Someone Has to Mind the Pharmacy

This column has highlighted the risks inherent when multiple physicians care for a patient with inadequate communication between them. The potential for serious injury expands even further when the patient is a heavily medicated minor and the pediatrician hands off care to an unknown “specialist.”

Baby Patient was born to a mother who had taken methamphetamines during pregnancy. Baby Patient was placed in foster care immediately, and made excellent strides in overcoming virtually all of the typical developmental problems associated with drug babies. Baby Patient was then transferred to another foster home at age four months where her biological sister and three other special-needs children resided.

Dr. P, a pediatrician, maintained all five children in Baby Patient’s new home as his patients. His normal course was to see the children every three to four months, though that interval sometimes went several months longer. All the children were taking various medications prescribed by Dr. P.

Contrary to the Baby Patient’s near normal behavior in her first foster home, her new care-giver told Dr. P that Baby Patient had abnormal sleep cycles, could not be taken out socially unless medicated, and could not interact normally with other family members. Given this information, Baby Patient’s prenatal exposure to drugs became a significant factor in Dr. P’s treatment plan. Dr. P prescribed Ventolin, Phenobarbital, Zyrtec, Clonidine and Xanax to control Baby Patient’s “jitters” and anxiety, and for some respiratory problems.

After two years, Baby Patient’s foster mother wanted Dr. P to refer Baby Patient to Dr. S, “a developmental specialist.” Though Dr. P did not know Dr. S, Dr. P made the referral. Dr. S, who actually was a family practitioner, added Propranolol, Prozac and Depakote to Baby Patient’s regimen for her “panic attacks” “anxiety disorder” and “chronic insomnia.”

Some six months after the referral, Baby Patient arrived at the Emergency Room with a depressed level of consciousness. The ER physician’s diagnostic impressions were altered level of consciousness, hypoglycemia, ketosis, dehydration and rule out sepsis. Baby Patient’s history and physical noted that “with her having such severe seizures, it is most likely that she has suffered severe hypoglycemia, leading to significant brain damage.” Her prognosis was “probably poor.”

Experts reviewing the case following a lawsuit filed against Baby Patient’s various physicians suspect that an increased level of Phenobarbital interacted with the Depakote to cause damage to her liver, leading to a hypoxic event.

On review, experts questioned Dr. P’s referral to the specialist he did not know and his level of trust in the foster mother. This was especially relevant given that there was an apparent misunderstanding as to dosage when the Phenobarbital was switched from solid to liquid form.

Baby Patient’s situation had many more complicating layers and was resolved before trial. The most basic lesson of the case, however, is that when complex situations such as Baby Patient’s come their way, juries will expect physicians to keep a strict watch over the medicine jar.

Gordon Ownby is CAP-MPT’s general counsel. Comments on Case of the Month may be directed to gownby@cap-mpt.com.