Failure to properly treat

Presentation

A 9-month-old boy was brought by his mother to his pediatrician’s office for treatment of a possible insect bite on the left buttock. The lesion appeared two days before, and had grown in size.

The patient’s vital signs were 98.9 degrees; respiration rate 28; and heart rate 130. The patient’s medical history included methicillin-resistant Staphylococcus aureus (MRSA) infection.

Pediatrician A diagnosed cellulitis and cutaneous abscess and prescribed mupirocin and warm soaks to the affected area. 

Physician action

Two days later, the mother brought the patient back to the office reporting increased illness, pain, fever, and redness. The patient was seen by the nurse practitioner (CPNP). The patient’s vital signs were temperature at 102.9 degrees; respiration rate 50; and heart rate 176.

The CPNP decided that incision and drainage (I&D) of the lesion on the patient’s left buttock was required. To prepare for the procedure, she ordered lidocaine, epinephrine, tetracaine (LET) topical analgesic and warm packs applied to the patient’s lesion. 

A physician assistant (PA) applied the LET and secured a warm pack over the lesion with self-adherent wrap. After preparing the patient, the PA left the room. 

A few minutes later, the patient’s mother came out of the room, and asked the CPNP to reapply the warm pack as it had moved out of place from the left buttock to the right buttock. The CPNP returned to the room and found the patient in distress in his mother’s arms. The warm pack had been removed and the patient’s right buttock was burned.

The CPNP proceeded with the I&D. The fluid obtained was purulent and culture was positive for MRSA. The CPNP documented a second-degree burn to the right buttock, and prescribed clindamycin palmitate HCI 75 mg/5ml, cool compresses, analgesics, and to return for follow up in two days. The mother was also instructed to bring the patient back earlier if there was increased redness, drainage, or other concerns.

The next day, the mother called the pediatrician’s office and reported that the burn on the right buttock was blistered and was approximately three inches in diameter. The mother also reported that the patient’s pain had increased. The patient was prescribed silver nitrate topical cream, acetaminophen, and cloth diapers to maintain moisture in the affected area. 

At the follow up appointment, the pediatrician saw the patient, documented blistering, and referred the patient to a burn center at a large local hospital. At the burn center, a full thickness burn (third- and fourth degree burn) was noted. Over the next nine weeks, the patient received burn treatment and fully healed. The patient has residual hyperpigmentation in the burn area.

Allegations

The patient’s family filed a lawsuit against the pediatrician’s practice alleging failure to adequately supervise the CPNP and PA, and failure to adequately treat the patient.

The lawsuit included claims for the patient’s pain and suffering, residual scarring, need for future scar revision, and parent’s lost wages for several weeks at home caring for the patient. 

Legal implications

Defense consultants were critical of the care provided in this case. All of the consultants questioned the use of warm packs that were so hot they would produce third- and fourth degree burns to an infant. They also criticized the poor supervision of the application of the warm packs. 

Another consultant felt the CPNP’s decision to perform the I&D procedure was not indicated. 

Disposition

This case was settled on behalf of the pediatrician’s practice.

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