Health Officer Reports: When Your Patient Is a Danger to Others

Under California law, physicians must report to local officials those patients whose medical condition causes a lapse of consciousness. When a physician is part of a larger team of doctors treating such a patient, he or she may think that such a report has already been handled. That could be a mistake.

A female patient, a Type I diabetic in her early 80s, was hospitalized four times over a four-year period for episodes of altered states of consciousness. Blood sugar levels over the four hospitalizations varied, from as low as 20 mg./dl to as high as 789 mg./dl.

Before the first hospitalization, the patient was found unconscious at home by a neighbor. Her longstanding treating internist ordered an EEG, CT scan, and carotid flow studies - all of which came back normal. After getting control of the patient's blood sugar (which was 21 mg./dl at admission) the internist discharged her on a split dose of insulin and continued to follow her.

During the second hospitalization for decreased level of consciousness (and blood sugar level exceeding 500 mg./dl), the patient's internist was unavailable. Dr. IM took over her care on the second day and discharged her on a modified insulin regimen.

Two days later, however, the patient returned to the emergency room confused, vomiting, and breathing rapidly. Her blood sugar level was 789 mg./dl. Dr. IM admitted the patient to the intensive care unit and consulted with an endocrinologist. During the stay, Dr. IM and the endocrinologist instructed the patient about diabetes. The endocrinologist made several adjustments to the patient's insulin medication and discharged her. The patient appeared to be doing well during three follow-up visits to Dr. IM. When she did not return for the fourth visit, Dr. IM assumed that she had returned to her original internist.

About that same time, the patient became disoriented while driving and was taken to the hospital's emergency room. She was not admitted, nor was Dr. IM contacted, even though he was listed as the family practitioner.

Eight months later, Dr. IM was contacted when paramedics took the patient to the same hospital. Dr. IM decreased her insulin dosage (her blood level was 20 mg./dl), discharged her the next day, and saw her on several follow-up visits.

Nearly one year later, the patient lost control of her car while driving, swerved into a bus bench, and killed a young mother. A blood sugar level taken at a nearby hospital was 20 mg./dl. The mother's child sued Dr. IM and other health care providers for medical negligence.

Under California Health & Safety Code Section 103900, "Every physician and surgeon shall report immediately to the local health officer in writing, the name, date of birth, and address of every patient at least 14 years of age or older whom the physician and surgeon has diagnosed as having a case of a disorder characterized by lapses of consciousness." Under plaintiff's theory, had Dr. IM or the other defendants reported the patient's medical condition to the local health officer, that official would have notified the Department of Motor Vehicles, which would have revoked the patient's license. Under this theory, the law would presume that the patient would not drive without a license, and a fatal accident would have been prevented.

Dr. IM was certainly not the only physician in a position to report the patient's medical condition to the local health officer. Nevertheless, recognizing that Dr. IM was integrally involved in treating the patient, Dr. IM's attorneys recommended contributing to the eventual settlement of the lawsuit.

Physicians treating patients with disorders causing lapses of consciousness should not rely on the "other guy" to complete (and document) this important public safety report. If you are unsure about how to make the report, contact your county's health department for assistance.

Gordon Ownby is CAP-MPT's general counsel. For more information on the regulations that define reportable disorders under H&S Code Section 103900, please address your inquiry to gownby@cap-mpt.com.