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
58
Dialogue Issue 1 , 2017