discipline summaries
ER by a parent with a history of possible antifreeze ingestion. The patient was asymptomatic and behaving appropriately. Poison Control was called and numerous recommendations were made that were not followed. The nurses’ note said that,“ MD would like to just observe for now.” From the nurses’ notes, the parent reported that the child was found with a basically empty windshield washer fluid bottle and with a drop of the fluid on his clothes. The parent was uncertain if any had been ingested. The patient was observed for two hours and discharged home. Documentation was incomplete and insufficient. Dr. X noted that there was no narrative describing Dr. Kamermans’ thought process or treatment plan regarding the presumed ingestion nor was there a physician reassessment documented prior to the patient being discharged. Discharge or follow up instructions were lacking as well. In Dr. X’ s opinion, there were three problems with Dr. Kamermans’ care of this child. Although Poison Control was called, Dr. Kamermans did not do the blood work that they recommended and asked to have reported back to them. This advice was not heeded and there was no documentation to justify the decision not to do it. Dr. X opined that blood work would offer a baseline for comparison. Dr. Kamermans testified that although some of the tests could not be done, most of them could have been completed at the hospital. Dr. Kamermans decided to simply observe the child as he thought that it was unlikely that the child ingested the antifreeze. Dr. X was critical of Dr. Kamermans’ assertion that he thought it was unlikely that the child ingested any antifreeze, as he had no idea what he based that judgment on. Dr. X’ s second criticism was that the patient was not observed long enough in the ER, as the metabolism of the toxins can be delayed for several hours and the symptoms will not be evident early on, but may take time to develop. The two hours that the child was in the ER was too short an observation period and Dr. X testified that in a child of this age, six to eight hours of observation is generally considered adequate although some literature says 12 to 24 hours is needed to observe. It is the metabolites of the antifreeze that are the problem according to Dr. X, and they can cause blindness and neurologic abnormalities. Dr. X, in his report, stated that in his discussion with Dr. Kamermans, the physician seemed to be basing his management decisions on the assumption that this case represented a low risk ingestion. Dr. Kamermans ordered a two-hour observation period according to the patient’ s chart. Dr. Kamermans told Dr. X in the interview that he did not have a particular duration of observation in mind. However, in his evidence-in-chief after hearing the testimony of Dr. X, Dr. Kamermans said that the period of observation would be about six to eight hours. Dr. Kamermans said that in determining the period of observation, it would depend on the parents and the child and how active the child was. He said the fact that the child’ s throat was not inflamed contributed to his determining how long to observe the patient. However, Dr. X testified that methanol is not caustic so it would not be something he would be looking for. In addition, Dr. X said that an inadvertent ingestion in a young child does not lead to inebriation because the volume ingested is too small. Thirdly, Dr. X testified that Dr. Kamermans did not seem to appreciate the serious risk to the child even if he had ingested a small amount. In this patient, two teaspoons would be toxic, he said. Dr. X testified that, in the interview, Dr. Kamermans said that he did not think the child would drink much of the antifreeze. Also, Dr. Kamermans commented that if the patient ingested something dangerous, like a lot of Tylenol or Advil, then he would go with the recommendations of Poison Control. However, Dr. X pointed out in testimony that although Tylenol overdose is dangerous, Advil is not. Dr. X testified that when Dr. Kamermans was asked at the interview why he did not go with the recommendations of Poison Control in this case, he replied that he thought it was because of the way the child presented and the story that the child’ s parent told. According to his testimony, Dr. X did not think Dr. Kamermans understood the nature and seriousness of methanol ingestion in pediatric patients based on his interview with Dr. Kamermans. Dr. X was of the opinion that in cases where there is concern for ingestion, an evaluation in the ER is appropriate and generally consists of observation, assessment of routine lab work, clinical assessment
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Dialogue Issue 1, 2017