell my own students this and you know, have learned to do it myself is if number one, for anyone who might be thinking about repeated complaints might be, you know, malingering or munchausen or fictitious, whatever we call it now, the real key there is if it’s the same complaint over and over. It’s not, it’s probably not psychiatric. It’s a physical thing we haven’t figured out yet, as opposed to the person that this week, it’s the abdomen, next week, it’s a headache. After that, it’s your foot, like, you know, every time it’s something different that you can see where there may be more of a mental health thing there. But for this repeated complaint, that’s really a red flag. But the other thing is that, I mean, I’ve noticed over the years that nurse practitioners in general, I think seem to have like, perhaps over empathize sometimes. And so if the patient’s in the office and the NP tells the patient, you need to go to the emergency room for this, and the patient says, I can’t, I have to go to work. I don’t have any insurance, who’s going to watch my kids, like all these really good reasons why they can’t go. NPs are more, have a greater tendency to try to work with that and like, well, okay, but, you know, we need to follow up daily or, you know, okay, we’ll go home with this prescription, but go to the ER, if X, Y or Z. And we just can’t do that because we’re the professional and they’re the lay person. And if you know that they need to go to the emergency room, you have to be firm on that and write it on your note. And if they don’t go, that’s their decision, then against medical advice, they can leave your office. But if you endure, even begrudgingly, or even if you know you really don’t want to let them go, but if you’re trying to work with somebody, you know, you then do become liable for a deviation in standard of care. And I’ve seen nurse practitioners write notes that say, I advise the patient to go to the emergency department, patient didn’t want to go for X reason. And so we agreed that they would go home and follow up or call back and then something bad happens. And, you know, it’s the on the hook. If we if we endorse that, that plan of not going home, that’s what they’re waiting for from us. And I found that if when you stick to your guns and say, I’m sorry, I can’t I can’t I can’t support that you need to go to the emergency room. Many times they’ll figure it out.

Dr. Wendy Wright  [28:52]  Absolutely. My other statement was something like that is you came here, for my opinion, and my opinion is this is not safe to go home. And so I am recommending you go to an ER. And if it’s life threatening, I don’t even recommend they go to an ER, I call 911 and have them come to my clinic. And then if that patient decides I’m not going in that ambulance, they literally sign their life away on those waivers. I don’t know if you’ve ever seen a paramedic tried to convince someone to get in an ambulance and the patient says no, they literally are having this patient sign their life away. Truly in today’s environment. I don’t want you calling an ambulance for every person with a sore throat. But if you’ve got someone actively having chest pain, and and that first bell in your head goes off, I talk about this a lot. We spend a lot of our time denying the bell. I say listen for the bell. The first thought that comes into your head is, gosh, I hope they’re not having a pulmonary emboli. Or I hope they’re not having a cardiac event. They may very well be trust that instinct and listen to it and cover yourself.

Dr. Sally Miller  [30:00]  And if it turns out not to be great, awesome.

Dr. Wendy Wright  [30:03]  Yeah, and if they’re mad that they had to sit in an ER, then you know, I tell people, you know, they said, I’m so angry with you for sending me I said, I’m thankful you’re alive. So I’m glad you’re here. And you can be angry with me all you want. But my allegiance was to you.

Dr. Sally Miller  [30:18]  I’ve had people call me from the ER and yell at me first and then [inaudible] the ER.

Dr. Wendy Wright  [30:24]  You know, listen, I’ve got pretty thick skin after 34 years, you can say a lot of things to me. But so I think our time is up. I do. It’s been really fun. I’m glad not fun. But you know, it’s good to hang out with you again. Talk about some of those things. And some good points.

Dr. Sally Miller  [30:41]  Yeah. I will definitely be looking more into growth hormone and elevated cerebral spinal fluid and share it with me.

Dr. Wendy Wright  [30:50]  I’ll be really curious to see what you find. So this concludes this episode of Scrubs and Subpoenas. Tune in. Sally and I are going to be filming a bunch of these over the course of the next few months, we hope. And so I think we have what, 50 up there now already. We’re going to try it really well. Yeah, I think there’s over 50 episodes. So maybe this will be 51. So thank you all so much for joining us today and tune in for the next Scrubs and Subpoenas. And so goodbye.

Dr. Sally Miller  [31:20]  Tune in for 52. See you soon. Thank you.

Dr. Wendy Wright  [31:24]  Thank you, [inaudible].

Narrator  [31:26]  Thank you for listening and learning with Scrubs and Subpoenas. Tales from the Witness Stand presented by Fitzgerald Health Education Associates. Please rate, review and subscribe to this podcast. And for more NP resources, visit FHEA.com. Join us again next time as we dissect more medical malpractice cases.