When a medical practice has a policy of ordering tests “STAT” but routinely accepts reports issued on a less than urgent basis, troubles lurk.
Baby Girl was born at 38 weeks weighing 7 lb., 8 oz. With a normal newborn course, Baby Girl was discharged with no apparent abnormalities, but had a bilirubin level of 5.2. The evaluating pediatrician saw no visible jaundice in the Hispanic-Asian baby, but informed the mother of the positive bilirubin value.
Baby Girl visited the pediatric office two days later. There, a medical assistant did a routine weight and jaundice check. The MA noted that Baby Girl was breast feeding every two to three hours, weighed 6 lb., 12 oz., with good bowel movements, and was having three wet diapers a day. The MA noted the patient looked jaundiced. As is the custom at the pediatric practice for newborns, the MA ordered a bilirubin test STAT. Blood was drawn at 12:42 p.m. and the result, reported via the lab’s dedicated printer in the pediatric office at 3:16 the next morning, showed a direct bilirubin of .7 and a total value of 15.3.
Later that morning, Dr. P1, the pediatrician on-call, ordered a re-test but in an apparent violation of office policy, the requisition was not labeled STAT. The lab report indicated that the blood was received at 11:23 p.m., with results reported at 1:42 p.m. the next afternoon. That report showed a total bilirubin of 14.6 (with no direct value). Per her custom and practice, Dr. P1 would have told the nurse to tell the mother that the results were appropriate for a four-day-old baby.
Baby Girl’s mother brought her in again a week later because she thought her daughter looked more jaundiced and was not interested in feeding. Dr. P2, another pediatrician at the practice, saw Baby Girl and noted “Color good. No rashes, birthmarks or lesions. Jaundice down to legs.” Baby Girl weighed 7 lb. 1 oz. Dr. P2 ordered a repeat STAT bilirubin, per her routine, and recommended to the mother that the baby return for a routine weight check in one week and for an examination in six weeks.
The lab received that day’s sample at 5:58 p.m. and reported the results via the dedicated printer at 2:42 a.m. the next day. Despite a direct bilirubin of 2.1 and total bilirubin of 46.2, the lab did not call Dr. P2. The medical office called the mother upon seeing the results when the office opened at 8:30 a.m.
When Baby Girl arrived about 45 minutes later, the mother told Dr. P2 that Baby Girl took a bottle that evening and had wet urine diapers, but also that she noticed less activity and that Baby Girl occasionally arched her back.
On examination, Dr. P2 found Baby Girl on her back with her head tilted back. Her eyes and skin were jaundiced and she made a weak cry when her head was repositioned. With Baby Girl’s presentation highly suggestive of kernicterus, Dr. P2 immediately called the local hospitalist and neonatologist about admitting her, with a planned transfer to the regional university medical center after that.
Baby Girl was admitted to the local hospital later that morning for a double volume exchange transfusion and intensive phototherapy. Her bilirubin levels ultimately returned to normal. Though tests could not pinpoint the cause of the crisis, the event left Baby Girl with substantial motor deficits. Baby Girl sued Drs. P1, P2, and the laboratory for her severe neurologic injuries.
At deposition, Dr. P2 testified that she did not expect Baby Girl’s bilirubin to spike and that she ordered the test STAT because it was the group’s practice. She had expected to be called if the result was abnormal and had not considered admitting Baby Girl because other than visible jaundice, she did not appear ill. Dr. P2 and the laboratory resolved the matter prior to trial. Dr. P1 was dismissed.
While Dr. P2’s examination and assessment during her first visit with Baby Girl merited deference, the group’s routine acceptance of STAT reports well into the next day presented a more troublesome issue.
That is because at trial, an attorney need only give jurors a short lesson in Latin on the meaning of statim for them to expect to see action taken “at once.”
Author Gordon Ownby is General Counsel for the Cooperative of American Physicians, Inc.(CAP).
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.