ED Doctor Hit With Lawsuit After Following Treatment Guidelines

This month we look at a case that took place in the emergency department (ED) of a hospital. The case looked at what the standard of proof is for a patient’s negligence claim against an ED physician. 

Just the Facts

Dr M was an emergency medicine physician working in the ED of a Texas hospital. In her position, she had handled all sorts of emergency situations, but this particular night brought something new.

The patient, a 13-year-old girl, Miss P, was brought to the ED by EMS at 9:15 pm. Miss P had been playing with her dog in her yard when she was bitten by a rattlesnake on her left foot. Her parents called paramedics who whisked her to the hospital. She was seen by Dr M at 9:20 pm.

The hospital had Snakebite Treatment Guidelines which were taken from recommendations of the American Academy of Family Practice and the manufacturer of the antivenom used by the hospital. Dr M reviewed the guidelines. According to the manufacturer, the antivenom was shown in clinical studies to be effective when given within 6 hours of snakebite, however, Dr M was concerned about the risks of the antivenom. She noted that the antivenom was contraindicated in patients with a known history of hypersensitivity to certain substances. Furthermore, 19 of 42 clinical trial participants experienced an adverse reaction, and 3 of those experienced a serious or severe adverse reaction. 

The Snakebite Treatment Guidelines set out a detailed, 7-part procedure for medical staff to follow when a patient is bitten by a viper. Part 1 is the initial assessment, including the patient’s vital signs and type of snakebite (if known). Part 2 lists initial lab tests to be ordered, and panels to be repeated 2 hours later. Part 3 deals with insertion of an IV and possible administration of a tetanus shot. Part 4, the antivenom decision tree, sets out the process that a doctor should use to determine whether (and when) to administer the antivenom. 

A patient’s severity score is assessed using several criteria, and the decision tree specifies that if the severity score is 3 or less and coagulation lab work is normal the patient should not be given antivenom, but rather be reassessed every 30 minutes for 8 hours. If the severity score is 4 or more, or coagulation lab work is abnormal, then the patient should be given the antivenom immediately. Parts 5 through 7 of the treatment guidelines cover dosing, adjunctive treatments that should and should not be administered, and follow-up once the patient is released. 

When Dr M initially assessed Miss P at 9:20 pm, the girl’s severity score was 2 and her coagulation lab work was normal. At 9:45 pm, the swelling had increased and the foot was discolored. By 10:15 pm, the swelling had progressed, but the patient’s severity score was still 2 based on the criteria. Dr M ordered morphine for the girl’s pain.

At 11:20 pm, Miss P told a nurse that she felt a burning pain in her toe. When the nurse reported this to Dr M, the physician added another point to Miss P’s severity score for paresthesia. Dr M also ordered that the girl’s coagulation workup be repeated on a stat basis. The lab results were returned at 11:39 pm and showed a drop in platelets and fibrinogen. These results increased the child’s severity score to 5.

Ten minutes later, at 11:50 pm, Dr M ordered 6 vials of antivenom be prepared. It was administered at 12:29 am, a little over 4 hours after the girl was bitten. The hospital did not admit children overnight, so Dr M arranged for Miss P’s transfer to a children’s hospital, which began its own antivenom protocol, and infused Miss P with more antivenom. Twenty-four hours after being transferred to the second hospital she was given her final dose of antivenom and was discharged on crutches the following afternoon after a physical therapy evaluation.