Presenting Complaint Overshadows More Serious Problem

Asplenic patients are usually aware that they do not have a spleen, but they may not recognize their associated risk for serious infection. The fact of the matter is that asplenic patients are immunocompromised. When an asplenic patient presents with a febrile illness that is consistent with OPSI, this is a true medical emergency. These patients must undergo a vigorous workup and expeditious administration of antibiotics to offer the best chance for survival. Even with appropriate antibiotic treatment and supportive therapies, mortality associated with OPSI ranges between 50% and 80%.

In this case, the emergency physician obtained a hematology/oncology consultation. There is a dispute between the defendant physicians as to whether antibiotics were recommended or even discussed. It is unclear from the record whether or not the emergency physician’s clinical note includes such a discussion. The jury apportioned the majority of the liability to the hematologist but still found the emergency physician negligent.

Conflict between clinicians or departments can get testy in the clinical record; don’t let that happen. An otherwise defensible record of care can become a nightmare for defense counsel when an interpersonal or interdepartmental conflict is played out in the clinical record. As with personal conflict, defensive addendums to a patient’s record can be damaging. Jurors generally reward “finger pointing” between medical professionals with a verdict for the plaintiff, even when the care itself may be defensible. Regularly held peer review offers clinicians an opportunity to discuss difficult cases without fearing that those discussions will be used as evidence. A formal peer review committee is the exclusive and proper outlet to discuss challenging clinical cases.

Appropriate care for our patients is the ultimate necessity. It can be tricky for a clinician seeking a consultation to challenge the consultant’s recommendation. When confronted with a recommendation that leaves you (the referring clinician) with “heartburn,” it may be helpful for you to restate your misgivings affirmatively—for example, “My concern with that approach is ___,” then state the risks in the gravest terms the situation will allow. Make your preferred course of action apparent: “Honestly, I’d like to admit the patient because of ____.”

If you remain uneasy, seek another colleague’s opinion. Record the substance of the consultation, concerns, and responses fully, accurately but dispassionately, in the patient’s record.

Make sure to give the consultant all the clinical information available; and if you are the consultant, be sure you have received all available information. Treat the consultation formally and with your full attention. The jury will expect the consultant to be fully involved in caring for the patient.

Here, if the emergency physician did not agree with the hematologist, it would have been reasonable for him to obtain a second opinion or to admit the patient and begin empiric antibiotic treatment. —DML