Wednesday, February 18, 2004

A Charles County jury awarded a La Plata couple more than $5 million in damages on Friday after finding that three doctors failed to detect symptoms of child abuse in an infant in 1998 and could have prevented a subsequent, more serious injury that has disabled the boy for life.
The Circuit Court jury found that pediatrician Soma Reddy and Civista Medical Center doctors Donald Shell and Hammond Dugan should have performed a CT scan on then-11-month-old Jack Sprague on Nov. 18, 1998, when his worried parents took him to the hospital after he suffered a head injury at the Waldorf home of his babysitter, Nancy J. Brookbank.
A CAT scan likely would have found evidence of a subdural hematoma, or bleeding in the brain, which is typically caused by shaking a baby, said Robert W. Weltchek, a lawyer for John and Robyn Sprague, the boy's parents. Two weeks later on Dec. 4, 1998, Jack suffered another, more serious hematoma while with Brookbank, an injury that nearly killed him and left him disabled for life.
The jury decided the Dec. 4 injury would not have occurred if the Nov. 18 injury had been diagnosed correctly, because the family would not have put Jack back in Brookbank's care. "It could have all been possibly prevented," said a juror who asked not to be named. "The CAT scan should have been done."

As with most cases of this type, the experts differed in their opinions:

Cindy W. Christian, director of the child abuse program at Children's Hospital of Philadelphia, said 11-month-old Jack Sprague did not show telltale signs of a subdural hematoma, or bleeding in the brain, when his worried parents brought him to Civista Medical Center on Nov. 18, 1998.
Her testimony was bolstered by Robert W. Block, chairman of the University of Oklahoma Department of Pediatrics, who also testified Friday in support of Civista Medical Center and three doctors who are being sued for $13 million by parents John and Robyn Sprague, whose son was examined by the three doctors.
Jack "was basically symptom-free," Block said. "There is no indication that [the doctors] should have had any perception of abuse." ......
Philip H. Cogen, the Washington Children's Hospital neurosurgeon who operated on Jack, has testified for the Spragues, saying he saw two separate injuries: the massive subdural hematoma caused on Dec. 4, 1998, and another smaller, older hematoma.......
The Spragues' lawyers contend the smaller, older injury occurred Nov. 18, causing Jack to appear "lethargic" and "not his usual self" for several days, according to his mother.
But Christian and Block countered that such an injury would have caused more serious and pronounced symptoms. If there was a small injury, it would have healed before Dec. 4, when a CT scan was performed, Block said.
"It is possible that the baby was injured some time after" Nov. 20, Christian testified. She said Jack had "unexplained vomiting" and other symptoms that she speculated could have been caused by abuse on Nov. 30 and Dec. 1, when the child was again in Brookbank's care.

So let me see if I get this right.... the physicians in question are being held liable because the parents say if they had known about the injury on November 18, they would not have used this person as a babysitter and thereby avoided the more severe injury on December 4. It seems to be a bit of a stretch of proximal causation as the lack of a CT did not directly cause the disability of the child. They are being held responsible for actions, taken by a third party, that took place two weeks after they had treated the child. While I take exception to the causation argument, there may be some merit to the argument that a CT should have been done.

According to the Eastern Association for the Surgery of Trauma's head injury practice guidelines:

CT scan of the brain is the cornerstone test in the evaluation of traumatic brain injury. The literature generally supports the use of CT scanning for all cases of MTBI in which at least one of the following is present: loss of consciousness; post-traumatic amnesia (PTA); confusion or impaired alertness.

These guidelines are pretty broad, and the details of the infant's neurologic exam are not found in the media reports. While recent studies and other guidelines advocate selective use of CT in head injuries, lawsuits like this one will make those suggestions difficult to follow. A physician practicing now is concerned aboout being sued here and now over a missed injury, not fifty years from now for a possible malignancy. A dichotomy exists concerning radiation use as physicians are hesitant to use radiographs in pregnant women because of concerns of exposure, but have little hesitation about exposing children once born.

Or, as Ted Frank, pinch-hitting at Overlawyered, asks:

How many healthy children will end up with cancer because of defensive medicine in response to this verdict?

The answer to that question is a "known unknown" ,as Donald Rumsfeld, would put it. But I know of three physicians who wish they had ordered one more.

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