Sunday, December 16, 2018

Summary: The plaintiff (3 Y/O) in this matter presented to the ER in June 2014 with elbow pain and was taken to local emergency room, but allegedly was not seen for 4-5 hours. The X-ray images revealed no injuries to the elbow and doctor reportedly said child was having a tantrum. The plaintiff’s parents noted that the child was vomiting and had a high fever. Upon taking the plaintiff to another ER, the patient was immediately diagnosed a scorpion bite and received scorpion anti-venom. The plaintiff recovered after a few days of illness.

Allegations/Questions: Was there a breach in the standard of care? Should the doctor have been able to diagnose the issue from the initial visit? Did the delay in diagnosis result in any increased complications in treatment?

 


Findings: An AMFS Emergency Medicine expert reviewed this matter and provided the following opinion: It can be very distressing to see any child, let alone your own child, in distress. However, it is not always immediately clear what the cause of this distress is and how best to help. Scorpion envenomation can be a very difficult diagnosis to make. Often, the affected site has a normal physical exam. Symptoms can develop over several hours, making return precautions or observation important to the diagnosis. The patient reported trauma to the first medical team and there was no documentation of the presence of scorpions. The patient then eloped from the first ER before nystagmus, fasciculations, or drooling was noted. The videos and photos do not show any exam findings to indicate the need for antivenom administration. Neither does the physical exam recorded in the initial ED visit.

It is possible that if the family had stayed for the evaluation recommended by initial treating physician, the patient would have had sufficient time to develop these symptoms. The family did not allow the medical team the opportunity for a re-evaluation of the child prior to discharge, nor a discussion of further care options. On the second ER visit, the physician’s physical exam contrasts with other documentation such as the order for anti-venom. Fasciculations and nystagmus were not noted on the physical exam, but were checked on the order form. According to UpToDate, symptomatic improvement typically occurs within 9 to 30 hours without antivenom therapy in severe envenomations, and sooner in mild envenomations. Pain and paresthesias may persist for up to several weeks. Acceptable treatments are either antivenom or supportive care with pain medications and benzodiazepines if needed.

Per my training, antivenom is not without some risks, and it is very expensive. There is no single appropriate treatment and the choice of treatment depends on the patient’s symptom severity and family preference. On visit number three, there is no mention of the patient having recently received antivenom, and her diagnosis is listed as “viral syndrome.” Was this information intentionally withheld from the medical team? The patient’s symptoms as reported by the family did not match the physical exam noted by both the physician and the nurse. Per their documentation, the patient appeared well. The patient recovered uneventfully, and in my opinion, there was no breach in the standard of care by the first treating ER team.